Central Venous Access via Tunneled Anterior Approach to the Internal Jugular Vein 

Central venous access is essential in providing quality medical care to many patients for whom intensive therapy is required. In many situations, a semipermanent tunneled central line is preferred (see Indications). An anterior approach to the internal jugular vein is the best option in this situation because it offers the easiest route with a low risk of complications.

In this procedure, a tunneled catheter is surgically inserted into a vein in the neck or chest and passed under the skin. Only the end of the catheter is brought through the skin; medicines and intravenous fluid can be administered through this catheter; other tasks, such as blood sampling, can also be performed. The fact that the catheter is passed under the skin helps secure the catheter, reduces the rate of infection, and permits free movement of the catheter port. The placement of a tunneled catheter should be carried out by practitioners with specific experience in the procedure.

• Complex or critically ill patients who need continuous hemodynamic monitoring
• Patients who require secure venous access for the infusion of agents that are very irritating or that have a very narrow therapeutic index, and which, therefore, require a very precise rate of delivery into the circulation (eg, cytotoxic drugs, inotropic agents)
• Patients who require long-term venous access for parenteral nutrition, chemotherapy, or long-term prophylactic antibiotics
• Patients in whom very frequent blood sampling or access to the circulation for other reasons is needed
• Patients in whom venous access cannot be secured by any other route (For information on other vascular access routes, see the Vascular Techniques section of the Clinical Procedures journal.)

• This procedure has no absolute contraindications.
• Relative contraindications include the following:

  • Severe coagulopathy
  • Physical status unfit for anesthesia
  • Unavailability of a suitable access site
  • Thrombosed veins
  • Overlying skin infection
• In patients who need long-term venous access (eg, patients with small bowel transplant), imaging of the neck veins may be necessary before the procedure.
• Doppler ultrasound (US) and/or magnetic resonance (MR) venography can establish venous patency and anatomy, thus improving planning and anticipation of potential problems with access.^[1]
• Particularly in patients with multiple medical problems, a complete blood count, clotting profile, and relevant renal and liver function tests should be included in the preoperative workup. Depending on the platelet count, platelet transfusion may be needed.

• A local anesthetic agent is used before tunneling the catheter.
• For more information, see Local Anesthetic Agents, Infiltrative Administration.

• Central venous catheter tray (line kit), shown in the images below Double-lumen tunneled line. Hemocatheter.
• Sterile gloves
• Antiseptic solution with skin swab
• Sterile drapes or towels
• Sterile gown
• Sterile saline flush, approximately 30 mL
• Lidocaine 1%
• Gauze
• Dressing
• Scalpel, No. 11
• Vascular forceps (DeBakey)
• Needle driver
• Prolene suture 4/0
• Steri-Strips
• Mepore adhesive tape

• Trendelenburg position with the head turned to the opposite side of the central venous line (CVL) insertion is optimal, as the internal jugular vein (IJV) distends in this position, providing a maximal cross-sectional area for access, as shown in the image below.^[2] Correct position of patient - head down and turned to opposite side with a roll under the neck.
• The ipsilateral arm should be extended minimally at the axilla.
• In adults, neutral position of the neck has been shown to be equally safe.^[3]

Preparation

• Skin cleansing with 2% chlorhexidine in alcohol is recommended for skin antisepsis, as this has been shown to be superior to povidone-iodine or 70% alcohol.^[4]
• Expose the neck from the angle of the jaw superiorly, to the nipples inferiorly, to the midaxillary line laterally, and to the sternum medially. Surround the exposed area with sterile drape or towels, as shown below. Correct exposure and draping of patient.

Locating and accessing the vein

• To locate the target vein for percutaneous placement of a central venous line (CVL) via the anterior approach, use landmarks or ultrasound guidance.

