Supraclavicular approach to the subclavian/innominate vein for large-bore central venous catheters

Review article: Feasibility of brachiocephalic vein central venous access for the resuscitation of shocked adult trauma patients: A literature review

Venous access is a key component of managing haemorrhagic shock. Obtaining intravenous access in trauma patients is challenging due to circulatory collapse in shock. This literature review examines the feasibility of direct puncture and cannulation of the brachiocephalic veins (BCVs) for intravenous access in shocked adult trauma patients. Three literature searches were conducted. OVID Medline was searched for articles on the use of the BCVs for venous access in adults and on the BCVs in shock. A third systematic search of OVID Medline, OVID Embase and Cochrane Library was conducted on the use of the BCVs for access in shocked trauma patients. After full-text review, 18 studies were selected for inclusion for the search on the use of the BCVs for access in adults. No studies met the inclusion criteria for the search on the BCVs in shock and BCV access in shocked trauma patients. The BCVs are currently used for central venous access, haemodialysis and totally implantable venous access devices (TIVADs) in adults. There is a preference for the right BCV (RBCV) over the left as the RBCV is more superficial, straighter, larger, has less anatomical variation and avoids the risk of thoracic duct puncture. The BCVs appear to be stabilised in shock by surrounding bony structures. The BCVs may provide a site for initial, rapid access in trauma resuscitation. Further research is required to determine if the BCVs collapse in shock and if venous access using the BCVs is feasible in a trauma resuscitation setting.

Success Rate and Complications of the Supraclavicular Approach for Central Venous Access: A Systematic Review

Central venous catheterization plays a key role in patients that require immediate resuscitation, long-term fluid management, and invasive monitoring. The supraclavicular (SC) and infraclavicular (IC) approaches are utilized for central venous catheterization and both have their benefits and limitations. In this systematic review, we aim to explore the success rate and various complications of the SC technique.

A literature review was conducted on the PubMed, EMBASE, Scopus, CINAHL, and Cochrane databases. All relevant original articles that evaluated success rates and complications of SC access were retrieved and included for qualitative synthesis.

After screening 1040 articles, 28 studies were included for further analysis. The overall success rate of SC access ranged between 79% and 100%. The overall complication rate in SC access ranged between 0% and 24.24% (Mean: 4.27%). The most prevalent complication was arterial puncture (1.39%) followed by catheter malposition (0.42%).

The SC approach can be used as an alternative to the IC technique because of its low access time and high success rate. The SC approach should be more commonly used in day-to-day central venous cannulation. Further studies on the role of ultrasound guidance are warranted for the SC approach.

[Central Venous Access in Children: Technique and Complications]

Children with complex diseases often need central venous catheter, not only for intraoperative use, but also for parenteral nutrition, multiple blood draw due to lab examination and to administer drugs that cannot be given via peripheral lines. Whereas the landmark driven vascular access was teached for years, nowadays the routine use of ultrasound based techniques can be called the gold standard. This article highlights standard locations for central venous access like cannulation of the internal jugular vein as well as novel alternatives such as the cannulation of the brachiocephalic vein. The correct insertion depth of central lines is essential to avoid serious complications. Several different formulas are available and can be used. Independent of the used formula, you have to make sure that complications due to incorrect depth of central venous line are a topic of the past. Finally, important tips and tricks to avoid failure and serious complications are discussed.

Which is the Easiest and Safest Technique for Central venous Access? A Retrospective Survey of more than 5,400 Cases

There is an ongoing debate on the technique for central venous catheterization associated with the lowest complication rate and the highest success rate. In an attempt to better define the easiest and safest venous approach, we have reviewed our 7-year experience with 5479 central venous percutaneous punctures (by Seldinger's technique) for the insertion of short-term (n=2109), medium/long-term (n=2627) catheters, as well as double-lumen, large-bore catheters for hemodialysis and/or hemapheresis (n=743). We have analyzed the incidence of the most frequent insertion-related complications by comparing seven different venous approaches: jugular vein, low lateral approach; jugular vein, high lateral approach; jugular vein, low axial approach; subclavian vein, infraclavicular approach; subclavian vein, supraclavicular approach; external jugular vein; femoral vein.

