The internal jugular vein (IJV) was first described by English in the 1960s and is the most frequently used approach for CVC insertion; it causes less complications, has a straight course to the RA, and has lower chance for thoracic duct and pleural dome puncture, both due to anatomic properties of right IJV, although some have claimed that the left IJV approach is as much easy. It also has a very high success rate (>90 %) even in infants and children accompanied with very low rate of other mechanical complications like arterial puncture, pneumothorax, and hematoma needing surgical intervention compared with all the other methods. Even in anatomically “difficult” patients, the IJV approach has a specific feasibility. The course of IJV especially the right one is straight, short, and with distinct anatomical landmarks; it is without venous valves until superior vena cava and right atrium and could be reached by most anesthesiologist even during the operation time. Its most common and easiest “central approach” described in 1970 by Daily et al. is even the simplest one among all the right IJV access methods in which the needle tip is inserted into the “apex of Sedillot’s triangle, which is between the sternal and clavicular heads of sternocleidomastoid (SCM) and the related portion of the clavicle located between the two SCM muscle heads.” See Fig. 4.3.

Correct sizing of the catheter length is a very challenging issue.

The following steps should be followed for insertion of CVC through right IJV:

The technique is similar to right IJV; however, the dome of the left pleura is higher than the right pleura, and also, thoracic duct passes from the left; these two anatomic features increase the risk for two important complication: pneumothorax and chylothorax. Chylothorax is exclusive to the left hemithorax. The LIJV is shorter than the right IJV, but the venous path from the left side to superior vena cava is longer than the right side. However, the chance for superior vena cava injury in left IJV is higher than right IJV since the path of right IJV is straightforward compared with left IJV.

This approach has some specific features, more patient comfort, an easy approach, and lower infection rate and often used for long-term IV therapy but not monitoring purposes.

A simple, really less risky approach, though having lower chance for success; of course, there are a few concerns for this approach:

Usually used when IJV or subclavian approaches are not available (e.g., in neck injuries or thoracic involvements). The femoral vein is entered in a place just medial to the femoral artery pulse; however, the needle should be introduced to the vein distal to the inguinal ligament to prevent the risk of retroperitoneal bleeding. Besides, femoral artery or femoral nerve injury, infectious complications, and thromboembolic complications are the main other potential complications of this approach. Two different length catheters have been used in this approach: “40–70 cm” and “15–20 cm” catheters; both are near to the SVC measurement but not exactly the same figures.

Peripherally inserted catheters as CVC have been used to decrease complications of CVC; but there is no difference between the two methods regarding infection rate. However, peripheral CVCs have more complications like “catheter tip malpositioning, thrombophlebitis, and catheter dysfunction”; hence, central CVCs seem to be preferred over peripheral catheters.

These include mainly vascular injuries (arterial puncture, venous injuries), cardiac tamponade, neural injury, tissue trauma, pneumothorax, and catheter or guidewire embolization. Vascular injuries could be arterial or venous.

Arterial puncture is the most frequent among all acute complications, often resulting in local hematoma, which usually resolves after a few minutes of local compression. Few numbers of the patients (especially when major arteries including aorta are injured) need more sophisticated care including emergent consult with a vascular surgeon. If arterial puncture is unintentionally used instead of central vein for catheter placement, the catheter should be removed urgently (except for very unusual circumstances) to prevent unwanted organ embolizations including CNS injuries. However, the risk of arterial bleeding at the puncture site is always potentially serious, needing more vigorous assessments and possible interventions by a vascular surgeon. If a central venous catheter is misplaced anatomically, the location of the catheter tip should be assessed. If it is not in a potentially risky place, we might withdraw the catheter; however, if the catheter tip is located in a risky organ which could not be compressed after catheter removal, or if the course of catheter passes through such an anatomic location, then the catheter should not be removed before an emergent consult with a vascular surgeon.

Other vascular injuries are frequent and diverse including minor venous injuries, hemomediastinum, hydromediastinum, hemothorax, hydrothorax, and chylothorax. And finally, delayed vascular injuries have been reported including different types of fistula between veins, arteries, bronchus, or other adjacent tissues, all being rare but needing vigorous attention and care.

Hemopericardium is the 2nd common and the most lethal complication of CVC placement. It is usually due to perforation of right ventricle, right atrium, or the segment of superior vena cava located inside the pericardium. The rupture would cause sudden cardiac tamponade blood or fluid tamponade. This is a delayed complication of CVC occurring usually in the 1st week after CVC placement and is usually preceded by arrhythmia unresponsive to anti-arrhythmia treatments. Mortality rates more than 80 % are reported for this complication. Would the clinician perform objective documentation of the CVC tip location (i.e., by CXR), this lethal complication could be prevented in many cases.

Pneumothorax is another mechanical complication occurring more commonly after subclavian approach; however, the IJV approach (especially the left IJV) could also lead to pneumothorax though with a lower rate compared with subclavian approach. Minor cases are treated with supportive care, while others need chest tube insertion. Vigorous care should be devoted to high-risk patients especially those underlying mechanical ventilation or those in whom multiple or bilateral punctures have been done to prevent the occurrence of tension pneumothorax which is very lethal.

Nerve injuries could be seen mainly at the following sites: brachial plexus, stellate ganglion, and phrenic nerve. Chronic pain syndromes are also possible.