  • Evidence suggests that ultrasound guidance outscores the landmark technique with regard to reduced failure rate, reduction in multiple attempts, reduction in misplacements, preservation of vein patency, and decrease in the incidence of line sepsis.^[5]
  • The ultrasound technique may slightly increase the risk of pneumothorax or arterial puncture, especially in inexperienced hands.
  • The open technique has a place in preterm neonates, in whom the percutaneous technique may be more difficult and more unsafe.
  • The internal jugular vein (IJV) is located between the clavicular heads of sternomastoid muscle. It is accessed best at the apex of the triangle the muscle heads make with the clavicle, as depicted in the image below. Neck anatomy showing the course of the internal jugular vein (IJV). Image reproduced with permission from BMJ Publishing Group.
• Seldinger technique, shown below Seldinger technique for internal jugular vein (IJV) puncture.

  • The IJV puncture may be performed with or without ultrasound guidance.
  • Perform a puncture aspiration of the IJV with a saline-filled syringe.
  • Use a 20- to 22-ga needle to permit passage of a guidewire through it.
  • Insert the needle at an angle of 45º to the skin surface, between the 2 heads of the sternomastoid muscle and pointing toward the ipsilateral nipple.
  • Aspiration of blood with ease confirms correct placement.
  • If blood is present but it is not aspirated with ease, then the needle is against the wall of the vein or is not fully within the lumen of the vein. Accordingly, the needle should be reinserted or manipulated gradually into the vein.

Insertion of central venous line with landmark guidance

• Guidewire passage, shown below Guidewire passage.

  • After ensuring that the needle is within the lumen of the vein, the guidewire is passed through the needle and the tip is positioned in the uppermost inferior vena cava (IVC); the wire should not be advanced into the retrohepatic vena cava.
  • Fluoroscopy or an image intensifier can be used to confirm the position of the guidewire tip.
  • Watch for ectopic beats on the ECG monitor to avoid stimulation of the sinoatrial (SA) node.
  • Placement of the guidewire tip in the IVC ensures safe manipulation while the dilator sheath is introduced. Also, the risk of cardiac perforation and tamponade is avoided.
• Introduction of dilator sheath, shown below Dilator peel-off sheath threaded over guidewire.

  • After confirming that the guidewire is positioned correctly, withdraw the needle and introduce a dilator sheath with the aid of an image intensifier to monitor correct travel of the sheath into the vein.
  • Remove the dilator sheath and, using a screwing motion, pass a peel-off sheath, ideally into the uppermost IVC or into the right atrium.
  • Remove the guidewire and trocar of the dilator sheath, and aspirate blood from the side arm to confirm positioning within the vein.
  • Flush the sheath with saline.
• Tunneling of the line, shown below Line tunneled in.

  • Make a 5-mm incision at the midpoint of an imaginary line between the nipple and humeral head.
  • An artery clip ensures dilatation for about 3-4 cm into the incision, where the line cuff will rest.
  • As the needle is introduced into the tunnel site through the incision, infiltrate local anesthetic generously along the planned tunnel track, up to the neck puncture site.
  • Introduce a tunneler to complete the tunneling up to the neck puncture.
  • Then pull the central venous line tip through from the incision into the neck puncture, to come to lie behind the peel-off sheath.
  • Determine the correct length of line required such that no looping of the line is present at the neck (see below).
• Correct length of line, shown below Line length being adjusted. Handle the line with vascular forceps only (no-touch technique).

  • Handle the line gently at all times, using vascular forceps (no-touch technique). Make sure the line is not damaged.
  • Place the line cuff about 2-3 cm from the incision entry point so that it will sit securely.
  • Using the image intensifier, align the line against the peel-off sheath to approximate the required length, and trim the excess.
  • When trimming the line, take care to ensure that it is cut without any irregularities.
• Line placement

  • This step requires good coordination between the assistant and the surgeon.
  • The assistant pulls out the trocar of the peel-off sheath when the surgeon is ready to insert the line, using 2 pairs of vascular forceps to hold the line.
  • Peel off the sheath gradually as the line is inserted, ensuring simultaneous advancement of the line as the sheath is peeled off outside the vein (ie, outside the neck incision, as depicted in the image below). Line insertion into peel-off sheath.
  • Obtain a radiograph to determine whether the final position is acceptable (in the high right atrium or at the junction of superior vena cava and right atrium, as shown below).^{[6, 7]} Radiograph showing final position of line in the right atrium.
  • Make sure the looping of the line at the neck into the vein is smooth, rather than an acute bend, to avoid line occlusion problems later on.
• Dressing/fixation of line

  • Affix the line to the skin with a nonabsorbable suture (eg, 4-0 monofilament suture), as depicted below. Line fixation with suture.
  • Leave the line undisturbed for 3 weeks under a semipermeable dressing (eg, Mepore), as shown in the image below. Mepore dressing.

