Placement of Tunneled Catheter
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.
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.
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).
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).
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.
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).
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.)
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]
The retention stitch may be removed once the cuff is secured (~3-4 weeks).
Complications
Intraprocedural complications include the following:
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Pneumothorax - When IJV access is obtained under US guidance, the incidence of this complication is nearly zero
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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
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Persistent bleeding from the insertion site - Treatment of this complication requires compression, correction of coagulation abnormality, use of gel foam, and, rarely, surgery
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Pulmonary embolism - This complication can occur if the passage was through a thrombosed vein
Delayed complications include the following:
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Venous thrombosis can occur; treatment usually requires line removal and may require anticoagulation [27] ; some clinicians anticoagulate 1-4 days before pulling the line
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Mechanical failure can occur if the lines are damaged; repair kits exist to address this problem
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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
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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]
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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.
