Procedure Guides
Venous

Central Venous Access

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Procedure Guide

Indications

  • Cytotoxic chemotherapy or long-term antibiotic therapy

  • Hemodialysis

  • Choice by length of access: generally (<14d) PIV > PICC, (15-29d) PICC, (>30d) PICC, TDC, ports

    • Polyurethane catheters are less prone to infection than silicone but higher cost and can’t use alcohol locking. “Locking” a catheter refers to injecting a limited amount of something into it to fill the lumen(s) and prevent clotting or colonization while not in use. The amount to inject is catheter specific and sometimes written on the catheter clamp. Protocols vary across institution. Common locking includes saline, heparin, and t-PA.

    • Catheter naming is sloppy with multiple names for the same thing and some common catheters referred to by brand name, e.g., Vortex port, Hickman

    • Infusaport = port-a-cath = i-port  =  mediport = chest-port = chemo-port

    • Tunneled cath = perm-cath = perma-cath

    • Groshong catheters: often PICC, has pressure mediated valve on side of tip to prevent backflow of blood and thrombosis so can avoid heparin lock

    • Broviac: floppy, wimpy catheter prone to fracture and hard to place, used in most often in pediatrics

    • Hickman: brand of popular central venous catheter which can be power injectable or not

    • Quinton Permcath: brand of popular long term hemodialysis catheter

    • Tesio: brand of popular pediatric hemodialysis catheter

    • Vortex port (AngioDynamics): good for high flow apheresis and RBC exchange, 9.6 Fr catheter, rounded hub reducing dead space and turbulent flow

    • “Power” port, PICC, etc is Bard branding not a specific type of catheter

    • Not all catheters are “power injectable” for diagnostic imaging. Newer catheters are labeled to indicate which ports are power injectable but not all.

Contraindications

None for non-tunneled CVC

Bacteremia - often need at least 48 hrs from last negative blood culture, can place TDC and treat through it but generally not recommended

Uncorrected coagulopathy (INR >1.7, Plt <50K)

Pre-procedure care

  • Obtain history of prior venous access, venous disease, bleeding disorders, AV fistulae or grafts, and obstructing masses to plan access. Good form to confirm new TDC access site with nephrology.

  • Ask patient preference for side/site, e.g., the patient may have a hobby where a right sided port or TDC would be in the way but left sided access would not.

  • Meds: hold coumadin/Plavix 5d, lovenox 1d. No need to hold ASA/NSAID

  • Labs: Coags and CBC

  • Technically SIR guidelines recommend pre-op abx only for TDC, not ports but many use Ancef for ports

Procedure

Tunneled Central Venous Catheter Placement Procedure:

  • US to identify suitable vein (IJ > BC > axillary/subclavian) -> access w/ 21G micropuncture kit w/ lateral approach behind SCM muscle just superior to junction with the subclavian

    • Advanced access techniques: Kesselman at Stanford advances a balloon as far as possible in the brachiocephalic and accesses the balloon.

    • Alternative is Surfacer device to puncture from inside out

  • Thread microwire and switch needle for 5Fr sheath

  • Can use microwire to measure intravascular intravascular length. 

    • TDCs: Most commonly 19 or 23 cm tip to cuff on the right and 27 cm on the left for TDC. Be sure to subtract access sheath hub length when measuring (~2.5-3.5 cm).

  • Establish stable access with Bentson/Amplatz into the IVC. Can place flowswitch over wire to hold in place or just a towel.

  • Choose a pocket/tunnel site, often 3 finger widths below the clavicle and halfway between sternum and axillary. Make dermatotomy just big enough for cuff pointing scalpel tip cephalad

  • Anesthetize track (can use micropuncture set needle for length). 

  • Tunneled catheter to venotomy site.

  • Advance peel away sheath under fluoroscopic guidance.

  • Remove wire and place tunneled catheter into peel away sheath. Check length and adjust as necessary. Crack sheath and peel away while threading catheter.

  • Note whether the sheath has a valve or not. Good practice to keep a thumb over it just in case.

  • Confirm desired catheter tip location (right atrium for ports and TDCs).

  • Check flow and local with heparin or saline. Suture in place. Dress. Close venotomy site with Dermabond.

Tunneled Central Venous Catheter Removal Procedure:

  • Place supine or reverse Trendelenburg. Prep and drape area.

  • Anesthetize around the catheter exit site and around the cuff. Don’t be stingy and use to hydrodissection around the embedded cuff.

  • Blunt dissect around the cuff, pulling with constraint traction until the cuff is free.

  • Remove during exhalation to avoid air embolism.

Port Placement Procedure:

  • Identify accessible vein for access (IJ > BC > axillary/subclavian)

  • Prep and drape with area large enough for making the pocket and tunneling

  • Anesthetize skin/subQ -> access the vein with a micropuncture set. 

    • Ideally position probe perpendicular to access the true IJ rather than parallel with clavicle with tendency to access the IJ-subclavian junction. Long-term access can damage the vein and stenosis at the junction is very difficult to treat.

