Vascular Access Surgery


Complications, risks, and consequences

Estimated frequency

Most significant/serious complications

Infection (overall)a

5–20 %

 Wound

5–20 %

 Within the catheter

5–20 %

 Systemic sepsis

1–5 %

Bleeding/hematoma formationa (wound)

1–5 %

Thrombosis – SVC thrombosis/internal jugular/cephalic vein

1–5 %

Migration/displacement of the catheter tube

1–5 %

Catheter failure (from whatever cause) [misdirection, occlusion, kinking, fracture/breakage, too long/short]

1–5 %

Rare significant/serious problems

Nerve injury (depending on positioning) [cutaneous nerve, Vagus X nerve damage, etc.]

0.1–1 %

Pneumothorax

0.1–1 %

Failure to perform catheter insertion (technical problems)

0.1–1 %

Catheter tip embolus

0.1–1 %

Cardiac arrhythmias (catheter irritation of endocardium)

0.1–1 %

Catheter or guidewire vascular perforationa

<0.1 %

Cardiac perforation and tamponadea

<0.1 %

Subclavian vein fistula

<0.1 %

Hemothorax

<0.1 %

Air embolism

<0.1 %

Multisystem organ failurea

<0.1 %

Deatha

<0.1 %

Less serious complications

Bruising

20–50 %

Residual pain/discomfort/neuralgia

1–5 %

Radiation exposure (for the patient) (low level)

>80 %

Wound dehiscence

1–5 %

Skin/fat necrosis

0.1–1 %

Delayed wound healing (including ulceration)

1–5 %

Wound scarring (poor cosmesis)

1–5 %


aDependent on underlying pathology, anatomy, surgical technique, preferences, and comorbidities





Perspective


See Table 6.1. The procedure is usually associated with a low complication rate and most are minor, such as bruising, difficulty gaining access to the vein, and minor superficial infection. Major complications are rare but can occur, such as pneumothorax, which may require further hospitalization or insertion of an underwater-seal chest drain tube. Cardiac arrhythmias and bleeding are risks during insertion. Immediate withdrawal of the catheter wire or tube several centimeters will usually settle the arrhythmia. Catheter thrombosis, cardiac arrhythmias, and migration of the catheter are also potentially serious as the catheter may require removal and later reinsertion. Catheter or guidewire perforation of vessels or the heart is very rare, but both are well reported, but these have been almost “designed out” with soft-ended devices. Percutaneous CVC lines invariably fail over time due to infection, mechanical problems, or thrombosis, and regular replacement may avert these issues as clinical complications. Failure to complete the procedure by the percutaneous method will not usually disallow its insertion, since the open approach can usually then be used. Bilateral attempts at central line insertion via the subclavian approach are not advisable within 24 h of each other, as there is a risk of inducing bilateral pneumothoraces. Use of the internal jugular approach is preferable after a failed subclavian approach to reduce pneumothorax risk.


Major Complications


The main severe acute complications are pneumothorax, cardiac arrhythmias, air embolism and hemothorax. Later , infection of the catheter line can lead to systemic sepsis and even multisystem organ failure, which is the major cause of mortality, especially in immunocompromised patients and severely ill patients. Catheter tip bacterial colonization or thrombosis with consequent embolization of material can occur and may be associated with bacterial endocarditis, metastatic infection, or pulmonary embolism. Removal of the central line invariably follows infection. Air embolism and hemothorax are very rare but can be life-threatening. Catheter blockage or leakage due to a variety of problems may require removal and reinsertion or adjustment. Catheter thrombosis and pulmonary embolism can occur and may be serious. Axillary, subclavian, internal jugular, or superior vena cava venous thrombosis can cause severe swelling of the arm, neck, head, and chest. Carotid artery puncture is minimized by the use of ultrasound guidance. Cardiac arrhythmias are usually terminated by withdrawal of the guidewire from the heart chamber, usually the atrium affecting the sinoatrial node. Catheter tip migration can occur into the jugular vein, opposite subclavian vein, right heart, IVC, or even pulmonary artery. Catheter or guidewire vascular perforation is very rare, especially with J-hooked, soft-tipped guidewires or soft catheters, but both are well reported. Cardiac perforation and tamponade is exceedingly rare. Catheter fracture and embolism is reported and may require radiological or rarely open surgical removal.


