Cardiovascular and Interventional Radiological Society of Europe
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ProgrammeTopic highlightsCentral venous access

Central venous access

We spoke to Dr. Elias Kehagias to find out more about venous access workshop that took place at CIRSE 2022.

The venous access workshop will cover all important aspects of central venous access regarding anatomy, indications, interventional technique, and complications.

Central venous access (CVA) is one of the most frequently performed procedures in interventional radiology and, therefore, the quality of medical care and service provided in these ostensibly easy procedures is projected onto the perception of interventional radiology as a whole by referring physicians, patients, and the public. To give an example of the enormous caseload: more than 400,000 ports are implanted per year in the USA alone. [1]

“Venous Access Devices” (VADs) include non-tunnelled and tunnelled central catheters (including peripherally inserted central catheters (PICC) and totally implantable (TI) VADs or “ports”. Arm VAD placement is a further valuable option for vascular access.

Learning objectives

  1. What are the indications for CVA placement?
  2. What are the different VAD subtypes?
  3. What is the relevant anatomy?
  4. Where should the tip of a central venous catheter lye?
  5. Which access techniques are used?
  6. What is the Rossi method of accessing the IJV, and why is it advantageous?
  7. Which techniques are used for the implantation of each VAD type?
  8. What are the most useful advanced techniques in tunnelling VADs?
  9. What are the major complications and how are they managed?


This course corresponds to chapter 2.2.1.3.7 – Central Venous Access – of the European Curriculum and Syllabus for IR.

Indications

Central venous access can be necessary to prevent a local reaction by the venous wall of smaller peripheral veins to administered substances, the necessity of high venous flow for dilution of a substance or dialysis, and finally to monitor parameters such as central venous or pulmonary arterial pressure.

Catheter types

Central venous access can be achieved by use of non-tunnelled or tunnelled devices (these can be totally implanted or not totally implanted).

Catheter types

Non-tunnelled catheters include central venous catheters, Swan-Ganz catheters (pulmonary artery catheter), acute dialysis catheters, and PICCs (peripherally inserted central catheter, usually inserted through the basilic or brachial veins). Tunnelled catheters include Hickman or Broviac catheters and tunnelled dialysis catheters. Ports are totally implanted tunnelled devices; usually in the chest, but also in the arm and elsewhere. The use of ports for dialysis has been reported.

Catheter choice

The choice between the different VADs depends on many factors, the most important being the expected duration of the central venous access and flow rates, but also factors like availability in emergency situations, familiarity with the device and relevant disease or further planned therapies (e.g. thrombosis after PICC line can limit the surgical option for brachial AV-fistula creation).

As a rule of thumb, non-tunnelled central venous catheters are indicated for a duration of up to two weeks and PICC lines are indicated for a duration of up to three months. Tunnelled catheters should be considered if the expected duration exceeds one month, or a port if the duration exceeds three months. More than one lumen is necessary when substances administered simultaneously should not be mixed, for dialysis or continuous physiologic measurements.

Insertion technique basics

For VAD insertion, strict sterility conditions and ultrasound-guided access are imperative and considered standard. Basic surgical skills are also needed. For tip positioning, the most commonly used method is fluoroscopy, but ECG tip tracking techniques are also available.

Reported technical success rates for VAD placement by an interventional radiologist are very high, ranging from 95% for PICC to 98% and 99% respectively for tunnelled catheters and ports. Acute complications are considered rare. Interventional radiological techniques allow the placement of a catheter through occluded vessels.

Complications

It is estimated that 3-10% of patients with a port at some point have a related infection, making this the most frequent indication for port removal.

Central venous catheters are a significant risk factor for central venous thrombosis. This is usually treated by therapeutic anticoagulation. If the catheter is functional, catheter removal is not absolutely necessary.

Figure 1: Schematic representation of various VADs

Figure 2: Photo of a three-lumen PICC

Figure 3: A female patient with a port implanted in the left chest, immediately after placement

Figure 4: On-table fluoroscopic image of patient with a port in Fig. 3

 

Elias Kehagias

 

University of Crete, Heraklion/GR

 

Elias Kehagias, MD, PhD, EBIR, FCIRSE is an Assistant Professor of Vascular and Interventional Radiology at the University of Crete, working in Heraklion University Hospital, Heraklion, Greece. His main areas of expertise are peripheral vascular interventions (diagnostic arterial and venous angiographies PTA and stenting, EVAR, emergency and elective embolization, central venous access), and non-vascular interventions (PTCD, ureteral stenting, image guided ablation, drainage and biopsies).

 

On the field of Vascular Access he has published two technique modifications, the “L-shaped tunnelling technique” for port placement in 2016, and the “Arm-to-Chest Tunneling technique” for arm placement of implantable ports or central catheters, in 2019.

 

Follow Dr. Kehagias on LinkedIn!

 

References

  1. Walser EM. Venous access ports: Indications, implantation technique, follow-up, and complications. CardiovascInterventRadiol. 2012;35:751–764
  2. Skolnick ML. The role of sonography in the placement and management of jugular and subclavian central venous catheters. AJR Am J Roentgenol. 1994;163:291–295
  3. Rossi UG, Rigamonti P, Tichà V, et al. Percutaneous ultrasound-guided central venous catheters: the lateral in-plane technique for internal jugular vein access. J Vasc Access. 2014;15(1):56-60
  4. Kehagias E, Tsetis D. The “L-shaped tunneling technique”: a modified technique facilitating a more discreet implantable port positioning. J Vasc Access. 2016;17(2):195-9
  5. Kehagias, E. & Tsetis, D. (2019) The “Arm-to-Chest Tunneling” technique: A modified technique for arm placement of implantable ports or central catheters. The Journal of Vascular Access. https://doi.org/10.1177/1129729819826039
  6. Lebeaux D et al. Management of infections related to totally implantable venous-access ports: challenges and perspectives. Lancet Infect Dis 2014; 14:146-159