Background
Long-term venous access is of critical importance to a wide group of patients. Such access is obtained by inserting tunneled central lines via the internal jugular vein (IJV) or the subclavian vein, either surgically or percutaneously. [1] Combined use of ultrasonographically guided vein puncture and fluoroscopy has significantly reduced the complications related to insertion. [2] This article gives a step-by-step guide to performing radiologic insertion of a tunneled venous line via IJV access. [3, 4]
For more information on central venous access, see Central Venous Access via Infraclavicular (Subclavian/Subclavicular) Approach to Subclavian Vein, Central 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.
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:
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Chemotherapy and bone marrow transplant (BMT)
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Plasmapheresis and leukapheresis
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Intravenous (IV) antibiotic and antifungal therapy
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Total parenteral nutrition (TPN)
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Pain management (rarely)
A meta-analysis of 17 studies (12 single-arm and five comparative) by Hon et al examined the incidence of catheter-related bloodstream infections (CRBSIs) with tunneled central venous catheters (TCVCs) and with peripherally inserted central catheters (PICCs) in adults receiving home parenteral nutrition (HPN). [7] In the comparative studies, CRBSI rates were lower with PICCs than with TCVCs; however, in the single-arm studies, CRBSI rates were comparable for the two device types.
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, one should wait for sepsis to settle.
Relative contraindications include local cellulitis (in which case one should use the opposite side or tunnel away from the area) and low platelet counts or deranged coagulation (in which case one should correct platelets and coagulation to acceptable levels before performing the procedure).
Technical Considerations
Procedural planning
IJV access is preferable to subclavian vein access because the IJV is easier to visualize with ultrasonography (US), 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. [8]
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.
Complication prevention
To prevent air embolism, a tilting table should be used to lower the patient's head before the line is inserted. If no tilting table is available, the patient should be asked 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 [9] :
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Direct puncture of the previous catheter's venous lumen for guide-wire insertion, as opposed to guide-wire introduction after the catheter is cut
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Light manual compression of the IJV venotomy site after catheter removal
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Valsalva maneuver (in cooperative patients)
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Valved introducers
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Correction of hypovolemia
Evidence indicates that the following measures can help prevent catheter infection [10, 11, 12, 13, 14] :
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Use of fully aseptic insertion technique
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Immediate removal of the line if infection is suspected
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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:
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Prophylactic use of IV or oral antibiotics at the time of insertion
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Use of lines impregnated with antibiotics, antiseptics, or silver
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Routine line replacement
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Ultrasound-guided vein puncture.
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Transverse ultrasonography of neck shows anterolateral relation of internal jugular vein to carotid artery and illustrates compressibility of vein.
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Ultrasound-guided vein puncture.
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Route of tunneled line.
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Fluoroscopy with wire in superior vena cava.
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Fluoroscopy with wire in superior vena cava.
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Measuring of required line length, using right bronchus as landmark.
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Tunneling of line.
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Line after tunneling. Peelaway sheath in situ in internal jugular vein.
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Tunneled line at completion.
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Check chest radiograph at completion.
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Closure of incisions.
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Equipment for placement of tunneled line.