Consent and Risk Reduction



Main Points to Explain



  • Discomfort


  • Bruising and bleeding


  • Infection


  • Pneumothorax (rare)


  • Cardiac arrhythmias (usually minor)


  • Failure of insertion


  • Catheter displacement/later failure


  • Further surgery



Tunneled Internal Jugular Central Venous Catheter Line Insertion



Description


Local anesthesia or general anesthesia may be used. The line can be inserted percutaneously or via an open approach. The aim is to insert the catheter into the subclavian or internal jugular vein percutaneously (or open) and to tunnel this subcutaneously to a convenient site in the anterior axilla, upper chest, or abdomen for exit and access. The line can be inserted percutaneously or via an open approach. If using the percutaneous route, the use of ultrasound guidance may lower the complication rate. It is important to measure the catheter so that the exit site lies in a reasonable location. The patient should be placed head-down to avoid air embolism. In patients with impaired renal function, the subclavian route for dialysis catheters should only be used as a last resort, as there is a 50 % incidence of subclavian vein stenosis. This can lead to problems if a fistula is created in the ipsilateral arm. When using the open approach, a cervical skin crease incision is placed over the carotid pulsation, 1 finger width above the clavicle. The SVC is secured above and below the venotomy site, and the largest catheter for the vein size is inserted. A circumferential 6/0 Prolene suture closes the venotomy against the catheter. Some catheters have a small Dacron cuff, which is positioned under the skin, to fixate the catheter.


Anatomical Points


The position of the subclavian and internal jugular veins is relatively constant; however, there is some relative minor variation, due to differences in the surrounding bony anatomy between individuals and the hydration status of the patient. Dehydration decreases venous size and can make access more difficult. The internal jugular vein can overlie or even be medial to the carotid artery in some patients, and ultrasound guidance may be of value. Placing the patient slightly “head-down” is also helpful in dilating the venous system of the head and neck facilitating easier entry of the initial needle and reducing risk of air embolism. The pleura lies behind the medial 1/3 of the clavicle on each side and is at risk of puncture and inducing a pneumothorax.


Table 6.2
Tunneled internal jugular line insertion estimated frequency of complications, risks, and consequences









































































































Complications, risks, and consequences

Estimated frequency

Most significant/serious complications

Infection (overall)a

20–50 %

 Wound

1–5 %

 Related to the catheter

5–20 %

 Systemic sepsis

1–5 %

Bleeding/hematoma formationa

 Wound

1–5 %

Thrombosis – SVC thrombosis/internal jugular/cephalic veina

1–5 %

Nerve injury (depending on positioning) [cutaneous nerve, Vagus X nerve damage, etc.]

<0.1 %

Catheter failure (from whatever cause) [misdirection, occlusion, kinking, fracture/breakage, too long/short]

1–5 %

Rare significant/serious problems

Catheter tip embolus

<0.1 %

Air embolism

<0.1 %

Cardiac arrhythmias (catheter irritation of endocardium)

0.1–1 %

Pneumothorax (rare with int. jugular cannulation)a

0.1–1 %

Migration/displacement of the catheter tube

0.1–1 %

Catheter or guidewire vascular perforationa

<0–1 %

Cardiac perforation and tamponadea

<0–1 %

Hemothorax (rare with int. jugular cannulation)

<0–1 %

Thoracic duct injury (left side only)

<0–1 %

Laryngeal edema

<0–1 %

Multisystem organ failurea

<0–1 %

Deatha

<0–1 %

Less serious complications

Residual pain/discomfort/neuralgia

1–5 %

Wound dehiscence

1–5 %

Skin necrosis

0.1–1 %

Radiation exposure (for the patient) (low level)

>80 %

Bruising

20–50 %

Failure to perform catheter insertion (technical problems) (depends on number of previous catheterizations in dialysis patients and use of U/S)

1–5 %

Seroma/lymphocele/lymphatic leak

1–5 %

Delayed wound healing (including ulceration)

1–5 %

Wound scarring (poor cosmesis)

1–5 %


aDependent on underlying pathology, anatomy, surgical technique, preferences, and comorbidities


Perspective


See Table 6.2. The procedure is usually associated with a low complication rate, and most are minor, such as bruising, difficulty gaining access to the vein, and minor superficial infection. Life-threatening complications are rare and less common than by the subclavian route. Major complications are rare but can occur, such as pneumothorax, which may require further hospitalization or insertion of an underwater-seal chest drain tube. Air embolus is very rare, especially with the “head-down” patient position is used. Cardiac arrhythmias and bleeding are risks during insertion. Immediate withdrawal of the catheter wire or tube several centimeters will usually settle the arrhythmia. Catheter thrombosis, cardiac arrhythmias, and migration of the catheter are also potentially serious as the catheter may require removal and later reinsertion. Percutaneous CVC lines invariably fail over time due to infection, mechanical problems, or thrombosis, and regular replacement may avert these issues as clinical complications. Failure to complete the procedure by the percutaneous method will not usually disallow its insertion, since the open approach can usually be then used. Bilateral attempts at central line insertion via the subclavian approach are not advisable within 24 h of each other, as there is a risk of inducing bilateral pneumothoraces. Use of the internal jugular approach is preferable after a failed subclavian approach or in patients with renal impairment.