    • Ideally approach under the sternocleidomastoid for comfort and comesis.

  • (Lots of variation in order of next steps) Exchange micropuncture needle for transition sheath.

  • Use microwire to measure intravascular length and remove. Advance working wire (e.g. in kit or Amplatz) into the IVC. Can place flowswitch over wire to hold in place or just a towel.

    • Can measure intravascular length by clamping with tip in ideal place and subtracting length of the hub (~2.5-3.0 cm) OR clamp with tip in ideal place and second clamp with tip at venotomy to use length between the two clamps.

    • It’s better to be a little long than short and some recommend measuring to be 1-2 cm longer than intended position in supine positioning because the mediastinum will lengthen and chest wall tissue will drop when the patient is upright.

  • Make the port pocket ideally 2-3 finger widths below the mid clavicle. Avoid placement too close to the deltopectoral groove and breast tissue as the redundancy will cause hypermobility and kinking.

  • Usually a 2-3 cm incision is needed. Anesthetize skin with lidocaine and subQ with lidocaine + epinephrine. Can fan out from both sides of the planned incision while anesthetizing to numb the planned pocket area.

    • Some make the pocket below the incision while others make it above to be able to cut down on the port during removal without risk of cutting the catheter. Neither is right or wrong, just need to plan incision accordingly.

  • Make a clean incision to the subQ with a #15 blade.

  • Use curved clamps and finger to make the pocket trying to stay parallel to the chest wall with sufficient overlying tissue.

  • Anesthetize planned tunnel. Can use micropuncture needle for longer reach and less puncture sites. Some tunnel in straight line vs gentle curve to venotomy site.

  • Tunneled the catheter. 

    • Some tunneled assembled port others tunnel just the catheter and then assemble and flush

    • If incision is below the pocket, important to put your finger in the pocket and pass the tunneler along the deep aspect of your finger to ensure the catheter leaves the superior pocket at the same plane that the port will lie.

  • (Optional) Suture port to chest wall. Done more often in pediatric due to more mobile tissues.

  • (Optional) Some fluoro to check that port hub is projected over a rib when in the pocket.

  • (Optional) Some double check catheter measurement prior to cutting after tunneling with port in the pocket by clamping at the measured length, lying the catheter across the chest simulating how it will lie intravascularly, and checking with fluoro.

  • Cut catheter and document length.

  • Exchange transition dilator/sheath for peel-away sheath and advance catheter through. Some recheck catheter length with fluoro prior to breaking the peel-away.

  • Break and remove the peel-away.

    • Some make the two sides flush with the skin pulling opposite directions. Others feel this widens the venotomy and pulls peel-away halves together with one hand away from the patient using a finger from the other hand to keep forward pressure on the catheter, splitting the peel-away.

  • Check and document final positioning.

  • Close access sites. Most just use dermabond and steri-strips at venotomy site and 3-0 deep dermal +/- 4-0 running subQ and dermabond and steri-strips.

  • Troubleshooting

    • Catheter flips into brachiocephalic/azygous/etc at end -> can disconnect catheter from port and use a stiff glidewire to redirect the catheter but reassembling the port can be very challenging

    • Catheter is too short or too long -> can use similar approach to above and either cut some off or exchange for new long catheter over a stiff glidewire and reassemble

Port Removal Procedure:

  • Most get spot film to document original positioning

  • Anesthetize skin for incision with 1% lidocaine and pocket with 1% lidocaine with epinephrine. Don’t be stingy fanning out around port hub and using the lidocaine to dissect away from chest wall.

  • If hypertrophic scar or keloid, can make ellipsoid incision to cut out the scar tissue.

  • Blunt dissection as much as possible using curved clamps +/- scissors. Rubbing with gauze is also great for dissection.

  • Isolate catheter and remove holding pressure at venotomy.

    • Tricks if the catheter is scarred in/stuck -  place glidewire through to secure access in case it breaks and pull harder. Can place 018 wire through catheter and a small ~3-4 mm balloon to dilate tract within the catheter, often issue is at venotomy. Can also get femoral access and use a snare or balloon to disrupt fibrin sheath or remove stuck/fractured intravascular component.

  • Dissect out port hub. Can be done before or after catheter removal. *Note* may need to cut and remove non absorbable sutures that some use to secure the hub to the chest wall.

  • Close incision as above

Malfunctioning Catheter Troubleshooting

  • Check catheter position on chest radiograph. If malpositioned, can use pigtail or snare to reposition tip. Otherwise, exchange and possible revision.

  • Fill catheter with 1-2 mg tPA and leave to dwell for 30-60 min. Repeat if first attempt is unsuccessful.

  • Contrast study under fluoroscopy. Often due to fibrin sheath, which can be stripped with a snare, disrupted with a balloon, or avoided by exchanging the catheter redirecting the wire outside the fibrin sheath.

Complications

  • Immediate: pneumothorax (<2%), air embolism (<2%), malpositioning (<1%), bleeding, injury to surrounding tissue (e.g. thoracic duct, nerves)

  • Delayed: malfunction (10-20%), venous thrombosis (5-15%), infection (5-10%), catheter fracture (<1%)

Post-procedure care

Can use immediately. 

