Overview of Vascular Tunneled Central Catheter Access

There are two main types of central venous catheters (CVCs), which are tubes that go into a large vein in your neck, chest, or leg near the groin. The first type is non-tunneled CVCs, which stay in place for a few days to a week. The second type is tunneled CVCs, which are placed under your skin and can remain there for weeks or months.

One type of tunneled CVC ends in a subcutaneous port. Basically, this is a small device placed under your skin which has one or two openings (also known as lumens). You can think of this port as a door that allows doctors to give you medicine, fluids, or nutrition without having to insert a needle into your vein each time. However, this type of port is not used for hemodialysis, a treatment for kidney failure that filters waste and extra fluid from your blood.

The other type of tunneled CVC exits the skin away from the vein entry point and does not have a subcutaneous port. This catheter has a cuff that helps it stay securely within the tissues under your skin. A big plus of this kind of CVC is that it does not require repeated needle-sticks for access. It can be used for providing nutrition, transmitting fluids, giving medications, and also for hemodialysis.

The placement of these tunneled catheters allows patients to continue receiving treatments directly into their veins even after they have been discharged from the hospital.

Anatomy and Physiology of Vascular Tunneled Central Catheter Access

Access to central veins is gained through the internal jugular, subclavian, and femoral veins. These are significant blood vessels that play a crucial role in delivering blood to and from different parts of the body.

The internal jugular vein carries blood from the head, face, and neck to a large vein called the superior vena cava. It lies next to the common carotid artery and the vagus nerve in the neck. It takes a different route on the right and left sides of the body. Lying down with head lower than the feet can increase its size for easier access during procedures. Care should be taken during this process for safety.

The subclavian vein, found beneath the collarbone, brings back blood from the arms. Its diameter can also be increased by positioning the patient with their head down. There is a risk of accidentally pricking the subclavian artery or the lining of the lung during procedures, so caution is always necessary.

The femoral vein, located in the groin area, returns blood from the lower limbs. It runs closely with the femoral artery. In emergency situations, this vein is often chosen for quick access. However, there’s a higher risk of bloodstream infection associated with procedures conducted on the femoral vein.

Understanding of these veins’ surface structures is key when conducting procedures. Using an ultrasound can help minimize complications, including blood leaks, unintended arterial access, lung puncture, and infections.

Why do People Need Vascular Tunneled Central Catheter Access

If a person needs long-term intravenous (IV) treatment, such as chemotherapy or nutrition, a piece of equipment called a tunneled central venous catheter (CVC) can be inserted into their body. This consists of a thin tube and a port (a small medical appliance) that are placed under the skin. The CVC connects to a major vein in the neck or chest area, allowing doctors to administer drugs or fluids directly into the bloodstream. The strong advantage of this method is that the equipment can stay in place for several months, allowing patients to live their usual lives, including activities like swimming and bathing, without worrying about damaging the catheter or getting an infection.

The procedure is done at least two weeks before treatment begins for the site to heal properly. Special needles that don’t cause damage are used to access the port, which contributes to its lifespan and prevents complications such as blood clots and infections.

Tunneled CVCs are also available without a subcutaneous port; in this case, the catheter comes out through a separate cut in the skin. This type is most often used for hemodialysis, a procedure that cleans the blood when the kidneys can’t. It’s usually installed in the right side of the neck, but the left side can also be used if necessary. It’s crucial that the catheter is inserted on the opposite side of the body to any planned or maturing arteriovenous fistula, a special type of access created for hemodialysis. Unfortunately, the use of the subclavian (under the collarbone) vein for placing the catheter can potentially lead to narrowing of the vein, which would compromise the function of the arteriovenous fistula.

When a Person Should Avoid Vascular Tunneled Central Catheter Access

Some people might have conditions that make getting a permanent tunneled central venous catheter (CVC), a tube inserted into a large vein for medical purposes, on their chest area slightly risky or not a good option. These conditions might include having a tumor, a severe burn or injury, or cystic fibrosis which requires chest physical therapy. For such people, a port (a small medical appliance inserted under the skin) may be put in the upper arm instead, but this comes with a higher chance of developing clots in the blood vessels. For patients needing dialysis, a procedure to cleanse the blood, another option can be using the femoral vein in the lower body for access.