The results of our retrospective study suggest that the ‘low lateral’ approach to the internal jugular vein, as described by Jernigan and modified according to our protocol, appears to be the easiest and safest technique for percutaneous insertion of central venous access, being characterized by the lowest incidence of accidental arterial puncture (1.2%) and malposition (0.8%), no pneumothorax, and an extremely low rate of repeated attempts (i.e. more than two punctures before successful cannulation) (3.3%). We advocate the ‘low lateral’ approach to the internal jugular vein as first-choice technique for venipuncture in both adults and children, for both short-term and long-term central venous percutaneous cannulation.

Retained Fractured Fragment of A Central Venous Catheter: A Minimally Invasive Approach to Safe Retrieval

BACKGROUND

Complication following fracture of a central venous catheter can be catastrophic to both the patient and the attending doctor. Catheter fracture has been attributed to several factors namely prolong mechanical force acting on the catheter, and forceful removal or insertion of the catheter.

CASE DETAILS

In the present case, the fracture was suspected during the process of removal. The tip of the catheter was notably missing, and an emergency chest radiograph confirmed our diagnosis of a retained fracture of central venous catheter. The retained portion was removed by the interventional radiologist using an endovascular loop snare and delivered through a femoral vein venotomy performed by the surgeon.

CONCLUSION

Endovascular approach to retrieval of retained fractured catheters has helped tremendously to reduce associated morbidity and the need for major surgery. The role of surgery has become limited to instances of failed endovascular retrieval and in remote geographical locations devoid of such specialty.

Permanent pacing in patients without upper limb venous access: a review of current techniques

Permanent transvenous cardiac pacing is usually accomplished through the upper limb veins. When these are occluded, several other vascular access options exist which include the internal jugular, external jugular, femoral and iliac veins as well as more proximal access of the subclavian veins. Anterograde and retrograde techniques to restore subclavian venous patency has been described. A review of these approaches is undertaken, with a discussion of their pros and cons. Familiarity with these techniques will enable the implanter to perform transvenous pacing when faced with limited vascular access.

Supraclavicular approach of central venous catheter insertion in critical patients in emergency settings: Re-visited

The supraclavicular approach was first put into clinical practice in 1965 by Yoffa and is an underused method for gaining central access. It offers several advantages over the conventional infraclavicular approach to the subclavian vein. At the insertion site, the subclavian vein is closer to the skin, and the right-sided approach offers a straighter path into the subclavian vein. Also, this site is often more accessible during CPR and surgical procedures. In patients who are obese, this anatomic area is less distorted and in patient with congestive heart failure and cervical spine instability repositioning is not required.

Central venous access port devices - a pictorial review of common complications from the interventional radiology perspective

Portacaths are tunnelled and totally implanted central venous access port devices (CVAPD). They are commonly used for intravenous antibiotic delivery in patients with cystic fibrosis. More recently, they are being used in oncology to deliver chemotherapy and apheresis. It is therefore important to be aware of portacath associated complications and their imaging features. This pictorial review illustrates and discusses common complications associated with Portacath devices.

Superior vena cava clamping for brachiocephalic vein cannulation during heart surgery

A new central venous catheterization during open heart surgery is seldom required. Clamping of superior vena cava (SVC) causes adequate brachiocephalic vein distension which facilitates vein puncture. In our experience, approximately 20 s is enough for adequate brachiocephalic vein distension. I usually prefer subclavian vein puncture by supraclavicular approach. By this approach, average superior vein clamping time is about 45 s.

