After the patient is positioned, the left and right internal jugular veins should be evaluated for patency using the ultrasound. A patent internal jugular vein appears to be a large, echolucent vessel that completely compresses when gentle pressure is applied through the ultrasound probe. The neck and infraclavicular area should then be prepped with chlorhexidine and draped using sterile technique.

The following describes a micropuncture technique; however, using the larger caliber needle provided in most central line kits is also acceptable. When the vein has been localized with ultrasound, the long axis of the probe is placed against the superior portion of the clavicle (Fig. 17.3a) with the image of the internal jugular vein centered on the monitor. Under ultrasound guidance, the area is infiltrated with lidocaine before puncturing the skin with a 21-gauge needle. The angle of puncture is important when using ultrasound guidance. The needle should be almost parallel to the probe, angled only a few degrees from vertical. This permits the tip of the needle to be visualized along its course from skin entry to venipuncture (Fig. 17.3b). The needle is exchanged over a 0.018-in. guidewire for the coaxial 3-French (F) and 5-F micropuncture sheath. The 0.018-in. wire and 3-F dilator are removed from the 5-F micropuncture sheath, and a 0.035-in. wire is inserted with the tip in the SVC. The 5-F sheath is then removed over the guidewire, and a dilator is inserted to dilate the skin track. The non-tunneled central venous catheter is placed over the guidewire and advanced into the SVC. The guidewire is removed and the catheter secured. All of the catheter lumen should be flushed, and the catheter may be locked with dilute heparinized saline depending on individual hospital protocol. A chest x-ray should be performed to confirm catheter tip location and evaluate for pneumothorax or hemothorax. Procedures performed with ultrasound guidance and under fluoroscopy do not usually require a final chest x-ray.

Single- or dual-lumen implantable ports are best suited for patients who require intermittent vascular access over a long period of time. Preparation and positioning are the same as described for central venous line placement. The long axis of the ultrasound probe is placed against the superior portion of the clavicle (Fig. 17.3a) with the image of the internal jugular centered on the monitor. Placing the ultrasound probe against the superior portion of the clavicle allows the needle to puncture the internal jugular vein approximately 1 cm above the clavicle. Vein puncture at this level allows the catheter to follow a gentle curve from the vein to its connection with the reservoir on the anterior chest. A higher vein puncture site may cause the catheter to kink, while a lower puncture risks injury to the great vessels and lung. After achieving ultrasound-guided access to the internal jugular vein as previously described, the micropuncture sheath, dilator, and 0.018-in. wire are left in place and temporarily secured to the drape.

The next several steps involve creation of the subcutaneous pocket and tunnel. An imaginary line at an angle of about 45° is drawn from the puncture site in the neck to the anterior chest below the clavicle (Fig. 17.4). This area will be the site of the subcutaneous pocket for the port. After establishing a field block with lidocaine, the skin is incised, and a 1-cm deep pocket is created on the anterior chest wall with blunt finger dissection. The overall size of the pocket should be limited to a few millimeters larger than the port itself. Keeping the subcutaneous pocket small minimizes the chance of the port moving or rotating. The pocket should extend to the level of the fascia for stable fixation points.

The pocket and the neck incision are then connected subcutaneously using the tunneling tool usually provided in the access kit. Attention is then returned to the neck access site. After removing the 3-F dilator and 0.018-in. wire, an 0.035-in. wire is advanced under fluoroscopic guidance into the SVC. Serial dilators are then passed over the wire before placing the peel-away sheath into the SVC. Most peel-away sheaths now have a protective cap, which prevents the sheath from entraining air when the wire and inner dilator are removed. If a protective cap is not in place, caution must be taken to avoid an air embolism when advancing the catheter into the peel-away sheath. The catheter tip should be positioned just within the right atrium. If the catheter triggers cardiac irritability on the monitor, it should be pulled back a few millimeters. The rationale for placing the catheter within the right atrium has to do with the fact that the patient is in a supine position. When the patient is upright, the heart will assume a lower position, and the tip of the catheter will most likely be located at the atrial-caval junction.

The peel-away sheath can then be partially removed to allow a small straight clamp to be placed on the catheter. The rest of the sheath is then peeled away, and a second clamp is placed on the catheter as it exits the tunnel into the subcutaneous port pocket. Placing these clamps establishes two fixed points on the catheter ensuring that the catheter position cannot be changed and that an appropriate length of catheter remains in the SVC. The catheter can then be attached to the port after trimming its excess length. The port is inserted into the pocket; the small straight clamps are removed; and the port is flushed. The skin incision can be closed with absorbable subcutaneous and subcuticular sutures. If vascular access is needed immediately, a Huber (non-coring) needle can be left in the port. A final fluoroscopic image should document the position of the catheter and port.