Tissue Trauma: Trauma due to needle, guidewire, dilator, or even the catheter had been reported. Dilator-induced tissue or vascular injuries are much more important since the dilators usually cause more harmful injuries than other items used in CVC kits. However, large-bore lumen catheters could lead to tissue injuries; catastrophic results should be anticipated if central vessels or cardiac chambers are injured or, in worst conditions, “ruptured” (see above).

Catheter or guidewire embolization usually mandates emergent consultation with an interventionist or a surgeon. During CVC placement, guidewire could be introduced inside the venous system unintentionally, so it is necessary that the clinician take control of the distal end of the guidewire before introducing the whole catheter into the venous system. Also, there are reports of partial catheter fracture; both of these states could lead to catheter or guidewire embolization into the venous system, cardiac chambers, or even the pulmonary veins, being dislodged in between the lung tissues. The medical team should check any catheter fractures continually in patients admitted in intensive care wards, especially when the patients are awake and there is the possibility for spontaneous changes in body position. Another critical time for occurrence of this complication is at the time of CVC removal, which mandates careful examination of the whole CVC length, and check for its tip to be intact after withdrawing from the patient.

These complications are more common in patients with femoral CVC and are lowest in subclavian approach. The primary nidus can change to an infectious complication or may dislodge to the pulmonary vasculature; usually these complications need surgical removal.

Infectious complications are among the most common late complication of CVC, with 30–50 % mortality. Strict adherence to aseptic techniques during catheter placement is cornerstone of all preventing strategies for CVC infection. Using subclavian approach, application of catheters coated with chlorhexidine and silver sulfadiazine or rifampin and minocycline, and selection of single-use catheters have been demonstrated as methods to decrease the rate of CVC-related infection. Also, the site of catheter insertion could affect the incidence of infectious complications being less in subclavian approach than other routes, though some controversies exist.

Arrhythmia is a very frequent and usually benign complication during CVC insertion especially in Seldinger technique (due to the guidewire); however, there are reported cases of malignant arrhythmias exactly at the time of CVC insertion, so careful attention to patient’s rhythm and hemodynamic status is a main concern during CVC insertion. However, the catheter itself could induce arrhythmias due to its physical effects if not in an appropriate location, which could happen intra- or postoperatively. Careful attention in the length of catheter entry is very important. Also, objective catheter tip confirmation by CXR is an essential job, confirming the CVC tip above the carina bifurcation; otherwise, the catheter should be a bit withdrawn in such a way that its tip is not far beyond carina.

Bleeding and air emboli are often related to CVCs with large-bore lumens, though other types of CVC may also have this side effect. Forgetting to secure the lumen ports could result in unnoticed bleeding. If the patient is hypovolemic, this complication would be manifested as air emboli entering the central venous circulation through the nonsecured lumen. Air embolism is also possible during two other situations besides unnoticed nonsecure ports; one is during catheter insertion, which is usually accompanied with small volumes of air going through the needle to the venous system, while the other situation is after CVC withdrawal which could be accompanied with air embolization through the skin lumen and subcutaneous tunnel created by after catheter removal. A compressed dressing with proper sealing could prevent both potential air embolism and CVC site bleeding after CVC removal.

Misinterpretation of data and errors in interpretation of data could lead to erroneous results and potential untoward clinical outcomes. For prevention of such erroneous judgments, the clinicians often do not rely only on the results of central venous pressure recordings; instead, the trend of CVP changes, curve of CVP, other measurements of filling pressures, jugular venous pressure figures, etc., are added to the online readings of CVP to prevent such unwanted events (Daily et al. 1970; Knopp and Dailey 1977; Berghella et al. 1979; Tyden 1982; Ferguson et al. 1988; Siradovic et al. 1988; Holmes et al. 1989; Kolodzik 1989; Meyer 1990; Heiss 1992; Mansfield et al. 1994; Tesio et al. 1994; English et al. 1995; Reed et al. 1995; Kuhn 2001; Merrer et al. 2001; Asheim et al. 2002; Keenan 2002; Woodrow 2002; Hind et al. 2003; Unal et al. 2003; Arai and Yamashita 2005; Botha et al. 2006; Di Iorio et al. 2006; Karakitsos et al. 2006; Ash 2007; Chen et al. 2007; Harrigan et al. 2007; Trieschmann et al. 2008; Brusasco et al. 2009; Kujur et al. 2009; Surov et al. 2009; Ishizuka et al. 2010; Kunizawa et al. 2010a, b; Omar et al. 2010; Furuya et al. 2011; Kang et al. 2011; Kim et al. 2011, 2012; McGee et al. 2011; Uchida et al. 2011; Urban et al. 2011; Boyce 2012; Calabria et al. 2012; Chopra et al. 2012; Ge et al. 2012; Godoy et al. 2012; Guleri et al. 2012; Hewlett and Rupp 2012; Lee and Kamphuisen 2012; Liang et al. 2012; Linnemann and Lindhoff-Last 2012; Marik et al. 2012; Miller and Maragakis 2012; Parienti et al. 2012; Pikwer et al. 2012; Reems and Aumann 2012; Stone et al. 2012; Turi et al. 2013; Vats 2012; Walser 2012; Zhou et al. 2012; Gibson and Bodenham 2013).