Chapter 17: Vascular access devices: insertion and management
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Evidence‐based approaches
Rationale
Tunnelled silicone catheters were first described by Broviac in Seattle in 1973 and were subsequently modified by Hickman and colleagues, who created a larger lumen of 1.6 mm internal diameter (Bjeletich and Hickman [38]). The special features added included an inert antithrombogenic flexible material and a subcutaneous Dacron cuff attached to the catheter (Ives [225]). The cuff has two functions: to secure the catheter and prevent infection; it achieves these by increasing the length of the subcutaneous tunnel – that is, the distance between the point of insertion of the catheter into the vessel and the exit site from the skin (Singh Vats [417]).
Indications
Contraindications
These are the same as for other CVADs.
Methods of insertion
The insertion of a skin‐tunnelled catheter is a surgical procedure usually carried out in an operating theatre or designated area, under aseptic conditions, using fluoroscopy and monitoring of the patient by pulse oximetry and ECG to detect arrhythmias (Benton and Marsden [27], Dougherty [123], Galloway and Bodenham [165], Weinstein and Hagle [465]). The procedure is now also performed by nurse specialists at the bedside and within radiology departments (Benton and Marsden [27], Boland et al. [46], Fitzsimmons et al. [149], Hamilton et al. [199], Light et al. [270]). The procedure is usually performed under sedation along with the use of local anaesthesia (Dougherty [123]). In some patients, for example children, the procedure is carried out under general anaesthesia.
The aim of the insertion is to place the catheter tip in the cavo‐atrial junction or right atrium via the internal jugular vein or the subclavian vein (Bodenham et al. [43], Galloway and Bodenham [165]). The internal jugular vein route presents the lowest incidence of mechanical and thrombotic complications (Biffi et al. [36], Bodenham et al. [43], Granziera et al. [184]). When there is an SVC obstruction from thrombosis or compression, the femoral vein can be used to access the inferior vena cava. Selection of vessels is as for non‐tunnelled CVCs (refer to ‘Vein selection’ within ‘Short‐term percutaneous central venous catheters (non‐tunnelled)’ above). Access may be gained percutaneously using a needle and guidewire or via an open surgical cutdown procedure.
The catheter can be inserted percutaneously when the venepuncture site is near the subclavian or internal jugular. The tunnelling rod is then passed under the skin and exits at a predetermined point on the chest. The catheter is then attached to the tunnelling rod and drawn through the subcutaneous tunnel. The catheter is then passed into the vein via a peel‐away sheath introducer (Davidson and Al Mufti [105], Galloway and Bodenham [165], Hadaway [194]). Position is confirmed by the easy aspiration of blood from each lumen and these are then flushed with heparin until correct tip placement has been confirmed. A chest X‐ray should be performed after insertion to check for correct placement and rule out pneumothorax (Bodenham et al. [43], Davidson and Al Mufti [105], Stacey et al. [427]).
Methods of removal
Removal techniques for skin‐tunnelled catheters vary. Removal should only be performed by specially trained nurses or doctors. It is recommended that the patient is placed supine and that aseptic technique is used throughout. There are two methods of removal: surgical excision and the traction method.
Surgical excision
This method involves locating the cuff and performing a minor surgical excision under local anaesthetic. Most cuffed devices need surgical cut‐downs as they develop complex adherent fibrin sleeves and scar tissue (Bodenham et al. [43]). A small incision is made over the site of the cuff and blunt dissection (i.e. using forceps) is carried out to prise the tissues apart (Galloway and Bodenham [165], Hudman and Bodenham [218]); this causes less damage to the tissues than using a scalpel. The cuff and the catheter are freed from the surrounding fibrous tissue (Dougherty [123]). The proximal section of the catheter is then removed and cut, and the distal end is removed via the exit site. Once the catheter has been removed, the wound is sutured using interrupted sutures, which can be removed after 7 days (Drewett [134], Galloway and Bodenham [165]).
Traction method
With the traction method, there is a greater risk of the catheter breaking, which can result in a catheter embolism. This method should only be used if the catheter has been in situ for less than 3–4 weeks, if healing is delayed or if the site is heavily infected, as in all of these situations the cuff may not be fixed and is easier to pull out (Light et al. [270]). If movable, the cuff will pull out with a series of tugs, as it passes through the tissues. If immovable, proceed to surgical removal to avoid breaking the catheter (Drewett [134]). Very long‐term catheters may become attached to the wall of the SVC or right atrium and cannot be removed by traction alone; cutting off and leaving in situ or surgical removal may be required (Bodenham et al. [43]).