Upper Body Venous Access for Transvenous Lead Placement?Review of Existent Techniques

Recent developments in permanent pacemaker and implantable cardioverter-defibrillator therapy have focused on the endocardial placement sites of leads ("selective site pacing"), detection and pacing algorithms, and indications for device therapy. In comparison, the surgical and venous access aspects of device therapy have received relatively little attention. Obtaining central venous access is a prerequisite for delivering device therapy through transvenously placed leads. This article reviews the different techniques available for obtaining upper body venous access for transvenous lead placement, even though the information will also be relevant to other specialties that require central venous access for other purposes.

UNRESOLVED ISSUES IN DIALYSIS: Long-Term Management of the Tunneled Venous Catheter

Despite their propensity for significant complications, tunneled central venous catheters have become a common means of vascular access in the United States for patients requiring maintenance hemodialysis for end-stage renal disease (ESRD). Reasons for their use include advanced patient age, peripheral vascular disease (arterial and venous), late referral for creation of vascular access, and more importantly, the lack of an interdisciplinary service line on vascular access among vascular surgeons, radiologists, and nephrologists. This review article summarizes complications commonly encountered in dialysis patients who use tunneled central venous catheters for vascular access-mainly thrombosis, stenosis, and infection. Special attention is given to novel approaches for the prevention of catheter-associated infections. Effective prevention and timely treatment of common catheter-associated complications can reduce the substantial morbidity associated with the use of these devices. However, these measures should not detract from the goal of avoiding or limiting the long-term use of catheters, thereby optimizing vascular access management by ensuring the timely availability of functioning arteriovenous fistulas.

Accidental extravascular insertion of a subclavian hemodialysis catheter is signaled by nonvisualization of catheter tip

Subclavian hemodialysis (HD) catheter placement under fluoroscopy with perforation of the superior vena cava (SVC) is a rare complication that needs to be recognized and treated appropriately. We report the case of a 47-year-old black woman under treatment for end-stage renal disease secondary to HIV-associated nephropathy who sustained an extravascular insertion of fluoroscopy-guided subclavian catheterization for HD. Subsequent successful removal of the extravascularly placed catheter along with repair of the lacerated SVC were effected by open thoracic surgery.

Transthoracic cuffed hemodialysis catheters: a method for difficult hemodialysis access

BACKGROUND

Recurrent vascular access failure is a major cause of morbidity in patients receiving long-term hemodialysis. Central venous catheters are often necessary for dialysis, and easily accessed vessels (ie, the internal jugular vein and subclavian vein) frequently occlude because of repeated cannulation. When standard access sites occlude, unconventional access methods become necessary. We report a technique of placing hemodialysis catheters directly into the superior vena cava (SVC).

METHODS

Between January 2002 and December 2004, 22 patients with documented bilateral jugular and subclavian vein occlusion underwent transthoracic SVC permanent catheter placement. Femoral vein access was obtained, and a sheath was placed. Under fluoroscopic guidance, a diagnostic catheter was then inserted into the SVC, and a venogram was obtained. By using the fluoroscopic image as a reference guide, supraclavicular access directly into the SVC was performed with lateral and anteroposterior views to better localize the SVC. Once venous blood was obtained, a hydrophilic wire was passed into the inferior vena cava. A 5F sheath was then placed, and, with the use of an exchange catheter, the wire was switched for a stiffer wire. The hemodialysis catheter was then placed in the standard fashion over this wire.

RESULTS

In a 24-month period, 22 patients underwent transthoracic permanent catheter placement. All patients had the permanent catheters successfully inserted. Two major complications occurred. One patient experienced a pneumothorax, and another patient experienced a hemothorax. Both patients were successfully treated with chest tube decompression. All permanent catheters functioned immediately with a range of 1 to 7 months.

CONCLUSIONS

Transthoracic permanent catheter placement is an appropriate alternative for patients in whom traditional venous access sites are no longer available.

Lymphatic Leak Complicating Central Venous Catheter Insertion

Many of the risks associated with central venous access are well recognized. We report a case of inadvertent lymphatic disruption during the insertion of a tunneled central venous catheter in a patient with raised left and right atrial pressures and severe pulmonary hypertension, which led to significant hemodynamic instability. To our knowledge, this rare complication is previously unreported.

