Central Venous Access via Tunneled Catheter

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.

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 ^{[5, 6]}
• Intravenous (IV) antibiotic and antifungal therapy
• Total parenteral nutrition (TPN)
• 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.

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).

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] :

• 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[10, 11, 12, 13, 14] :

• 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

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 used in obtaining central venous access via a tunneled catheter includes the following:

• Good ultrasound machine with linear probe
• Fluoroscopy
• Chlorhexidine (favored) or povidone-iodine solution for skin disinfection
• Heparinized saline (1000 IU heparin in 1000 mL of 0.9% saline)
• 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

Equipment for placement of tunneled line.

Lines cut to length include the following:

• 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
• 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:

• Groshong catheter - With this catheter, tunneling is performed after line positioning
• 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]
• 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
• 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

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.

Clean the skin with chlorhexidine or povidone-iodine solution from the mandible to the nipple, including the angle of the mandible, chin, and axilla, to the opposite sternal border. The authors routinely clean this area on both sides, in case occlusion or stenosis of central vessels is encountered and it proves necessary to perform the procedure on the opposite side.

Perform ultrasonography (US), with a sterile probe cover, to choose a point on the skin above the vein. Infiltrate 3-5 mL of local anesthetic, and make a small (≤ 1 cm) horizontal skin incision. Under US guidance, puncture the internal jugular vein (IJV) with an access needle (18- or 20-gauge micropuncture; see the image and video below). A lateral approach may give the catheter a smoother course, which is less likely to kink.

Ultrasound-guided vein puncture.

Advance the 0.035-in. or 0.038-in. guide wire provided in the kit. Use fluoroscopy to guide the wire into the inferior vena cava (IVC) so as to minimize the risk of arrhythmia or cardiac injury, and position the wire inferior to the junction of the IVC and the right atrium (RA). (If fluoroscopic guidance is not available, insertion can still be accomplished safely.[17, 18, 19] ) An appropriate wire course confirms that access is venous. Avoid moving the wire back and forth through the RA and the right ventricle (RV); this can trigger arrhythmias. 

Choose a skin exit site about 7.5-10 cm (3-4 in.) below the clavicle but away from breast tissue and any prominent veins (see the image below). (For fixed-length catheters whose location depends on length measurement, see the measurement step below.) Infiltrate the remaining 15 mL of local anesthetic, starting at this point and continuing along the full length of the expected tunnel.

Route of tunneled line.

Make a skin incision, and use either the metal or plastic tunneler to make a tunnel from the skin exit site on the chest to the venotomy site, ensuring that the tunneler is angled upward (see the image below).

Tunneling of line.

Attach the catheter to the tunneler, and pull it through the tract until the cuff enters the tract. To reduce the risk of infection, ensure that the cuff is at least 1-3 cm (commonly ~2 cm) from the skin exit site. Note, however, that a cuff position more than 4 cm from the skin wound may complicate eventual catheter removal.

Detach the tunneler. Cut the catheter to a suitable length, which is measured by advancing a guide wire through the jugular sheath to the superior RA or by placing the line over the chest and cutting below the right main bronchus after fluoroscopy (see the image below).

Measuring of required line length, using right bronchus as landmark.

Predilate the tract in the neck, if necessary, over the previously inserted guide wire, then introduce the peelaway sheath premounted over a dilator. Use fluoroscopy when advancing dilators to minimize the risk of atrial injury.

Ask the patient to stop breathing. Remove the inner dilator and wire, closing the opening in the sheath with a finger. (Note that some current dialysis lines come with a pneumostatic valve.) Feed the line into the peelaway sheath, and peel the sheath (see the image below). If possible, tilt the table 10º lower at the head to prevent air embolism when the line is fed into the peelaway sheath.

Line after tunneling. Peelaway sheath in situ in internal jugular vein.

The optimal position of the line tip is in the lower superior vena cava (SVC) or the upper RA, as shown in the chest radiograph at completion (see the images below).

Fluoroscopy with wire in superior vena cava.

Fluoroscopy with wire in superior vena cava.

Anchor the line with 2-0 nonabsorbable sutures, and close the skin incision in the neck with 4-0 absorbable sutures, Steri-Strips, or skin glue (2-octyl cyanoacrylate). (See the images below.)

Closure of incisions.

Tunneled line at completion.

Flush all the lumina of the lines with heparinized saline after aspirating blood (a higher heparin concentration is used for dialysis catheters).

Perform radiography of the chest to assess for proper line positioning and exclude pneumothorax (see the image below).[20]

Check chest radiograph at completion.

The retention stitch may be removed once the cuff is secured (~3-4 weeks).

Intraprocedural complications include the following:

• Pneumothorax - When IJV access is obtained under US guidance, the incidence of this complication is nearly zero
• Air embolism ^[21]  - If air embolism is suspected, turn the patient to the left and bring the right side up so as to retain the air in the RA and RV rather than let it enter the pulmonary artery, where the consequences would be worse; if air embolism leads to cardiac arrest, manage it as an acute cardiac arrest
• Persistent bleeding from the insertion site - Treatment of this complication requires compression, correction of coagulation abnormality, use of gel foam, and, rarely, surgery
• Pulmonary embolism - This complication can occur if the passage was through a thrombosed vein

Delayed complications include the following:

• The line can be malpositioned, can migrate, ^[22] and can become infected ^{[23, 24, 25, 26]} ; rarely, if the line is not anchored properly, it can fall out ^[12]
• Venous thrombosis can occur; treatment usually requires line removal and may require anticoagulation ^[27] ; some clinicians anticoagulate 1-4 days before pulling the line
• Mechanical failure can occur if the lines are damaged; repair kits exist to address this problem
• Fibrin can accumulate around the line tip like a sock, and a fibrin sheath can form, obstructing aspiration ^[28] ; this may be treated by administering tissue plasminogen activator (tPA); if tPA fails, the catheter can be exchanged over a wire
• Infection can be local (involving the tunnel) or intravascular; treatment options depend on the location and severity of the infection and include antibiotics, trading the catheter over a wire, or removing the line and placing a new line at a separate site

SVC occlusion may rarely develop; endovascular management appears to be safe and effective.[29]