Major Complications


The main severe acute complications are pneumothorax, cardiac arrhythmias, air embolism and hemothorax. Later , infection of the catheter line can lead to systemic sepsis and even multisystem organ failure, which is the major cause of mortality, especially in immunocompromised patients and severely ill patients. Catheter tip bacterial colonization or thrombosis with consequent embolization of material can occur and may be associated with bacterial endocarditis or metastatic infection. Removal of the central line invariably follows infection. Air embolism, pneumothorax, and hemothorax are very rare with the jugular approach, but can be life-threatening. Catheter blockage or leakage due to a variety of problems may require removal and reinsertion or adjustment. Catheter tip migration can occur into the jugular (or subclavian depending on the vessel of insertion) vein, opposite subclavian vein, right heart, IVC, or even pulmonary artery but is relatively rare as the cuff holds it in place. Catheter fracture and embolism is reported and may require radiological or rarely open surgical removal. Axillary, subclavian, internal jugular, or superior vena cava venous thrombosis can cause severe swelling of the arm, neck, head, and chest. Failure to thread the wire can be a problem, particularly in renal patients who have had previous central venous lines. Carotid artery puncture may be minimized by the use of ultrasound guidance. Cardiac arrhythmias are common when the guidewire enters the heart chamber, usually irritating the sinoatrial node, usually terminated by withdrawal of the catheter from the right atrium into the SVC. Catheter or guidewire vascular perforation is very rare, especially with J-hooked, soft-tipped guidewires or soft catheters, but both are well reported. Cardiac perforation and tamponade is exceedingly rare.


Consent and Risk Reduction



Main Points to Explain



  • Discomfort


  • Bruising and bleeding


  • Infection


  • Pneumothorax (rare)


  • Cardiac arrhythmias (usually minor)


  • Failure of insertion


  • Catheter displacement/later failure


  • Further surgery


Venous Access Devices (Infusion Port) Insertion Percutaneous Insertion



Description


General anesthesia is usually preferable; however, local anesthesia may be used on occasions. The aim is to gain access to the subclavian or internal jugular vein using a percutaneous Seldinger technique (guidewire, dilator, separable sheath, Silastic catheter). A separate subcutaneous pocket is made for the port, which is attached to the Silastic catheter. The catheter is tunneled to reach the sheath and inserted into the vein, and then the sheath can be stripped away. The position of the catheter in the superior vena cava can then be checked using image intensification radiology. The skin is then closed to render the whole system subcutaneous.


Anatomical Points


The position of the subclavian and internal jugular veins is relatively constant; however, there is some relative variation, due to differences in the surrounding bony anatomy between individuals. Placing the patient slightly “head-down” is also helpful in dilating the venous system of the head and neck facilitating easier entry of the initial needle and reducing air embolism. The pleura lies behind the medial 1/3 of the clavicle on each side and is at risk of puncture and inducing a pneumothorax.


Table 6.3
Open venous access devices (including infusion port) insertion estimated frequency of complications, risks, and consequences


































































Complications, risks, and consequences

Estimated frequency

Most significant/serious complications

Infection (overall)

1–5 %

 Wound

1–5 %

 Within the port

1–5 %

 Systemic sepsis

0.1–1 %

Bleeding or hematoma formation

 Wound

1–5 %

Bruising

20–50 %

Thrombosis – SVC/internal jugular/SCV/axillary/cephalic vein

1–5 %

Catheter failure (from whatever cause) [misdirection, occlusion, kinking, fracture/breakage, too long/short]

1–5 %

Port leakage/extravasation

1–5 %

Rare significant/serious problems

Pneumothorax (rare with int. jugular cannulation)a

0.1–1 %

Cardiac arrhythmias (catheter irritation of endocardium)

0.1–1 %

Catheter tip embolus

0.1–1 %

Nerve injury (depending on positioning) [cutaneous nerve, Vagus X nerve damage, brachial plexus, etc.]

0.1–1 %

Catheter or guidewire vascular perforationa

<0.1 %

Cardiac perforation and tamponadea

<0.1 %

Subclavian vein fistula/injury

<0.1 %

Hemothorax

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Feb 26, 2017 | Posted by in CARDIOLOGY | Comments Off on Vascular Access Surgery

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