Fig. 60.1
Percutaneous insertion of needle into the jugular vein
Fig. 60.2
Color flow Doppler of jugular vein and carotid artery in short-axis plane. Carotid artery (red) jugular vein (blue)
Fig. 60.3
Color flow Doppler of jugular vein and carotid artery in long-axis plane. Carotid artery (red) jugular vein (blue)
Fig. 60.4
Echogenic tip of needle in the lumen of the jugular vein, transverse view
For tunneled catheters, our group prefers the lateral approach to the jugular vein, which was initially described by Silberzweig and Mitty in 1998 [2]. A standard transverse view is obtained at the base of the neck with the ultrasound probe placed parallel to and just above the clavicle. Both the anesthetic and access needle are inserted into the skin at a similar 45° angle, lateral to the transversely oriented probe. Following the needle point is essential to prevent a “through and through” puncture of the carotid artery, which occurs if the needle tip is out of plane with the ultrasound beam. We have found that this approach minimizes the risk of kinking by allowing a gentle curve of the catheter at the base of the neck into the lateral wall of the vein. The probe can also be reoriented to show a longitudinal plane, where insertion of the guidewire into the innominate vein can be followed (Fig. 60.5).
Fig. 60.5
“Low and lateral” approach to sticking the jugular vein for tunneled catheters
One of the most compelling early studies to examine the effectiveness of using ultrasound was performed by Denys et al. in 1993. Their group prospectively analyzed over 300 patients accessed by both traditional landmark techniques as well as ultrasound guidance. A higher technical success rate was seen with ultrasound-guided access (100% vs 88.1%), with 78% of veins successfully punctured on first pass attempts as opposed to 38% with the traditional landmark-based group. The average time to access from the skin to vein was 9.8 s and 44.5 s, respectively, and complication rates were far less in the ultrasound group with regard to inadvertent carotid artery puncture, brachial plexus irritation, and access site hematomas [3].
Subsequently, several other prospective trials have compared the ultrasound-guided access with that of landmark techniques, most of which were randomized and controlled. A randomized trial of 450 critical care patients demonstrated a higher technical success rate with an ultrasound-guided access and higher complications with the landmark method. A carotid artery puncture rate of over 10% and a hematoma rate of 8.4% were seen, as compared to 1.1% and 0.4%, respectively, in patients with ultrasound-guided access. A direct correlation was also observed between bloodstream infection and the number of passes, which was substantially reduced by imaging-guided puncture [4]. Three years later, Turker et al. conducted a randomized study involving 380 patients comparing ultrasound-guided procedures to that of landmark techniques. This was one of the lowest reported carotid puncture and hematoma rates while using the landmark technique (4.73% and 3.68%); however, there was still a statistically significant increase as compared to ultrasound-guided access [5].
In 2003, a meta-analysis of central venous cannulation was performed, examining studies of the internal jugular, subclavian, and femoral veins. The jugular vein was the most studied access site, but all sites were included for analysis. A relative risk reduction of 86% was found for failed catheter placement, 57% for placement complications, and 41% for failure on the first attempt when ultrasound-guided access was used. Most series also showed fewer required attempts for successful cannulation and less time to achieve access when ultrasound was used as an adjunct [6].
Subclavian Vein
The subclavian vein has also been used for both temporary and permanent central catheters, albeit less frequently. It is accessed in the costoclavicular space of the thoracic outlet.
The subclavian vein, artery, and brachial plexus all pass through this space, in close proximity to the pleural cavity, making a precise puncture critical. Arterial cannulation is difficult to manage, especially once a sheath has been inserted, and pneumothoraxes have been reported much more frequently with subclavian vein access attempts than with the jugular vein.
A standard transverse view is more difficult to obtain, and longitudinal views below and above the clavicle are often employed. In addition, conventional compression is not usually feasible secondary to the bony architecture surrounding the vein. The presence of intraluminal echoes and respiratory phasicity with Doppler waveform analysis is generally all that is used to assess the vein for clot burden. The skin puncture is at the junction of the medial two-thirds and lateral one-third of the clavicle, and the needle is visualized in the same plane as it enters the lumen of the vessel. A classic Seldinger technique then ensues (Figs. 60.6 and 60.7).
Fig. 60.6
Subclavian vein , longitudinal (long axis) plane (B-mode)
Fig. 60.7
Subclavian vein, longitudinal (long axis) plane, color flow Doppler
Series comparing landmark with ultrasound-guided techniques are limited; however, the results have shown ultrasound guidance to be superior in certain outcomes. Between 1994 and 1998, three prospective, randomized trials by Branger et al., Gualtieri et al., and Lefrant et al. showed a statistically significant relative risk reduction of 86% of failed catheter placement, along with a lower complication rate [7–9]. The sample sizes were not as large as those seen in some of the series looking at the internal jugular vein, but ultrasound has shown itself to be of clear benefit in accessing the vein. We feel strongly that in both routine and complex situations, ultrasound should be considered for vessel cannulation. The difficulty with visualization around the clavicle can be more technically demanding, but the results with the use of two-dimensional imaging far outweigh the risks associated without it.
Femoral Vein
The common femoral vein is viewed as the simplest access point to the deep venous circulation. This is predominantly due to its location and the lower risks associated with access, compared to others. The vein lies medial to the common femoral artery and travels with the artery proximally under the inguinal ligament. It can be easily cannulated while the patient lies in the supine position and is currently the site most amenable to emergency access.