Sometimes, when a person has a mild blood clotting disorder, it is better to correct this before inserting a catheter in order to prevent bleeding and formation of a hematoma, a solid swelling of clotted blood within the tissues.

Also, if a person has a partial blood clot in a vein where a CVC is already present, the clot might be carefully removed by inferring drugs that break down clots or by surgical procedures. A new catheter might be carefully placed in such a vein under imaging guidance to ensure the vein is open and to avoid the clot getting dislodged and causing harm. However, inserting a catheter into a completely blocked vein should be avoided.

On the other hand, there are some conditions where inserting a tunneled CVC is completely unsafe. These include when a person has severe blood clotting disorder that cannot be corrected, an uncontrolled widespread infection, or bacteria in the blood. In such cases, the doctors may place a temporary, non-tunneled catheter until the person can get treated for the clotting disorder or the infection. If a person already has a tunneled catheter and then develops a widespread infection due to bacteria in the blood, the recommendation is to take out the CVC.

Equipment used for Vascular Tunneled Central Catheter Access

To lower the chances of getting an infection, doctors must follow very strict cleanliness procedures. They need to wear special hospital clothes, which include a head cap, a face mask, a clean gown, and gloves. They also use a large clean sheet, known as a sterile drape, to cover the patient’s body where they will insert the needle, and the point where the needle will exit the body.

Next, the doctor cleans the area thoroughly with a special antiseptic solution, either chlorhexidine or povidone-iodine, to kill off bacteria and prevent infection. An anesthetic, similar to the kind used by dentists, is applied to numb the area where the needle will be inserted. They also numb the area under the skin where a special tunneling device will be used. Sometimes, they might also numb an area where a small container, a subcutaneous port, will be placed under the skin.

The doctor generally uses an ultrasound machine, protected with a clean cover, to get a clear image of the vein they’re targeting. An X-ray machine may also be used to ensure the catheter, a thin tube, is properly placed inside the patient. The equipment used to insert the catheter typically comes as a complete pack with everything the doctor needs.

Once the procedure is complete, the doctor stitches the needle insertion point and, for some catheters, firmly attaches the catheter to the skin where it exits. If a subcutaneous port is used, they use a special type of thread that the body can naturally break down over time to stitch the skin over it. Before putting into place, the catheter is filled with a sterile saltwater solution. The doctor will draw out a small amount of fluid through the catheter and then flush it again with the same solution. A solution with the addition of a substance called heparin may also be used to prevent blood clots from forming in the catheter. After the procedure, the exit point of the catheter is covered with a clean bandage, or a transparent adhesive wrap, depending on the type of catheter used. Sometimes, a special kind of surgical glue may be applied to the cut in the skin where the port is located.

Who is needed to perform Vascular Tunneled Central Catheter Access?

Tunneled Central Venous Catheters (CVCs) are typically put in by doctors who specialize in general or vascular surgery, or by doctors who specialize in using medical imaging to guide treatment procedures—these are called interventional radiologists. If these doctors aren’t trained in a type of anesthesia that leaves you awake but relaxed and free of pain (known as conscious sedation), then a special anesthesia doctor or nurse should be there.

If this procedure is done in an operating room, a specially trained medical worker or registered nurse should be there to help. If done by an interventional radiologist, a technician who’s dressed in sterile clothing to assist should also be there. There should be also an additional registered nurse in both the operating room and the room where the radiologist works to make sure the patient is well cared for and all necessary equipment is ready to use. If the operating room doesn’t have the ability to take X-ray images, a technician that specializes in X-ray or fluoroscopy (a type of medical imaging that shows a continuous X-ray image on a monitor) should be there to make sure the catheter (a flexible tube) is placed correctly.

