Central Venous Access—Nontunneled
Sidney Regalado
Brian Funaki
Central venous (CV) access devices can be placed faster, more safely, and with fewer complications when imaging guidance is utilized than when placed with reliance on external anatomic landmarks (1). The placement of a nontunneled CV catheter has certain advantages over the placement of a tunneled CV catheter or implantable subcutaneous chest port. Nontunneled CV catheters are commonly placed using local anesthesia only, often at the bedside in an intensive care unit (ICU) setting when patients are too ill to be transported. As these temporary catheters are placed without subcutaneous tunneling, less stringent adherence to coagulation parameters can be observed. When the indication for these CV catheters no longer exists, these devices can be easily removed at the bedside.
Indications (2)
1. Therapeutic indications
a. Administration of chemotherapy, total parenteral nutrition (TPN), blood products, intravenous medications, and fluids
b. Performance of hemodialysis and plasmapheresis discussed in Chapter 33
2. Diagnostic indications
a. To confirm a diagnosis or establish a prognosis
b. To monitor response to treatment
c. For repeated blood sampling
Contraindications
Absolute
1. Cellulitis at insertion site
2. Allergy to catheter material
Relative
1. Uncorrectable coagulopathy
2. CV occlusion
3. Peripherally inserted central catheters (PICCs) are contraindicated in patients who are at risk for chronic renal failure or who have chronic kidney disease due to concern for damage to potential future dialysis fistula sites.
Preprocedure Preparation
The preprocedure preparation is similar irrespective of the access device that is chosen.
1. Review of medical history to:
a. Establish an indication
b. Obtain a history of concurrent or prior CV access devices and history of related complications, such as extremity or facial swelling
c. Identify pertinent allergies
2. Review of prior imaging studies to assess for anatomic variants and vessel patency. A quick ultrasound survey is recommended.
3. Physical examination of extremities, including pulses
4. Informed consent
5. Nil per os (NPO) status is not needed as the procedure is typically performed with local anesthesia only.
6. Guidelines for coagulation parameters should be followed. PICCs and nontunneled CV access are considered to be low risk for bleeding, which is easily detected and controllable (3).
a. International normalized ratio (INR) should be checked in patients on warfarin. INR goal is less than 2.0.
b. Partial thromboplastin time (PTT) is recommended in patients receiving intravenous unfractionated heparin. PTT should be less than 1.5 times control.
c. Platelet count not routinely recommended, but transfusion is recommended for counts less than 50,000 per µL. Others utilize a platelet count ≥25,000 per µL (4).
d. Plavix and aspirin do not need to be withheld.
e. Low-molecular-weight heparin (therapeutic dose) should be withheld for one dose before procedure.
7. Prophylactic antibiotics are not given before nontunneled CV catheter placement.
Procedure
1. General considerations
a. Nontunneled CV catheters and PICCs are placed in the interventional radiology (IR) suite or at the bedside (with or without fluoroscopic guidance) depending on operator preference and the clinical status of the patient.
b. The skin is sterilized with a 2% chlorhexidine-based preparation. Standard surgical scrub protocol for the operator includes hand scrubbing, gloves, mask, cap, and gown.
c. Local anesthesia with 1% lidocaine is utilized for all line placements.
d. Choice of line
(1) CV catheters differ in composition, length, number of lumens, and size. A large internal lumen is optimal for infusions of viscous liquids, whereas multiple lumens facilitate infusion of incompatible infusates. Generally speaking, increasing the number of lumens in the catheter will increase the size of the catheter. For multilumen catheters, if one lumen increases in size, the other lumens may have to decrease in size to maintain a reasonable catheter outer diameter. The choice of catheter size and number of lumens is significant, as the risk of vessel thrombosis and infection increases as the size of the catheter and number of lumens increase.
(2) Power injectable PICCs and nontunneled CV catheters are available and can be identified by the catheter tubing which indicate the injection rate parameters. The Bard Power PICC (Bard Access Systems, Salt Lake City, UT) has a maximum injection rate of 5 mL per second at 300 psi.
e. Guidance technique
(1) Ultrasound (US) guidance is always recommended for venipunctures to avoid inadvertent arterial puncture.
(2) When the patient can medically tolerate movement to an angiographic suite, fluoroscopic guidance is used for visualization of guidewires, catheters, and venography. A spot fluoroscopic image at the conclusion is used to document the catheter tip.
(3) When bedside CV lines are placed, only US guidance is used. Thus, a follow-up radiograph is obtained to verify catheter tip position.
f. Catheter tip position
(1) Superior vena cava-right atrial junction is ideal.
(2) Catheter tips can migrate with respirations, retraction due to pendulous breast tissue, and with movement from the supine to upright position (1).
(3) Preexisting CV stenoses or fibrin sheaths may necessitate placement either higher in the superior vena cava (SVC) or deeper in the right atrium.
2. PICC placement
a. Choice of vein
(1) Either arm can be used, but the nondominant arm is preferred.
(2) Some operators will choose the largest vein in the upper arm above the elbow as their access vein, whereas others will routinely select the basilic vein, as it is not adjacent to the brachial artery and nerve.
(a) The cephalic vein may be used but is prone to spasm and thrombosis.
(b) The brachial veins travel alongside the brachial artery increasing the risk of arterial puncture.
b. A tourniquet is placed in the upper arm to distend the veins.
c. US guidance and a micropuncture needle (typically 21 gauge) are used for venous access. The access vein can also be punctured using fluoroscopic guidance after injection of contrast medium.
d A 0.018-in., 60 cm mandril guidewire is advanced centrally under fluoroscopic guidance or until resistance is felt, if fluoroscopy is not available.
e. A skin nick is made, and an appropriately sized peel-away sheath is placed.
f. Using fluoroscopy, the required catheter length is measured using the guidewire, and the PICC line is cut to length. If the procedure is performed at bedside, catheter length is estimated.
g. The PICC is advanced using a stiffening stylet or a guidewire to the desired position.
