Translumbar inferior vena cava catheterization
Proper preparation for the procedure includes contrast-enhanced CT. This study is necessary to visually confirm the patency of the inferior vena cava (IVC) and precisely evaluate the depth to which the instrument must be advanced during the posterior approach.
The procedure is performed on a fluoroscopy table, with the patient in the prone position (prone). To facilitate vessel localization, a transfemoral venogram (contrast injection of the vessel via a femoral approach) may be performed beforehand.
Technique is as follows:
- A long 22G needle is inserted superior to the middle of the right iliac crest.
- The direction of movement is toward the right lateral surface of the body of the third lumbar vertebra (L3).
- The physician advances the needle strictly under fluoroscopic guidance (fluoroscopic guidance) until a free flow of blood is obtained.
A venogram is then performed to confirm that the needle tip is specifically within the inferior vena cava. A guidewire (guidewire) is advanced through the needle lumen into the right atrium. The tract is then dilated, and a long peel-away introducer (peel-away sheath) is placed. A long permanent central catheter is tunneled subcutaneously from the right lateral abdominal wall directly to the puncture site and inserted through the introducer. The final position of the tips in the inferior vena cava and right atrium must be verified fluoroscopically.
Transhepatic dialysis catheter placement
This venous access option is performed into relatively peripheral hepatic veins under direct ultrasound guidance. After confirming the correct site selection using venography, the physician inserts a fine 0.018-inch guidewire. In the next step, it is exchanged for a stiffer 0.035-inch guidewire. The procedure concludes with tract dilation and placement of hemodialysis catheters routed into the right atrium under fluoroscopic control.
Disadvantages and risks of the method: Transhepatic access is associated with a high rate of malfunction (malfunction) and malposition (malposition) of the placed system. The primary reason lies in physiology: during respiration, excursion of the diaphragm and liver occurs, causing the catheter tips to constantly move back and forth. Such mechanical instability can lead to trauma of the right atrial or tricuspid valve wall, which in turn provokes thrombosis. There is also a risk of line kinking (kink) or complete dislodgment (dislodge).
Peripherally inserted central catheters (PICC)
For PICC placement, the patient's selected arm is prepared, draped with sterile fields, and local anesthesia is administered under ultrasound guidance. A tourniquet (tourniquet) is applied above the antecubital fossa (antecubital fossa). Using a micropuncture needle, one of the veins is cannulated: the brachial (brachial), basilic (basilic), or cephalic (cephalic). After successful puncture, the assistant outside the sterile field removes the tourniquet.
A 0.018-inch guidewire is advanced into the inferior vena cava under direct fluoroscopic observation. An important technical nuance: to prevent inadvertent entry of the guidewire into the internal jugular vein (IJV), the patient's head is turned toward the insertion side and they are asked to lower their chin.
Insertion of the catheter itself is performed according to the classic Seldinger technique (Seldinger technique) through a peel-away introducer (after prior removal of the internal dilator). The tip must be precisely positioned at the atriocaval junction (atriocaval junction).
To reduce the risk of thrombosis, some operators avoid trimming the device tip to length. In such cases, the excess catheter is carefully coiled and securely taped to the patient's arm. Chest radiography is performed or a fluoroscopic image is saved for final documentation of the position.
Risks and complication statistics
Venous access complications are classified into intraprocedural (also known as short term — short term) and long-term (long term). With careful preoperative planning and strict imaging control, most problems can be avoided, so the rate of short-term complications typically remains under 1–2%.
Complication rates with image-guided placement:
- Haemorrhage or haematoma (Haemorrhage/haematoma): less than 2%.
- Catheter malposition or kinking (Catheter malposition/kinking): less than 1%.
- Venous perforation (Venous perforation): less than 1%.
- Infection (Infection): less than 1%.
- Arterial puncture (Arterial puncture): less than 1%.
- Pneumothorax (Pneumothorax): 0–1%.
Briefly: answers to topical questions
What long-term complications are characteristic of translumbar venous access?
Long-term venous access complications include infectious processes and the formation of a fibrin sheath.
- Infection (Infection) is the most frequent cause of catheter removal and can lead to bacteremia; it manifests with erythema, local warmth, and cellulitis.
- Fibrin sheath (Fibrin Sheath) is an endothelialized proteinaceous scar tissue that occludes catheter side holes and tethers it to the vessel wall, causing a flap-like effect (inability to aspirate blood while flushing remains possible).
Translumbar access has an infection complication rate comparable to other methods.
What are the absolute contraindications to translumbar venous access?
Absolute contraindications for performing the access include local pathological and postoperative changes.
- Inflammation — the presence of an active inflammatory process at the planned access site.
- Surgery — recent surgical intervention at the access site.
Pronounced hemorrhagic diathesis caused by thrombocytopenia, hypofibrinogenemia, or coagulopathies is only a relative contraindication to the procedure.
To prevent the guidewire from migrating into the internal jugular vein during PICC placement, the patient should "look at their hand and nod to it" (turn the head toward the puncture side and lower the chin).
Class and exam questions
Which imaging modality is used to confirm vessel patency prior to translumbar access?
Contrast-enhanced computed tomography (CT) may be performed initially. It allows confirmation of inferior vena cava patency and precise evaluation of tissue depth for the posterior approach.
What is the patient's position during translumbar puncture?
The patient is positioned prone on the fluoroscopy table.
Why does transhepatic access for a dialysis catheter carry a high risk of dysfunction?
Due to respiratory excursion of the diaphragm and liver, the catheter tip constantly shifts back and forth. This leads to a risk of kinking, tricuspid valve trauma, and subsequent thrombosis.
What is the risk of pneumothorax during image-guided catheter placement?
The rate of this intraprocedural complication is extremely low, ranging from 0 to 1%.
What else to study on this topic
- Seldinger technique: procedural steps and basic instrumentation
- Transfemoral venography: indications and contrast technique
- Atrial thrombosis as a complication of long-term catheterization
- Long-term complications of central venous access
- Anatomy of the atriocaval junction and radiological landmarks
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