Preparing for Vascular Tunneled Central Catheter Access

Before having surgery, it’s important for your doctor to understand your overall health. This involves discussing your medical history and having a physical examination. By doing this, your doctor can identify any risk factors that might affect the surgery and work to address them. For example, if you have a history of heart issues, your doctor might need to ensure your heart health is good before proceeding with the surgery. It’s also crucial to check for possible blood clotting disorders to make sure there are no complications after the surgery.

In addition, your previous medical conditions matter when deciding how to do the procedure. Say, if you have had kidney problems in the past, certain approaches might not be the safest for you.

A good physical exam can reveal any past issues that might influence the surgery, like skin infections (cellulitis), prior injuries, or other conditions that may affect the procedure.

Your doctor will also carry out some lab tests, including a blood test (complete blood count), tests to check the levels of salts and other chemicals in your blood (basic metabolic panel), and clotting studies. These tests help your doctor to make sure everything is in order and if anything is off, they’ll work on getting it right before the surgery.

In some situations, your doctor might ask for a chest X-ray and a heart test (electrocardiogram) before the surgery. This is especially important if you have been a smoker, have lung cancer, kidney disease, or heart disease. In addition, mapping the chest area while standing up helps to find the best place to insert the necessary surgical devices.

Your body type or build also matters in deciding the safest and most effective approach to the surgery. This helps to determine the best place to access your veins.

Finally, it’s vital for your doctor to consult with the doctor who referred you for the surgery. This helps them understand what specific type of device to use during the surgery, and how many channels it needs to have (lumens). All these preparations help enhance your safety during and after the procedure and ensure you get the best possible care.

How is Vascular Tunneled Central Catheter Access performed

This process describes how a doctor inserts a catheter into a vein in the neck of a kidney dialysis patient who’s waiting for the vein in their arm to mature and be ready for treatment.

First, the doctor locates an easily accessible vein in the neck at a spot where the clavicle (collarbone), sternocleidomastoid (muscle that runs down the side of your neck), and sternum (breastbone) meet. To simplify, this area is usually at the lower neck portion. The patient is then put in a position where their head is slightly lower than their feet. This position helps to widen the neck vein, making it easier for the doctor to insert the catheter.

In this method, the doctor uses a needle to access the vein in the lower part of the neck, then advances the needle at an angle towards the breastbone while continuously pulling back on the needle’s syringe. This helps to avoid drawing air into the vein and to make sure the needle is in the vein.

Once they’ve confirmed that the needle is in the vein, the doctor then removes the syringe and leaves the needle in the vein. They then insert a wire through the needle into the vein. To make sure the wire is in the right place in the vein, the doctor uses a type of X-ray machine called a fluoroscope.

The doctor then makes a small cut at the place where the needle was inserted and slides two dilators (tools that help to gently widen the vein) over the wire. The second dilator leaves behind a sheath (thin tube) in the vein. A special pen is then used to mark the exit site for the catheter on the chest. The doctor measures the catheter to make sure it will extend up to the right spot inside the vein. A tunneler (a long instrument) is used to guide the catheter under the skin from the chest to the vein in the neck.

The doctor then carefully guides the catheter through the peel-away sheath. Once the catheter is in place, they remove the sheath, making sure not to dislodge or twist the catheter as this can cause problems. After the catheter is in place, the doctor uses the fluoroscope again to confirm that the catheter is positioned correctly.

The doctor then checks if the catheter works by flushing it with saline (salt water), then locks the catheter with heparin (a medicine to prevent blood clots). They close the incision site with a stitch, and the catheter is secured with more stitches. A chest X-ray is then ordered to double check the catheter’s position and ensure there are no complications.

If ultrasound is used, it will help show clear images of the vein and the adjacent carotid artery in real-time. The doctor applies pressure to the ultrasound probe to differentiate between the vein and the artery, as the artery remains firm and pulsating. The ultrasound makes sure the needle is placed correctly and helps to avoid unwanted injury.

Possible Complications of Vascular Tunneled Central Catheter Access

Immediate complications are the problems that can occur within the first 30 days after a catheter placement. Some of these include bleeding, trapped air in the body (air embolism), a punctured lung (pneumothorax), wound separation (wound dehiscence), catheter moving from its intended position (catheter migration) and heart related issues (cardiac complications), as well as infections. Unlike in the past, the most common complications like accidental puncturing of an artery and resulting blood clot formation (hematoma) have decreased due to the routine use of ultrasound guidance.

