Patient and OR preparation
Every intervention begins with an analysis of medical records and imaging (CT, MRI, ultrasound). It is essential to rule out venous thrombosis, stenosis, and evaluate the position of any legacy catheters. To prevent lymphedema, punctures on the side of prior breast surgery and axillary lymph node dissection should be avoided.
Coagulation studies are mandatory: if the INR is above 1.5 or platelets are below 50 × 10^9/L, medical correction or transfusion is required. In reduced estimated glomerular filtration rate (eGFR), contrast agents are used with caution. Anticoagulants are withheld according to local protocols.
In the fluoroscopy suite, the WHO surgical safety checklist must be completed to prevent major errors (wrong-patient or wrong-side procedures). The procedure is performed under aseptic conditions with local anesthesia (e.g., 1% lidocaine) and cardiac monitoring. The patient is placed in the supine position; a Trendelenburg position (head-down tilt) or a chest roll is used to engorge the jugular veins.
Types of venous access devices
Device selection depends on clinical goals and the planned duration of therapy:
- Polyurethane catheters: used for short-term access (removed or replaced after 7 days to reduce infection risk).
- Silicone catheters: used for long-term access, frequently tunnelled under the chest wall skin.
- Hickman line (Hickman line): a classic tunneled central venous catheter (CVC). It is equipped with a Dacron cuff that causes local inflammation and ingrows into the subcutaneous tract, securely fixing the catheter.
- Groshong catheter (Groshong catheter): distinguished by a three-way valve at the tip. The valve opens outward during infusion and inward during aspiration, remaining closed at rest. This minimizes the risk of thrombosis and fibrin sheath formation.
- Implantable ports (TIVAD): consist of a titanium reservoir with a silicone self-sealing septum and a catheter. Placed in a subcutaneous pocket and completely hidden under the skin. Accessed using special Huber needles. Characterized by high cosmetic appeal and allow patients to maintain an active lifestyle (e.g., swimming).
Tunnelled CVC placement technique
The preferred access site is the right internal jugular vein (RIJV). It is easily visualized on ultrasound, has a direct anatomical course to the right atrium, and is easily compressible in case of bleeding. Alternatives: left internal jugular, external jugular, and subclavian veins.
- Puncture: performed under strict ultrasound guidance (in-plane) using an 18G needle as close to the clavicle as possible so that the catheter lies in a smooth parabola without kinking.
- Guidewire advancement: a 0.035-inch J-tip guidewire is advanced through the right atrium into the inferior vena cava under fluoroscopy.
- Tunnelling: an incision is made on the anterior chest wall. The catheter is attached to a tunneller and pulled subcutaneously to the neck puncture site. The anchoring cuff is embedded 3–5 cm into the tunnel.
- Positioning: a peel-away sheath is placed over the guidewire, through which the catheter, trimmed to the required length, is inserted. The target tip position is near the cavoatrial junction (2–3 cm below the carina of the trachea).
- Completion: after removing the introducer sheath, the catheter is checked by aspiration, flushed, and locked with heparin. Incisions are closed (e.g., with 2-0 silk suture).
Complications and their prevention
The most significant short-term complications are bleeding and inadvertent arterial puncture.
Venous bleeding (loss of more than 500 mL of blood) is most successfully controlled by firm manual compression, even in the setting of high central venous pressure in dialysis patients. The introduction of thrombin directly into the tunnel tract in uncontrolled bleeding is acceptable, but carries a high risk of tract infection.
Arterial puncture can lead to massive blood loss and toxic reactions (due to inadvertent drug administration). To completely eliminate this risk, the landmark-based puncture technique is no longer used. Ultrasound guidance has become the mandatory standard.
On ultrasound, a vein is differentiated from an artery by the following criteria:
- Change in diameter depending on the phases of respiration.
- Complete compressibility of the vessel upon transducer pressure in B-mode.
- Characteristic blood flow on color Doppler mapping.
- Waveform on spectral dopplerography.
Briefly: answers to topical questions
Which veins can be used for central venous access?
The following venous access options are specified in the sources for central venous access:
- Right internal jugular vein (RIJV) — usually the preferred access: easily visualized on ultrasound, can be manually compressed in case of bleeding, and has the most direct course to the target area.
- Left internal jugular vein (LIJV).
- External jugular veins.
- Subclavian veins — indicated as an alternative access; they are less amenable to compression.
- Cubital or brachial veins — used for placement of peripherally inserted central catheters (PICC-line).
- Inferior vena cava (IVC) — can be used via translumbar access.
- Peripheral hepatic veins — used for transhepatic placement of a dialysis catheter.
- Umbilical vein — used in neonates; the tip of the umbilical venous catheter should be located at the junction of the inferior vena cava and the right atrium.
What late complications are characteristic of long-term central venous catheters?
The following potential complications and issues for long-term central venous catheters are specified in the sources:
- Infectious complications — tunneling of silicone catheters reduces the incidence of infections; fully implantable ports have a reduced risk of infections due to isolation from the external environment.
- Catheter thrombosis and fibrin sheath (fibrin sheath) formation — the risk of these complications is minimized by the Groshong catheter design.
- Venous thrombosis.
- Massive pulmonary embolism.
- Catheter fracture or tip detachment (line tip fracture).
- For transhepatic dialysis access, catheter dysfunction, malposition, kinking, or complete dislodgement are described.
What types of devices are used for central venous access depending on the duration of therapy?
The choice of central venous access device in the sources is related to the anticipated duration of therapy and the type of treatment.
| Duration / situation | Device |
|---|---|
| Short-term use | Polyurethane CVCs: removed or replaced after 7 days to reduce the risk of infections and thrombosis. |
| Shorter therapy durations than long-term therapy exceeding 3 months | Peripherally inserted central venous catheter (PICC). |
| Long-term therapy exceeding 3 months | A subcutaneous venous port system is most convenient. |
| Long-term access | Silicone tunneled central venous catheters (CVCs), including the Hickman line; the Groshong catheter also belongs to tunneled central venous catheters. |
Class and exam questions
Why is the right internal jugular vein preferred for catheter placement?
The RIJV is easily visualized using ultrasound, has a straight anatomical course to the heart without sharp bends, and in case of bleeding, it can easily be compressed manually.
What is the main advantage of totally implantable venous access devices (TIVADs) over Hickman catheters?
Ports are completely submerged under the skin into a created pocket. This reduces the risk of infections, provides an excellent cosmetic result, and does not restrict patient activity (bathing and swimming are permitted).
How to prevent accidental puncture of the carotid artery?
Blind landmark puncture must be abandoned. The physician must use ultrasound, distinguishing a vein from an artery by full compressibility under probe pressure and lumen variation with respiration.
What else to study on this topic
- Features of the "reverse tunneling" technique during Groshong catheter placement
- Surgical steps for creating a subcutaneous pocket for venous ports
- Application of peel-away introducers and dilators in interventional radiology
- Doppler ultrasound modes (color and spectral) for vascular assessment
- Management of deep vein thrombosis: catheter-directed thrombolysis and vena cava filters
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