Most TCs are used for dialysis access, long-term TPN, or chemotherapy. Note that different catheters have been specifically designed for each of these needs. The risk of infection and thrombosis increases with the number of catheter lumens [11, 12]. Therefore, the lowest number of lumens necessary to fulfill the clinical needs should dictate catheter choice.

The technique for inserting a TC parallels the steps described for placing a chest port with a few pertinent details. For internal jugular vein placement, keeping the needle puncture site approximately 1 cm above the clavicle allows the catheter to take a gentle bend as it exits the subcutaneous tunnel and enters the vein. This prevents kinking of the catheter that invariably leads to catheter malfunction. After placing the micropuncture catheter in the vein, fluoroscopy can help choose the appropriate catheter length. The tip of the wire is advanced under fluoroscopy to the desired catheter location; the wire is then marked where it exits the skin, removed, and measured to determine the distance from the atrial-caval junction to the vein puncture site. This distance can be added to the distance from the puncture site to the anterior chest wall to determine the appropriate catheter length. The anterior chest wall is then anesthetized along the route toward the internal jugular puncture site. To minimize bleeding from the tunnel, a purse-string suture can be placed at the chosen chest wall exit site. A small incision is then made in the center of the purse-string suture, and the catheter is tunneled subcutaneously towards the internal jugular puncture site. The catheter is then placed using the peel-away sheath technique previously described. Fluoroscopy during and after catheter placement allows accurate placement of the catheter tip and ensures that the catheter is not kinked [58]. The catheter is then secured in place by tightening and tying the purse-string suture around the hub of the catheter.

The anatomic relationship between the subclavian vein and the clavicle changes with shoulder position [59–61]. Magnetic resonance imaging shows that passive retraction of the shoulders by placing a rolled towel between the shoulder blades compresses the subclavian vein between the first rib and clavicle which impedes successful cannulation of the vein [62]. The angle between the subclavian and internal jugular veins increases when the patient’s head is rotated to the contralateral side. This change in angle may increase the chance of passing the catheter from the subclavian into the ipsilateral internal jugular vein rather than into the SVC [62]. In other studies, having the patient’s head rotated towards the cannulation side failed to improve positioning of the catheter into the SVC [63, 64]. Trendelenburg position does not affect the caliber of the subclavian vein, which is held open in the flat, supine position by the fibrous attachments to the clavicle. Placing the patient in Trendelenburg still provides benefit by increasing venous filling and minimizing the risk of air embolism [65].

In preparation for subclavian vein cannulation, the patient is placed in a supine position in 10–15° of Trendelenburg. Adducting the patient’s ipsilateral arm will move the subclavian vein closer to the underside of the clavicle. The shoulders typically assume a more cephalad orientation with the patient in Trendelenburg position which can distort the anatomic landmarks. This tendency should be countered by the use of gentle caudal arm traction.

The goal of subclavian venipuncture is to pass the needle below the clavicle and above the first rib to puncture the subclavian vein as it courses over the first rib. The appropriate course for the needle passes immediately beneath the junction of the medial one-third and lateral two-thirds of the clavicle (Fig. 17.5). This junction or so-called “break” of the clavicle is the point at which the anterior convexity of the medial clavicle transitions into an anterior concavity laterally [65]. The needle should be inserted 1–2 cm inferior and lateral to this transition point, aiming the needle slightly deep to the sternal notch. The needle tip may initially come into contact with the clavicle. The needle should be “walked down” the clavicle to reach its underside. Keeping the needle parallel to the floor (the coronal plane) allows it to slide under the clavicle and enter the vein without injuring the lung or pleura. If the attempt is unsuccessful, these steps should be repeated with the needle pointed more cephalad.

Kilbourne and colleagues examined video recordings of surgery and emergency medicine residents performing subclavian cannulation during trauma resuscitation. They identified six common technical errors, five of which involved anatomic considerations including cutaneous puncture too close to the clavicle, passage of the needle through the clavicular periosteum, too shallow a trajectory beneath the clavicle, failure to identify landmarks properly, and orientation of the needle in a cephalad direction away from the sternal notch. The final error was extravascular displacement of the needle after successful venipuncture but before introducing the guidewire [66]. Being aware of these errors can improve the teaching effectiveness of experienced operators and encourage safe practice among clinicians learning the procedure.