Insertion of central venous line under ultrasound guidance

• Ultrasound guidance, as shown below, may help greatly in placing central venous lines safely and reliably, especially in situations in which placement may be difficult (eg, venous thromboses or multiple previous line insertions).^{[8, 9]} Ultrasound-guided internal jugular vein (IJV) puncture (arrow shows needle entering IJV). Image reproduced with permission from BMJ Publishing Group.
• A high-frequency, high-resolution probe (eg, 7-15 MHz) gives the best visualization of the venous anatomy.
• Hold the probe so as not to compress the veins but with adequate skin contact to obtain a good image, as shown below. Some preliminary training generally is needed to obtain an optimal image that shows all the relevant structures (IJV, carotid and subclavian arteries, pleura). Ultrasound of the neck showing venous anatomy: (a) internal jugular vein; (b) common carotid artery. Image reproduced with permission from BMJ Publishing Group.
• With care, the insertion of the line can be done relatively low on the neck, with the probe resting on the clavicle, to gain access to the widest part of the IJV as it joins the subclavian vein to form the innominate vein.
• Alternatively, the line insertion can be performed more easily high in the neck, directly into the IJV; however, this leaves a loop of line that is more obvious and may be more prone to kinking.
• When puncturing the skin, hold the needle at an acute angle to the ultrasound probe so that the direction of the needle travel can be visualized accurately on the screen.
• Rafael et al elaborate the methodology to employ ultrasonography for locating the IJV, underlining the safety and reliability of the technique. The authors also detail the intraoperative use of sterile ultrasonography.^[10]

• To prevent line sepsis, use a full aseptic technique, including the following:

  • Chlorhexidine preparation
  • Full draping
  • Minimal handling of the line (no-touch technique)
  • Care when using ultrasonography for guidance
• Before use, flush the line and accessory devices (dilators, wires, peel-off sheath) with saline.
• Ultrasound-guided insertion requires familiarity with the probe, image acquisition, orientation, and interpretation.
• ECG monitoring of the patient is necessary to alert the operator to the occurrence of dysrhythmias.
• Heparin flush should be used at the end of procedure and subsequently to preserve patency when the line is in infrequent use.
• Prompt recognition and treatment of line sepsis is important.

  • Especially in neonates and infants, a chronic line infection may have a subtle presentation, with increasing bilirubin, falling platelet count, and low-grade pyrexia.
  • Suspicion of line sepsis requires prompt and repeated testing for microbiology, including testing for fungi.
  • Line sepsis requires aggressive treatment with intravenous antibiotics as per institutional protocol. Early removal is advocated to avoid loss of veins.
• Avoid line placement in the following sites:

  • Damaged skin sites (eg, infection, burn, radiotherapy)
  • Mastectomy/axillary node dissection, other surgery sites
  • Pacemaker wires
  • Breast prosthesis
  • Ventriculoperitoneal (VP) shunt

Intraoperative

• Arterial puncture/catheterization
• Hematoma formation
• Air embolism
• Hemothorax
• Pneumothorax
• Chylothorax
• Misplaced line
• Multiple attempts leading to damage to adjacent structures (esophagus, trachea, recurrent laryngeal nerve, vagus nerve)
• Dysrhythmias
• Cardiac perforation/tamponade

Postoperative

• Bleeding
• Pain
• Thrombosis
• Sepsis
• Pinch-off syndrome (compression of the line between the clavicle and first rib)
• Catheter block
• Catheter fracture