You may experience minor bleeding where the catheter comes out of your body, but this is not usually severe. In fact, less than 0.1% of patients need a blood transfusion because of prolonged oozing. The doctors might suggest you to sit upright to lower the blood pressure in your veins. In case, you have kidney disease and experience abnormal bleeding, doctors might give you a drug called desmopressin.

Heart-related issues can arise when the catheter is not placed properly. The ideal position for the catheter is at the junction of the large vein carrying deoxygenated blood to the heart (cavoatrial junction) to avoid complications like irregular heart rhythm (arrhythmias), tearing of the heart (cardiac rupture), clotting in the catheter and catheter movement. If the catheter position is above this junction, it might flip into other large veins.

Although very rare, trapped air in the vein (air embolism) can occur during catheter placement. This complication accounts for roughly between 0.2% and 1% of patients getting a catheter. The severity can vary from having no symptoms to complete heart failure, depending on the air embolism size. Patients with air embolism might hear a type of heart sound called ‘millwheel’ murmur. The treatment protocol involves positioning the patient in specific ways and attempting to remove extra air from the heart and lungs through the catheter.

After 30 days, complications usually involve infections or blood clots (thrombosis). The infections can occur at the skin pocket for subcutaneous catheter or along the tunnel tract, or even inside the catheter, causing a condition known as CLABSI (Central Line-Associated Bloodstream Infection). If CLABSI is suspected, initial treatment involves administration of broad-spectrum intravenous antibiotics. An antibiotic lock technique, in which a high concentration of antibiotic and anticoagulant (heparin) solution is infused into the catheter, can also be used. This technique has been shown to decrease occurrences of CLABSI.

Stenosis (narrowing) and thrombosis in the catheter can develop from two main causes – damage to the vein wall leading to narrowing or blockage of the vein and deposition of proteins and cells within the catheter leading to thrombosis. To prevent these complications, a “locking solution” containing sodium citrate or concentrated heparin is used.

A London-based study following patients undergoing hemodialysis, which is a common reason for having a catheter, for an average of 4.7 years found that about 4.3% patients developed central venous stenosis (narrowing of central veins). Catheters placed on the left side of the body were found to have a greater risk of stenosis due to the narrower course of a large vein on the left side of the neck.

A study in Canada followed 1,041 adult patients who initiated outpatient maintenance hemodialysis therapy with tunneled catheters, and found complications of catheter malfunction (15%), blood infection (bacteremia) (9%), and central stenosis (2%) at 1 year.

What Else Should I Know About Vascular Tunneled Central Catheter Access?

Non-tunneled central venous catheters, or CVCs, are tubes inserted into a large vein, and are usually used for emergencies. These emergencies could include the need for urgent kidney dialysis or to help revive someone who’s dangerously ill. The right side of the neck (right IJ) is the usual place where these catheters are inserted, especially if the patient has a sudden kidney problem. But if a person is overweight, the left side of the neck is often chosen over the leg vein because it’s less likely to result in a certain type of infection, known as central line-associated bloodstream infections, or CLABSI. Non-tunneled catheters should be taken out right away if there’s an infection in the skin around them or if CLABSI is detected. If someone needs ongoing dialysis for their kidneys, permanent access is usually best, instead of using a non-tunneled catheter. If long-term medication infusions are needed, switching to a tunneled type of catheter or a PICC line, which is inserted in the arm, should be considered.

Tunneled CVCs are frequently used for dialysis access. Even though a connection created surgically between an artery and a vein (an arteriovenous fistula, or AVF) is the ideal access for dialysis, tunneled catheters could be employed in those who’ll need dialysis for three weeks or more while they’re waiting for an AVF to mature. Additionally, they could be used while planning different forms of dialysis, waiting for a kidney transplant from a living donor, or when no other access is feasible. They come in different designs and materials without any major differences in how they perform. It’s important to keep everything sterile when inserting and removing these catheters. They’re usually inserted in the right side of the neck, and then the left. Ideally, they should be placed on the opposite side from a future AVF. Veins in the collarbone area (subclavian veins) should be avoided because they increase the risk for vein narrowing. The cleanliness of the exit site is crucial for reducing CLABSI.

