Central Venous Access via Tunneled Catheter

Updated: May 03, 2017
  • Author: Sapna Puppala, MBBS, MRCS, MRCS(Edin), FRCS(Edin), FRCR, CBCCT, EBIR; Chief Editor: Justin A Siegal, MD  more...
  • Print
Overview

Background

Long-term venous access is of critical importance to a wide group of patients. Such access is obtained by inserting tunneled lines via the internal jugular vein (IJV) or the subclavian vein, either surgically or percutaneously. Combined use of ultrasonographically guided vein puncture and fluoroscopy has significantly reduced the complications related to insertion. This article gives a step-by-step guide to performing radiologic insertion of a tunneled venous line via internal jugular access. [1]

For more information on central venous access, see Central Venous Access via Subclavian Approach to Subclavian VeinCentral Venous Access via Supraclavicular Approach to Subclavian Vein, Central Venous Access via External Jugular Vein, Central Venous Access via Posterior Approach to Internal Jugular Vein, Central Venous Access via Tunneled Anterior Approach to Internal Jugular Vein, Femoral Central Venous Access, and Central Venous Access.

Next:

Indications

Long-term venous access is indicated in various settings where access is required for continuous infusions and blood volume exchanges for longer than 3 weeks. Such settings include the following:

  • Chemotherapy and bone marrow transplant (BMT)
  • Plasmapheresis and leukapheresis
  • Hemodialysis [2]
  • Intravenous (IV) antibiotic and antifungal therapy
  • Total parenteral nutrition (TPN)
  • Pain management (rarely)
Previous
Next:

Contraindications

Systemic sepsis is an absolute contraindication for central venous access via tunneled catheter because it can lead to line infection. In patients who require a long-term tunneled line for a reason other than IV antibiotic administration, wait for sepsis to settle.

Relative contraindications include local cellulitis (use the opposite side or tunnel away from the area) and low platelet counts or deranged coagulation (correct platelets and coagulation to acceptable levels before performing the procedure).

Previous
Next:

Technical Considerations

Procedural planning

IJV access is preferable to subclavian vein access because the IJV is easier to visualize with ultrasonography, IJV access carries a reduced risk of pneumothorax and thrombotic complications, and IJV access carries no risk of uncontrollable arterial injury. The right IJV is preferred to the left IJV because it has a relatively straight course into the right atrium (RA), which reduces the risk of great-vessel injury caused by the peelaway sheath or stylet. [3]

The IJV lies anterior and lateral to the carotid artery (see the video below). A low puncture increases the risk of pneumothorax, and a high puncture increases the risk of arterial puncture, in that the artery now lies posterior to the vein.

Transverse ultrasonography of neck shows anterolateral relation of internal jugular vein to carotid artery and illustrates compressibility of vein.

Complication prevention

To prevent air embolism, use a tilting table to lower the patient's head before inserting the line. If no tilting table is available, ask the patient to hum or hold his or her breath.

In addition to adopting the Trendelenburg position, the following measures may be helpful in reducing the risk of air embolism during tunneled catheter exchange [4] :

  • Direct puncture of the previous catheter's venous lumen for guide-wire insertion, as opposed to guide-wire introduction after the catheter is cut
  • Light manual compression of the IJV venotomy site after catheter removal
  • Valsalva maneuver (in cooperative patients)
  • Valved introducers
  • Correction of hypovolemia

Evidence indicates that the following measures can help prevent catheter infection [5, 6, 7, 8, 9] :

  • Use of fully aseptic insertion technique
  • Immediate removal of the line if infection is suspected
  • Use of the smallest possible device, with no more lumina than are required for the task (eg, for antibiotic infusion, a single-lumen 6-French Broviac line is sufficient, and there is no need for a double- or triple-lumen line)

The following measures are sometimes employed to prevent catheter infection, but definitive evidence supporting their use for this purpose is not available:

  • Prophylactic use of IV or oral antibiotics at the time of insertion
  • Use of lines impregnated with antibiotics, antiseptics, or silver
  • Routine line replacement
Previous