American Society of Diagnostic and Interventional Nephrology Section Editor: Stephen Ash: An Alternative Approach to the Central Circulation from Above the Diaphragm

This is a review of a new fluoroscopically guided safe technique to place tunneled cuffed hemodialysis (HD) catheters via the supraclavicular location. Right supraclavicular catheters were placed in 12 patients who had no patent internal jugular veins. The placements were all successful and without serious complications. Over the 2 years of follow-up, two episodes of thrombosis/stenosis (16.7%) resulted in catheter removal. The rate of infection was 8%, or one episode in 1204 patient-days. The average length of use was 111 days. The average rate of blood flow was 354 cc/min. The right supraclavicular approach for tunneled HD catheters is safe and compares favorably to the internal jugular approach for patients with limited access options.

Bedside exclusion of clinically significant recirculation volume during venovenous ECMO using conventional blood gas analyses

STUDY OBJECTIVE

To investigate prospectively whether blood gas samples drawn from extracorporeal membrane oxygenation (ECMO) cannulae help to exclude at least clinically significant recirculation volumes in patients with acute respiratory failure.

DESIGN

Feasibility study.

SETTING

Intensive care unit at a university-affiliated hospital.

PATIENTS

Ten consecutive adult patients suffering from severe respiratory failure and undergoing ECMO.

INTERVENTIONS

The drawing (venous) ECMO cannula was placed into the inferior vena cava via a femoral vein, and the oxygenated blood was returned via the right subclavian vein by supraclavicular access directly into the right atrium. Blood gas samples were obtained from both cannulae.

MEASUREMENTS AND MAIN RESULTS

The median arterial oxygen tension (PaO(2)) obtained from the arterial cannula was 537 mmHg (range, 366 to 625 mmHg), the median mixed venous oxygen tension (PvO(2)) drawn from the venous cannula was 42 mmHg (range, 25 to 54 mmHg), which was less than 10% of that observed in the arterial cannula, and also within the physiologic range of PvO(2). The ECMO flow necessary to maintain patients' oxygen saturation above 90% (4.1 L/min; range, 1.95 to 5.8 L/min) was significantly lower than the patients' cardiac output (CO; 6.2 L/min; range, 4.1 to 7.9 L/min; p < 0.001). CONSLUSIONS; We recommend obtaining blood gas samples-immediately after initiation of ECMO-from both cannulae. A PvO(2) within physiologic range and below 10% of PaO(2) rules out any clinically relevant recirculation volume.

Central venous catheter pinch-off and fracture: recognition, prevention and management

The so-called pinch-off syndrome is observed in up to 1% of all central venous catheters (CVCs), and is a valuable warning prior to fragmentation, which occurs in approximately 40% of the respective cases. As long-term indwelling CVCs are used with increasing frequency, this paper describes the necessity of pinch-off monitoring following the experiences of a case study and a review of the current literature on this specific topic in order to point out preventive practice guidelines. Besides easy preventive practices such as a high level of suspicion and adequate X-ray controls, findings give strong evidence that the most important specific factor might be the adequate approach. In our hands, the supraclavicular technique has provided the best results with regards to percutaneous introduction of large bore CVCs.

[Central venous catheterization: complications of different placements]

STUDY AIM

The aim of this prospective multicentric non-randomised trial was to report the complications of the central venous catheter insertion with different techniques and to assess the advantages of the low lateral approach to the internal jugular vein, according to the technique originally described by Jernigan et al, with our own modifications.

PATIENTS AND METHOD

From January 1993 to August 1997, 2,290 CVC (2,286 by percutaneous puncture and 4 by surgical approach) were placed. The following complications were analysed prospectively: pneumothorax, accidental arterial puncture, more than two punctures of the same vein, necessity to shift to another venous approach, complete failure, malposition of catheter.