The ultrasound probe is oriented transversely over the femoral vessels, parallel to the groin crease. Similar to the jugular vein, the vein is compressed and B-mode assessment of intraluminal thrombus is done. Once patency is confirmed, the needle is positioned inferior to the midportion of the probe and directed at a 45° angle into the plane of the ultrasound beam. The echogenic tip is followed as it advances through the anterior wall of the vein.
Success rates have been well established for a number of years. In 1990, Mallory et al. were one of the first to show a significant decrease in the amount of time to cannulation (2.5 min vs 6 min), as well as a higher number of successful cannulations with the first pass [10]. Since then, five different studies, both prospective and retrospective, have confirmed their group’s results. For the most part, retrospective series have reported better technical success, including more successful first attempt punctures, along with lower hematoma rates and inadvertent femoral artery punctures [11, 12].
A prospective study by Hilty et al. evaluated femoral cannulation in patients undergoing cardiopulmonary resuscitation, showing a relative risk reduction of failed catheter placement by 71% [13]. Another prospectively randomized trial of 110 patients undergoing femoral vein dialysis catheter insertion reported improved technical success (98.2% vs 80%) and reduced complications (18.2% vs 5.5%) in patients randomized to ultrasound-guided access [14].
We have previously published our institutional experience with central venous access for inferior vena cava filter placement. The focus of our study was on the safety of using the subclavian vein for access during inferior vena cava filter placement. A striking finding during our review, however, was how fast the procedures were when performed using the femoral vein for access [15]. During filter placement, we also routinely assess the femoral veins with the probe. This helps visualize any clot burden, acute or chronic, in addition to reducing the number of passes for successful cannulation and inadvertent punctures. The later can be devastating in this clinical scenario in that some patients may already be on anticoagulation.
Popliteal and Tibial Veins
The popliteal vein is clearly the least accessed of all deep veins. It is most commonly used in patients with acute deep venous thrombosis undergoing thrombolysis. The popliteal veins lie on either side of the popliteal artery and branch distally into the tibial veins, similar to the corresponding arterial anatomy. Intraluminal thrombus is often present, making access to either popliteal vein challenging, and avoidance of inadvertent arterial puncture is paramount in patients undergoing lytic therapy.
The most common technique to access the vein is via prone positioning, and ultrasound insonation should occur by a transverse orientation. A standard angle of 45° is used; however, a steeper angle of approximately 60° may be required. In the popliteal fossa, the veins are deeper during a prone approach, and we have found that identifying the small saphenous vein can sometimes be helpful. Following its course as it empties into the popliteal vein can make access easier by identifying a more superficial vein to cannulate, especially if there is already a significant thrombus burden in the popliteal veins. Once the needle has entered the lumen, the procedure can continue (Fig. 60.8).
Fig. 60.8
Popliteal veins (transverse view, B-mode)
The anterior tibial and posterior tibial veins are accessed even less than the popliteal. They may be of some use in ascending venography, when peripheral intravenous catheters in the feet cannot be attained. The patient is usually in a supine position, and the ultrasound image helps identify both tibial veins for each corresponding artery. Accessing one will allow for a suitable catheter injection and ascending venogram. Occasionally, we have even used the posterior tibial vein for lytic access, but this is only done if attempts at cannulating the popliteal vein are unsuccessful.
Peripheral Venous Access
Great and Small Saphenous Veins
With the advent of radiofrequency and laser ablation, endovenous procedures for great saphenous vein (GSV ) ablation can now be performed without surgical intervention in the majority of patients. It produces similar results, with significantly decreased morbidity. Ultrasound only aids in providing safe access to accomplish these various procedures.
The GSV lies within the saphenous sheath and runs down the medial border of the entire lower extremity. It is a superficial vein, with four or more large sets of perforators throughout its course. Typically, in reflux surgery, the vein is larger than 3 mm in its entirety and is accessed at the level of the medial condyle of the femur. The needle is inserted at a 45° angle to the skin surface, directly beneath the probe. In a transverse view, the needle tip is identified superior to the vein, and puncture can occur in either this view or a longitudinal one, as the needle is advanced. Upon blood return, a standard Seldinger technique is used for sheath placement. An ablative catheter is then inserted, and visualization of its tip should always be ensured. Here, a longitudinal view of the saphenofemoral junction is imperative. In this view, the inferior epigastric vein is visualized, and the catheter should be withdrawn to a point inferior to this branch. Finally, a transverse projection is employed again, and tumescence anesthesia is injected within the saphenous sheath along the entire course of the vein (Figs. 60.9 and 60.10).
Fig. 60.9
Saphenofemoral junction ) ) (longitudinal plane, B-mode)
Fig. 60.10
Transverse view of common femoral artery, common femoral vein, and great saphenous vein (transverse view, B-mode)
The small saphenous vein is only cannulated in ablative procedures and lower extremity deep venous thrombosis. Ultrasound can be used to identify the small saphenous vein approximately three to four fingerbreadths below the level of the lateral femoral condyle on the lateral aspect of the lower extremity, and a standard image-guided technique is utilized. The literature regarding the use of ultrasound to access this vein is limited; however, it is clearly less invasive and is likely associated with a lower complication rate.
Basilic Vein
The superficial veins of the upper extremity are most often accessed by nursing or ancillary staff during peripheral intravenous access. At our institution, specialty nurses also achieve access for peripherally inserted central catheters. Portable ultrasound units are used at the bedside to do so, and they are present in each hospital for use by all staff, if needed.
It is only on occasion that our group needs to access the basilic vein in the interventional suite, with the most common case being thrombolysis for upper extremity deep venous thrombosis. The basilic vein is identified in the transverse plane just above the antecubital fossa. It lies on the medial portion of the upper arm over the groove between the bicep and tricep muscles (Figs. 60.11 and 60.12).