Tunneled CVCs with ports under the skin are used in patients who need long-term and intermittent IV treatments. This includes cancer patients and those needing nourishment given directly into their bloodstream over an extended period. When used correctly, these ports can meet their requirements with minimal risks of infection. Practical tools such as ultrasound and x-ray guidance can help control the possible short-term complications associated with catheter placement such as tissue inflammation, internal bleeding, and lung puncture.

Frequently asked questions

1. What type of tunneled central venous catheter (CVC) is recommended for my specific medical condition? 2. What are the potential risks and complications associated with the placement of a tunneled CVC? 3. How long can the tunneled CVC remain in place before it needs to be replaced? 4. What steps will be taken to prevent infections during and after the procedure? 5. What are the signs and symptoms of complications that I should watch out for after the placement of the tunneled CVC?

Vascular Tunneled Central Catheter Access involves gaining access to central veins, such as the internal jugular, subclavian, and femoral veins, to deliver blood to and from different parts of the body. This procedure can be done by positioning the patient with their head down to increase the size of the veins for easier access. However, caution is necessary to avoid complications such as accidental pricking of arteries or lung lining. Using an ultrasound can help minimize these complications.

You may need Vascular Tunneled Central Catheter Access if you have conditions that make getting a permanent tunneled central venous catheter on your chest area risky or not a good option. This could include having a tumor, a severe burn or injury, or cystic fibrosis which requires chest physical therapy. In these cases, a port may be inserted in the upper arm instead, but this comes with a higher chance of developing clots in the blood vessels. For patients needing dialysis, using the femoral vein in the lower body for access can be an option. Additionally, if you have a mild blood clotting disorder, it may be better to correct this before inserting a catheter to prevent bleeding and formation of a hematoma. If you have a partial blood clot in a vein where a CVC is already present, the clot might be carefully removed and a new catheter placed under imaging guidance. However, if a vein is completely blocked, inserting a catheter should be avoided. On the other hand, if you have a severe blood clotting disorder that cannot be corrected, an uncontrolled widespread infection, or bacteria in the blood, a temporary, non-tunneled catheter may be placed until you can receive treatment for the clotting disorder or infection. If you already have a tunneled catheter and develop a widespread infection due to bacteria in the blood, the recommendation is to remove the CVC.

A person should not get a Vascular Tunneled Central Catheter Access if they have conditions such as a tumor, severe burn or injury, cystic fibrosis, or a mild blood clotting disorder that is not corrected. Additionally, it is unsafe to get this procedure if a person has a severe blood clotting disorder that cannot be corrected, an uncontrolled widespread infection, or bacteria in the blood.

The recovery time for Vascular Tunneled Central Catheter Access is not mentioned in the provided text.

To prepare for Vascular Tunneled Central Catheter Access, the patient should discuss their medical history and undergo a physical examination with their doctor. Lab tests, such as blood tests and clotting studies, may be conducted to ensure the patient is in good health for the procedure. It is also important for the doctor to consult with the referring doctor to determine the specific type of device to use during the surgery.

The complications of Vascular Tunneled Central Catheter Access include bleeding, air embolism, pneumothorax, wound dehiscence, catheter migration, cardiac complications, and infections. Other complications can include hematoma, arrhythmias, cardiac rupture, clotting in the catheter, trapped air in the vein, thrombosis, and central venous stenosis.

The text does not provide information about specific symptoms that would require Vascular Tunneled Central Catheter Access. It only mentions that this type of access is used for long-term intravenous treatment, such as chemotherapy or nutrition, and for hemodialysis.

Based on the provided text, there is no specific mention of the safety of Vascular Tunneled Central Catheter Access in pregnancy. It is recommended to consult with a healthcare professional for personalized advice and to discuss the potential risks and benefits in the context of pregnancy.

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