Bannon and colleagues published an excellent description of subclavian vein cannulation using a supraclavicular approach (Fig. 17.5a, b) [67, 68]. The essential landmark for the supraclavicular approach is the lateral border of the clavicular head of the SCM muscle as it attaches to the clavicle. Turning the patient’s head to the contralateral side accentuates the posterior head of the SCM and provides unobstructed access to the subclavian vein [67]. The point of cutaneous puncture lies 1 cm superior and 1 cm lateral to the SCM attachment site. The junction of the SCM with the clavicle forms the claviculosternomastoid angle. The needle tip should be angled posteriorly 5–15° off a coronal plane and advanced along a line that bisects the claviculosternomastoid angle. This technique will lead to subclavian venipuncture between the clavicle and the anterior scalene muscle. Other authors suggest cutaneous puncture directly at the claviculosternomastoid angle. The needle is then advanced along the claviculosternomastoid angle bisector parallel and inferior to the clavicle to enter the vein at an insertion depth of 1–2 cm [63]. Anatomic data from three-dimensional computed tomography reconstructions suggest that, with the SCM-clavicular junction as a cutaneous puncture point, the needle should be oriented approximately 11° medially and 35° posteriorly as the needle is advanced approximately 1.4 cm to enter the vein. Unfortunately relatively large variation associated with these mean values limits their clinical utility [69]. In contrast to the infraclavicular approach, supraclavicular subclavian cannulation can be facilitated by ultrasound guidance.

Air embolism is a rare but potentially lethal complication that can occur during central VA via the internal jugular or subclavian vein. Although it is an entirely preventable problem, air embolism will occur if the practitioner fails to take precautions during central venous catheter placement. In the most common clinical scenario, air enters the vascular system through the needle, dilator, or sheath when the patient suddenly inhales or coughs. Acutely aspirating more than 50–100 mL of air directly into the right atrium and ventricle can cause a fatal obstruction of the right side of the heart. Studies have demonstrated that negative intrathoracic pressure can quickly entrain a large amount of air into the vascular system. A pressure difference of 4 cm H₂O allows 90 mL/s of air to pass through a 4-cm, 18-gauge needle. Intubated patients have a lower risk of air embolism than spontaneously breathing patients due to the absence of negative intrathoracic pressure [7].

To minimize the risk of air embolism, the lumen of the needle, dilator, or sheath should be covered at all times. Asking the patient to hum during catheter insertion decreases the chance of sudden inhalation or coughing [37]. Some catheter manufacturers have developed a sealing valve for the peel-away sheath that prevents air aspiration once the wire and dilator have been removed. Symptomatic air emboli can cause tachyarrhythmias, chest pain, cardiovascular collapse, dyspnea, coughing, and hypoxemia. In the event of an air embolism, the patient should be turned onto their left side and placed into the Trendelenburg position. This maneuver is designed to trap the air in the right ventricular apex; however, its effectiveness has not been rigorously studied. Aspirating through the central venous catheter if it is in place can potentially remove some of the intracardiac air. The patient should also be placed on 100 % oxygen to increase resorption of the air pocket. Supportive measures including fluid resuscitation and adrenergic agents should be used as needed.

Misadventures involving the guidewire or catheter can result in foreign body embolization. During insertion, the guidewire can become knotted or entrapped inside the catheter leading to wire fracture and embolization. The catheter itself can also fracture and embolize due to the shear forces exerted by the wire [70–72]. Embolization of a wire or catheter segment can have severe consequences including perforation or infarction of the heart or occlusion of a great vessel. Retrieving an embolized foreign body can involve endovascular techniques using a loop snare device or open surgery to directly expose the affected vessel [73]. Removal of a small segment of catheter that fractured off and embolized is not always necessary if this foreign body does not pose an obvious danger [7]. Decisions about whether to intervene in these cases requires sound clinical judgment. Guidewires can also become entangled with a previously placed IVC filter causing displacement and structural compromise of the filter. Being aware of the IVC filter and using careful technique can usually prevent this complication [74].

Iatrogenic cardiac perforation and inadvertent injury to the great vessels during central VA placement can result in hemothorax, cardiac tamponade, and mediastinal hematoma. Failure to recognize any of these conditions, alone or in combination, can be fatal. Vessel perforation and arterial misplacement that occur more frequently during internal radiographic signs of these complications include an atypical catheter course and tip position, pleural effusion, or widened mediastinum (Fig. 17.6). Jugular and femoral vein catheter insertion than with subclavian access [4, 30, 75, 76].