Sutures for TDC can be removed after a couple weeks if painful as the cuff will keep it in place.

Keep port incision dressing in place, e.g., steri strips until they fall off in the shower in a few days or can remove if still in place after 1 week.

Avoid submerging in water until skin healed for port incisions and the entire time the tunneled line is in place.

Catheter-related infections (2009 IDSA Guidelines)

  • For suspected catheter-related blood stream infection (CRBSI), obtain peripheral blood culture + blood culture from catheter

  • Perform catheter tip culture if removed for suspected CRBSI plus swab of any purulent discharge from catheter site

  • Short-term CVC or arterial catheter (AC)

    • Cultures neg but no other source of fever identified -> CVC removal should be considered

    • Cultures neg but at least 15 CFU growth from catheter -> treat 5-7d for S aureus, monitor for other microbes

    • Seriously ill (shock) -> remove catheter

    • Uncomplicated CRBSI (resolves w/in 72 hrs, no intravascular hardware, endocarditis, suppurative thrombophlebitis; no active malignancy or immunosuppression for S. aureus)

      • Coag neg Staph -> remove and tx 5-7d OR tx w/ antibiotic lock 10-14d

      • S. aureus -> remove and tx at least 2wks

      • Enterococcus or Gram neg bacilli -> remove and tx 1-2wks

      • Candida spp -> remove and tx 14d after 1st negative blood culture

    • Complicated CRBSI -> remove catheter and tx 4-6wks (6-8wks for osteomyelitis)

  • Long-term CVC or port

    • Uncomplicated CRBSI 

      • Coag neg Staph -> retain and tx + abx lock for 10-14d OR remove if any deterioration

      • S. aureus -> remove and tx 4-6wks OR shorter therapy if no diabetes, immunosuppression, no intravascular device, endocarditis, suppurative thrombophlebitis, and fever/bacteremia resolve in 72 hrs

      • Enterococcus -> retain and tx + abx lock for 10-14d OR remove if any deterioration

      • Gram neg bacilli -> remove and tx 7-14d OR use abx lock for 10-14d and remove if no response

      • Candida spp -> remove and tx 14d after 1st negative blood culture

    • Complicated CRBSI

      • Septic thrombosis, endocarditis, osteo -> remove and tx 4-6wks (6-8wks for osteomyelitis)

      • Tunnel infection or port abscess -> remove and tx 7-10d

  • Tunneled HD catheter -> empiric abx + abx lock

    • Resolution in 2-3d

      • Coag neg Staph or Gram neg bacilli -> retain and tx + abx lock for 10-14d OR exchange over wire

      • S. aureus -> remove and tx 3wks if TEE is negative

      • Candida spp -> exchange over wire + tx 14d after 1st negative blood culture

    • Persistent bacteremia/fungemia -> remove, tx 4-6wks, look for metastatic infections (CT chest and TEE)

KDOQI 2019 Guideline Update

  • Patients with progressive CKD, eGFR 15-20, or on kidney replacement therapy should have individualized ESKD life plan that is regularly reviewed, updated, and documented in the medical record

  • Indications for short-term non-tunneled HD catheter - limited circumstances where the indications below will resolve within 2 weeks

  • Indications for short-term TDC

    • AVF/AVG created awaiting maturation

    • Acute transplant rejection

    • PD patient with complication awaiting resolution

    • Living donor confirmed awaiting transplant

    • AVF/AVG complication requiring prolonged nonuse

  • Indications for long-term TDC

    • Multiple failure AV accesses with no available options or absence of AV access creation options

    • Valid patient preference where AV access would substantially compromise their life plan

    • Limited life expectancy

  • If placing CVC with anticipated use >3mo and no AV access use, right is preferred to left with the following sites

    • IJ  > EJ > Femoral > Subclavian > Lumbar

  • AVF/AVG generally preferred over TDC due to less infections and AVF over AVG

    • Anticipated limited duration (<1 year) -> consider forearm loop AVG or brachiocephalic AVF if high likelihood of unassisted maturation

    • Generally UE > LE or HeRO graft

    • Whole arm exercise can be used to facilitate AVF maturation. Does NOT recommend medication to assist maturation or prevent failure such as heparin or clopidogrel

    • Rope ladder cannulation preferred over button hole

  • For PD, recommend placement at least  2 wks prior to use when possible

  • Vessel preservation by avoiding PICCs and unnecessary venipunctures

  • CVC Dysfunction:

    • Recommends low-concentration citrate (<5%) or heparin locking as well as tPA locking once per week.

    • ASA may be used to maintain patency in patients with low bleeding risk

    • Thrombus/fibrin sheath - recommends trialing tPA + 4% citrate per limb -> exchange with fibrin sheath disruption -> new site as last resort

    • CRBSI (infection) - ppx antibiotic lock if high risk for prevention -> individualized approach re treating through, exchange, removal, etc