Preprocedural Planning
It is important to confirm that the patient has no contrast allergy, has relatively normal coagulation, and has a platelet count higher than 50,000/μL. The patient should receive nothing by mouth for 4-6 hours prior to the procedure for moderate sedation.
Local practices vary regarding the administration of antibiotic prophylaxis; options include intravenous (IV) cefazolin 1 g and cefuroxime 750 mg.
Equipment
Equipment used in obtaining central venous access via a tunneled catheter includes the following:
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Good ultrasound machine with linear probe
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Fluoroscopy
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Chlorhexidine (favored) or povidone-iodine solution for skin disinfection
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Heparinized saline (1000 IU heparin in 1000 mL of 0.9% saline)
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Central line kit (see the image below), including needle, guide wire, dilators, and line; all of the tunneled lines have a polyethylene terephthalate cuff, which helps in tissue fibrosis to anchor the line to the tunnel and decrease infection risk
Lines cut to length include the following:
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Hickman catheter - This is a 9-French dual-lumen (6 + 3 or 4.5 + 4.5) catheter with or without antibiotic impregnation; it is tunneled forward, and the line is cut to the required length; this type of catheter is used for chemotherapy but works for other indications as well
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Broviac catheter - This is a 6-French single-lumen catheter (a 2.7-French version is available for neonates); it is tunneled forward and cut to length; this type of catheter is usually used for antibiotics or parenteral nutrition; transdiaphragmatic tunneled Broviac catheters appear to be cost-effective for central venous access in infants undergoing cardiac surgery [15]
Fixed-length lines include the following:
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Groshong catheter - With this catheter, tunneling is performed after line positioning
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Dialysis line - This is a dual-lumen line (10-14.5 French) that comes in fixed lengths of 28 cm, 32 cm, and 40 cm; the lumina have staggered ends and extra side holes to improve the flow; it is tunneled forward; a variation is the Ash Split Cath [16]
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Tessio catheter - This 10-French single-lumen line is tunneled backward from neck to chest after line positioning; two lines are usually inserted for dialysis
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Apheresis line - This is a 14-French dual-lumen line of fixed length, with staggered ends to each lumen for stem-cell harvesting and infusion; it is tunneled forward
Patient Preparation
Anesthesia
Local anesthesia is necessary, using lidocaine 1% or a 1:1 combination of lidocaine 1% and bupivacaine 0.25%, or else following local hospital guidelines. About 3-5 mL is infiltrated in the neck at the site of venipuncture; about 15 mL is used for the full length of the tunnel. Local anesthesia along the full length of the tract can be achieved with a spinal needle. (See Local Anesthetic Agents, Infiltrative Administration.)
Procedural sedation is optional, depending on the patient and local practices. General anesthesia is usually required for pediatric patients but is rarely necessary for adults.
Positioning
Patients should be positioned supine; the neck may be turned away from the side of vein puncture. Pillows should be avoided unless they are clearly needed.
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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.
