Central Venous Access via Tunneled Anterior Approach to 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 (IJV) 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 (IV) fluid can be administered through this catheter; other tasks, such as blood sampling, can also be performed. Passing the catheter under the skin helps secure the catheter, reduces the rate of infection, and permits free movement of the catheter port. Placement of a tunneled catheter should be carried out by practitioners with specific experience in the procedure.

Compared with femoral site access, IJV or subclavian vein access was associated with a lower risk of catheter-related bloodstream infections (CRBSIs) in some studies; however, subsequent studies found no significant differences in CRBSI rates between these three sites.[1]  Overall, the IJV is a more suitable site, especially in children, though other factors (eg, interindividual variations in vein size) must be kept in mind.[2]

Indications for a tunneled approach to the IJV include the following:

• 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 therefore require a very precise rate of delivery into the circulation (eg, cytotoxic drugs or inotropic agents)
• Patients who require long-term venous access for parenteral nutrition, chemotherapy, or long-term antibiotic prophylaxis 
• 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

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

• Severe coagulopathy
• Physical status that renders the patient 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 a small-bowel transplant), imaging of the neck veins may be necessary before the procedure.

Doppler ultrasonography (US), magnetic resonance (MR) venography, or both can be used to establish venous patency and anatomy, thus improving planning and anticipation of potential problems with access.[3]

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 preprocedural workup. Depending on the platelet count, platelet transfusion may be needed.

Materials required for the procedure include the following:

• Central venous catheter tray (line kit; see the images below)
• 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
• Polypropylene suture 4-0
• Steri-Strips
• Mepore adhesive tape

Anesthesia

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

Positioning

Trendelenburg positioning with the head turned to the side opposite the central venous line insertion is optimal (see the image below); the internal jugular vein (IJV) distends in this position, providing a maximal cross-sectional area for access.[4] The ipsilateral arm should be extended minimally at the axilla. In adults, neutral positioning of the neck has been shown to be equally safe.[5]

A 10-15º head-down (Trendelenburg) position distends the IJV and also elimimates the risk of air embolism. This dual advantage also facilitates successful venipuncture on the first attempt.[6]

The video below illustrates placement of a central line in the internal jugular vein (IJV).

The description below outlines the author's approach to this procedure.

Site preparation

Skin cleansing with 2% chlorhexidine in alcohol is recommended for skin antisepsis; it has been shown to be superior to povidone-iodine or 70% alcohol.[7]

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 (see the image below).

Locating and accessing vein

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

Evidence has suggested that US 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.[8]  Accordingly, some consider this approach the current standard of care.[9, 10, 11] The US-guided 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. With expertise, however, it is possible to place tunneled lines in neonates and infants under US guidance.[12, 13]

The IJV is located between the clavicular heads of the sternocleidomastoid. It is accessed best at the apex of the triangle the muscle heads make with the clavicle (see the image below).

The Seldinger technique is shown in the image below.

The IJV puncture may be performed with or without US guidance. Perform a puncture aspiration of the IJV with a saline-filled syringe. Use a 20- to 22-gauge needle to permit passage of a guide wire through it. Insert the needle at an angle of 45º to the skin surface, between the two heads of the sternocleidomastoid 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

After ensuring that the needle is within the lumen of the vein, pass the guide wire through the needle so that the tip is positioned in the uppermost inferior vena cava (IVC); the wire should not be advanced into the retrohepatic vena cava (see the image below).

Fluoroscopy or an image intensifier can be used to confirm the position of the guide wire tip. Watch for ectopic beats on the electrocardiography (ECG) monitor to avoid stimulation of the sinoatrial (SA) node. Placement of the guide wire tip in the IVC ensures safe manipulation while the dilator sheath is introduced. Also, the risk of cardiac perforation and tamponade is avoided.

After confirming that the guide wire 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; then, using a screwing motion, pass a peel-off sheath, ideally into the uppermost IVC or into the right atrium. Remove the guide wire and trocar of the dilator sheath, and aspirate blood from the side arm to confirm positioning within the vein. Flush the sheath with saline. (See the image below.)

Next, 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. (See the image below.)

Determine the correct length of line required so that no looping of the line is present at the neck (see the image below). 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.

Placement of the line requires good coordination between the assistant and the surgeon. When the surgeon is ready to insert the line, the assistant pulls out the trocar of the peel-off sheath, using two 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; see the image below).

Obtain a radiograph to determine whether the final position is acceptable (in the high right atrium or at the junction of the SVC and the right atrium; see the image below).[14, 15, 16]  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.

Affix the line to the skin with a nonabsorbable suture (eg, 4-0 monofilament suture; see the first image below). Leave the line undisturbed for 3 weeks under a semipermeable dressing (eg, Mepore; see the second image below).

Insertion of central venous line under ultrasound guidance

US guidance (see the images 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).[17, 18]

A high-frequency, high-resolution probe (eg, 7-15 MHz) gives the best visualization of the venous anatomy. To obtain a good image, hold the probe in such a way as to achieve adequate skin contact without compressing the veins. Some preliminary training generally is needed to obtain an optimal image that shows all the relevant structures (IJV, carotid and subclavian arteries, pleura).

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 elaborated the methodology for US-guided location of the IJV, underlining the safety and reliability of the technique; they also detailed the intraoperative use of sterile US.[19]  The utility of US as a training tool in vascular access in children was outlined in detail by Murphy et al.[20]

Pearls

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 employing US for guidance

Before use, flush the line and accessory devices (dilators, wires, peel-off sheath) with saline.

US-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

Improving catheter stay-in time

It has been shown that use of antibiotic lock enhances the longevity of the central venous catheter. As a useful adjunct strategy, a concentrated solution of antibiotic, saline, and heparin is prepared as per standard protocol, to be injected after catheter access is obtained. This can help prevent the formation of a bacterial biofilm and avert consequent infectious sequelae.[21, 22]

Another factor in prolonging the catheter stay-in time time is the position of the line tip. When the catheter tip location is at the superior vena cava (SVC)-atrial junction or in the right atrium, the dwell-in time is significantly longer than that when the tip is in the SVC. Catheter functionality is better with the above line-tip position, reducing the need for reinsertion or catheter change. The overall longevity of the catheter is thereby extended.[23]

Intraprocedural complications include the following:

• Arterial puncture/catheterization
• Hematoma formation
• Air embolism
• Hemothorax
• Pneumothorax
• Chylothorax
• Misplaced line ^[24]
• Multiple attempts leading to damage to adjacent structures (esophagus, trachea, recurrent laryngeal nerve, vagus nerve)
• Dysrhythmias
• Cardiac perforation/ tamponade

Postprocedural complications include the following:

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