Prospective studies report a 6 % incidence of carotid artery puncture during internal jugular vein access [77]. Higher rates of carotid injury (18–25 %) have been reported in the pediatric population [75, 78]. Approximately 40 % of carotid punctures cause a hematoma, and failure to control the bleeding with manual compression can lead to airway obstruction, dissection, arteriovenous fistula, cerebrovascular compromise, and death [77, 79–83]. Puncture of the subclavian artery has a slightly lower incidence, occurring in 0.5–4 % of patients undergoing central VA placement [4, 30]. Hemothorax resulting from inadvertent arterial injury complicates about 1 % of vascular access cases [4]. In an unusual case, a hemothorax following dialysis catheter insertion caused spinal cord infarction and quadriplegia [84].

Perforation or cannulation of the carotid or subclavian artery by large-bore catheters occurs in up to 1 % of central VA procedures [85–87]. This complication can have serious and potentially fatal consequences including hemorrhage and stroke [87–89]. Stroke and other neurological events occur in approximately 27 % of patients who sustain unintentional arterial catheterization with an associated mortality rate of 20–40 % [85, 86].

Minimizing the risk of arterial injury during central venous catheter insertion has two components:

Ultrasound guidance offers the most effective safeguard against needle puncture of the artery. Visualizing the tip of the needle when entering the vein lumen with real-time ultrasound imaging significantly decreases the chance of arterial puncture [76, 90, 91]. It is important to understand that inadvertent arterial punctures can still occur even with the use of ultrasound guidance. These events usually involve incorrect identification of the vascular structures or manipulation of the needle after venipuncture. The needle can then penetrate the opposite wall of the vein and puncture the underlying artery. Bright red, pulsatile blood flow from the needle usually alerts the operator that an arterial puncture has occurred. Unfortunately, this warning sign is not always recognized especially in clinical circumstances involving hypotension and hypoxemia. If the location of the needle or micropuncture catheter is unclear, the catheter can be connected to a pressure transducer to confirm low venous pressures and the absence of arterial pulsations before dilating and placing a large-bore catheter [76, 92]. Other methods have been described to identify an arterial puncture; however, none are infallible [80, 93]. Perforation of the aorta during central VA can occur in conjunction with a SVC injury [94]. An injury at the pericardial reflection often leads to cardiac tamponade, which has a mortality rate exceeding 90 % [95, 96]. Aortic injuries can occur as a result of multiple venipuncture attempts or the improper use of large dilators [97, 98]. In a typical clinical scenario, forceful advancement of the dilator causes it to override the wire and perforate the central vein or SVC. The technique of frequently ensuring that the wire moves freely as the dilator is advanced can minimize the risk of this complication.

Recognizing and treating a great vessel injury require a high index of suspicion and prompt diagnostic imaging. A chest x-ray can be misleading while ultrasound provides limited visualization of intrathoracic structures. Diagnosing a central vessel injury can require a contrast-enhanced CT scan or catheter-directed angiography depending on the clinical urgency. Balloon tamponade can provide temporary vascular control while preparing for open surgical repair or endovascular intervention using a stent graft or closure device [99–102].

Pseudoaneurysms and arteriovenous fistulas represent rare complications of inadvertent arterial cannulation or vessel perforation [103, 104]. Arteriovenous fistulas have an incidence of 0.6 and 0.2 % after internal jugular and subclavian vein access, respectively [81, 105]. Clinical signs of an arteriovenous fistula include a palpable thrill or audible bruit in the neck. A pseudoaneurysm is a contained pocket of blood flow associated with an underlying arterial injury. Depending on the size and location, a pseudoaneurysm can present as a pulsatile mass or cause compressive symptoms on adjacent structures. Although fistulas and pseudoaneurysms can cause acute symptoms, they usually have a delayed clinical presentation [106]. Injury to the vertebral artery can also occur during subclavian or internal jugular vein access and may be associated with an adverse neurological event [107].

In the past, open surgical repair was the only treatment option for pseudoaneurysms and arteriovenous fistulas resulting from VA procedures. Endovascular intervention including the use of stent grafts now offers an effective and less invasive alternative in many cases [106, 108]. Ultrasound-guided thrombin injection has been reported in the treatment of a carotid artery pseudoaneurysm; however, this technique should be used with caution because of the potential for cerebral embolization [109].