RESULTS

The veins the most frequently used were internal jugular vein (48.7%), femoral vein (27%) and subclavian vein (24.2%). Internal jugular vein was punctured especially by low lateral approach (75%) and subclavian vein by infraclavicular approach (92%). With these two placements, the rate of pneumothorax was 0% and 3.1% respectively (p < 0.001), the rate of accidental arterial puncture was 1% and 2.7% respectively (p < 0.03) and the rate of more than two consecutive punctures was 3.1% and 6.3% respectively (p < 0.008).

CONCLUSION

On our experience, we advocate the low lateral approach to the internal jugular vein as first choice technique for venipuncture in both adults and children for both short and long-term central venous approach, because it is associated to high rate of outcome and to low rate of complications in comparison with other techniques.

Expanding our interventional skills: placement of totally implantable injection ports by internists/intensivists

Totally implantable injection ports are usually placed by surgeons or radiologists using fluoroscopic guidance. In a prospective study we evaluated the efficacy of percutaneous insertion of these devices without the use of fluoroscopic control by internists/intensivists experienced in the placement of permanent cuffed catheters. The supraclavicular approach to the subclavian vein was chosen for first line puncture site because of its low rate of malpositions and complications. 101 ports were inserted in 101 consecutive patients, 96 from the supraclavicular approach. Difficulties in introducing the catheter through the peel-away sheath, misplacement into adjacent vessels, secondary migration, or fragmentation of a line were not observed. Function was excellent in all ports. Three pneumothoraces (3%) and three arterial punctures (3%), none of which required intervention, were recorded. Two ports (2%) had to be revised, one due to local hematoma and another because of inadequate catheter length. Catheter survival was 94% in a 30-month observation period. Placement of totally implantable port systems by internists/intensivists experienced in placing central venous lines is safe and efficient, thus the implantation can easily be performed with minimal technical expenditure in the setting of an intensive care unit. The supraclavicular approach is suitable for insertion of permanent infusion port systems without fluoroscopic control.

Safe and efficient emergency transvenous ventricular pacing via the right supraclavicular route

Infraclavicular and internal jugular central venous access are techniques commonly used for temporary transvenous pacing. However, the procedure still has a considerable complication rate, with a high risk/benefit ratio because of insertion difficulties and pacemaker malfunction. To enlarge the spectrum of alternative access sites, we prospectively evaluated the right supraclavicular route to the subclavian/innominate vein for emergency ventricular pacing with a transvenous flow-directed pacemaker as a bedside procedure. For 19 mo, 17 consecutive patients with symptomatic bradycardia, cardiac arrest, or torsade de pointes requiring immediate bedside transvenous pacing were enrolled in the study. The success rate, insertional complications, pacemaker performance, and patients' outcomes were recorded. Supraclavicular venipuncture was successful in all patients, in 16 of 17 at the first attempt. Adequate ventricular pacing was achieved within 1 to 5 min (median, 2 min) after venipuncture and within 10 s to 4 min (median, 30 s) after lead insertion (</=30 s in 15 of 17 patients). The median pacing threshold was 1 mA (range, 0.7 to 2.5 mA). No procedure-related complications were recorded. Throughout the pacing period of 1538 h (median: 62 h, range, 1-280 h) two reversible malfunctions caused by inadvertent lead dislodgement after 122 and 171 h were recorded; in one patient the pacemaker had to be removed because of local infection after 14 days of pacing. We conclude that the right supraclavicular route is an easy, safe, and effective first approach for transvenous ventricular pacing and might provide a useful alternative to traditional puncture sites, even in a preclinical setting.

IMPLICATIONS

Temporary transvenous cardiac pacing can yield high complication rates especially under emergency conditions. We investigated emergency pacing via the right supraclavicular access in 17 consecutive hemodynamically compromised patients and found good safety, efficacy, and a low complication rate.

Technical aspects of central venous catheterization

Central venous access has been widely used in the treatment of different categories of patients but it is associated with a wide range of complications. Different catheters, approaches and techniques have been employed to minimize those complications related to catheter insertion as well as those related to the prolonged use of catheters. This article reviews the technical aspects of central venous catheterization and associated complications.