Vascular access

Section: Vascular Curriculum: Curriculum, page 66, Curriculum, page 70

Key principles

• Typically for long-term venous access e.g. Chemotherapy or dialysis
• Typically use subclavian vein, however can also use IJV
• Hickmann and Port-a-cath insertion follow similar steps, however, a port-a-cath has a port placed in a subcutaneous pocket which can be accessed via a Huber needle

Operation Details

• Typically performed under GA. IV Cephazolin
• Prep and drape
• Flush all device used with heparinised saline heparinised saline (10 units/mL) - place 5000U into a 500ml bag of NaCl

Subclavian

• Patient supine with a roll beneath shoulder blades.
• Head up neck turned to contralateral side
• Identify landmark- junction of outer 1/3 and middle 1/3 clavicle
• Cannulation of the SCV using a Seldinger tecnhque, needle towards opposite shoulder, walk down under clavicle, bevel downwards and advance until flashback
• Place guidewire placed watching for ventricular ectopics under II guidance
• Remove needle
• Small skin incision
• Advance dilator over wire
• Remove dilator
• Advance catheter over guidewire
  • Usally 15cm on right and 20cm on left
  • Check position with XR
• Secure catheter and place sterile dressing

Internal jugular vein

• Anatomical landmarks
  • Internal jugular vein lies lateral to carotid artery, within the carotid sheath
  • Right IJV preferred (straighter path to SVC, lower risk of thoracic duct injury)
  • Common landmark: apex of triangle formed by the sternal and clavicular heads of sternocleidomastoid (SCM), just above the clavicle
  • Needle directed caudally, slightly laterally, and posteriorly toward ipsilateral nipple
• Steps
  • Patient supine in 15–20° Trendelenburg (reduces air embolism, distends vein)
  • Turn head slightly to the contralateral side
  • Sterile prep and drape; local anaesthetic infiltration at puncture site
  • Use either landmark technique or ultrasound guidance (preferred)
  • Insert introducer needle at apex of triangle, lateral to carotid pulsation
  • Advance with aspiration until dark venous blood is aspirated
  • Insert guidewire through needle
  • Remove needle, make small skin incision
  • Advance dilator over guidewire, dilate soft tissue
  • Remove dilator, pass catheter over wire to appropriate depth (usually ~15 cm)
  • Remove guidewire, aspirate and flush catheter ports
  • Secure catheter with sutures, apply sterile dressing
  • Confirm position and rule out complications with chest X-ray

Hickman line insertion

• Vein cannulation
  • As above - either IJV or SV, typically IJV
  • Canulation → guidewire → dilate
  • Insert peel-away sheath over guidewire
• Exit site
  • Usually 5–10 cm below clavicle)
  • Create a subcutaneous tunnel from the exit site to the cannulation site
  • Use tunnelling device to pull catheter through the tunnel and out the first cannulation site
  • Ensure cuff lies in the tunnel ~2 cm from exit site
    • Dacron cuff to allow tissue ingrowth
  • Advance catheter through peel-away sheath into SVC (tip at cavoatrial junction)
  • Remove sheath, confirm catheter flow and flush all lumens
  • Secure at skin with sutures or securement device
  • Apply sterile dressing
  • Chest X-ray to confirm tip position and exclude pneumothorax

https://www.youtube.com/watch?v=PvQXthhhl7I&ab_channel=VascularAccess

Port-a-Cath insertion

• This is the same process as above with a similar second incision 5-10cm inferior to the clavicle
• Steps
  • Venous access
    • As above
  • Pocket is created
    • Pocket is created on the chest wall, exposing the pectoral fascia.
    • Subcutaneous tunnel created
    • Catheter passed to venous access site and placed via the peel-away sheeth
  • Port fixation
    • The infusion port is fixed to chest wall by placing sutures that pass through the flanges of the port onto the fascia of the chest wall in 4 places to ensure that the port will not flip.
• The skin is closed
• Port accessed and locked with heparinized saline

Intraoperative complications & challenges

• Arterial cannulation or unable to cannulate SCV o Try contralateral side o Try IJV o Convert to cephalic vein cut down to place port

Post-operative complications

• Immediate o Pneumothorax – 1-3% - may need chest drain o Air embolism – administer high flow O2 o Bleeding o Arrhythmia o Rarely pericardial tamponade • Early o Infection o AV fistula • Late o Catheter migration o Thrombosis o Line sepsis o Fracture o Failure

Specific post-operative care

• CXR in recovery • Access as required

https://www.youtube.com/watch?v=-jWMYh0Y6gg&t=17s&ab_channel=IREducation