Vascular Access

The goal of vascular access devices is to find the best way to administer the therapies required to help the patient recover while doing the least amount of damage to the patient’s vascular system.

Veins:    In order of preference, the veins which are commonly accessed are:

  • Internal Jugular vein
  • External Jugular vein
  • Collateral vein **
  • Femoral vein ***
  • Translumbar IVC
  • Transhepatic IVC

Technique:

  • The vein is accessed using ultrasound guidance
  • Using fluoroscopy, the catheter is placed in appropriate position based on the type of the catheter.

 

Peripheral venous access:

  • Venflon

  • PICC

 

Central venous access:

  • Non Tunneled catheter

  • Tunneled catheter

  • Portcath

 

Equipment:

  • Ultrasound

 

  • Fluoroscopy

 

  • Cone beam CT

 

 

1. What is venous access?

Venous access is introduction of a needle into a vein.

2. Why do I need venous access?

Venous access is usually used for the purpose of withdrawing blood or administering fluids or medication.

3. What are the types of venous accesses?

There are a variety of options available for venous access.

These are broadly divided into:

  • Peripheral venous access
  • Peripherally inserted central venous access
  • Central venous access

These are tailored to each patient’s needs and to the type, duration, and frequency of infusion.

4. What is peripheral venous access?

Peripheral venous access is a simple, inexpensive way of venous access used for short-term IV therapy.

Veins are typically accessed in the patient’s hand or arm, and sometimes in the foot.

5. What are the risks associated with the peripheral venous access and how to avoid?

Infiltration and phlebitis increase dramatically with increased catheter dwell-time, due to small caliber veins.
These cannot be used for more than a few days.

These can be avoided by

  • Replacing the lines and rotating the site of access at least every 72 to 96 hours.
  • Opting for central venous access, if the need for IV access is for more than few days.

6. Why do I need central venous access?

Central venous access is recommended if the IV access is needed for more than a few days. It is cost effective and avoids the risks associated with the peripheral venous access.

The indications for central catheters include the following:

  • Administration of IV fluids, medications, or blood products, either in large quantities or over a prolonged period of time;
  • Administration of medications that are harmful to peripheral veins (eg, chemotherapy);
  • Long-term access to the central venous system for repeated procedures, such as blood sampling; and
  • Poor or inaccessible peripheral venous access

7. What is central venous access?

When a catheter or line which are a long thin plastic tubes are placed by entering into a vein in the arm, neck or front of chest and extending into a central vein next to the heart is called central venous access.

8. What are advantages of the central venous access?

  • The larger central vein can tolerate the catheter line much better than a small vein.
  • The catheter can stay there safely for weeks or months, sometimes more than a year or years depending on the type of vascular device.
  • Easy administration of the medications that are harmful to the peripheral veins.

9. How do you place central venous access?

Central venous access catheters can be placed by accessing the veins in the neck, chest, groin, lumbar, hepatic or through veins in the arms (also known as a PICC line, or peripherally inserted central catheters).

10. What is peripherally inserted central venous catheter (PICC)?

These are central venous catheters most commonly inserted via the basilic, brachial, or cephalic veins with the tip lying in the central veins next to the heart.

11. What are the advantages of the PICC?

Easy and safer insertion.

Common indications include:

Parenteral delivery of

  • Nutrition,
  • Antibiotics,
  • Analgesics
  • Chemotherapy and
  • Repeated blood transfusions.

12. What are the disadvantages/complications of PICC?

Require frequent flushing and dressing changes, and the insertion site should not get wet.

Complications include:

  • Dislodgment,
  • Occlusion,
  • Mechanical phlebitis, and
  • Deep vein thrombosis (DVT).

13. What is a midline?

  • These are inserted into the antecubital (or other upper arm) veins like the PICC, but their tips do not reach the central veins of the thorax.
  • These are recommended for short term when wire cannot be accessed into the central veins.
  • They have a limited duration of between 1 and 4 weeks.
  • They are not advised for administration of vesicant or highly irritating drugs that could harm the peripheral veins

14. What are Centrally inserted catheters?

For central insertion, preferred veins include the internal and external jugular.

Although access to the subclavian might be technically easy using bony landmarks in the absence of ultrasound guidance, it is generally not advised to place VADs directly into this vein owing to the relatively high incidence of venous thrombosis and the increased risk of catheter damage or fracture associated with subclavian lines.

15. What are the types of central venous catheters?

The 3 main types of centrally inserted catheters are:

  • Non-tunneled,
  • Tunneled, and
  • Implantable ports.

Non-tunneled catheters

  • Short-term access
  • Typically meant for rapid resuscitation or pressure monitoring.
  • The lifespan of the catheter is 5 to 7 days
  • Associated with a higher risk of infection
  • Inappropriate for patients who require central venous access for longer than 2 weeks.

Tunneled catheters

  • Appropriate long term access
  • Reduce the incidence of infection by increasing the distance between the skin entry site and the venotomy.
  • They do have risk of thrombosis, occlusion, and infection in the long term requiring removal or exchanges or replacements.

 

Implantable ports

These consists of a catheter attached to a reservoir that is implanted into a surgically created pocket on the chest wall or upper arm. A needle is inserted through the port’s septum to access the reservoir.

Advantages include

  • Less interference with daily activities,
  • Less frequent flushing, and
  • Reduced risk of infection

Disadvantages include

  • The need for needle insertion,
  • Increased discomfort, and
  • The risk of extravasation.
  • Expensive

16. Is it painful?

A local anesthetic is used to temporarily numb the skin at the site of access. There might be pricking sensation to start with, after a few seconds it should become numb.

17. Will I be awake for this procedure?

Most of these procedures can be performed using local anesthetic. However, depending on the case and safety some sedation can be given which makes patient a little sleepy.
In extreme cases, anesthesia support is taken to perform the procedure.

18. Who performs the procedure?

A Radiologist is a doctor who is specially trained in using the X-ray equipment and ultrasound scanner to guide him or her during procedures can perform these procedures.

Alternatively, a specially trained nurse or a surgeon may carry out the procedure.

19. Where can the procedure be performed?

The procedure is carried out in a specially designed room which has X-ray and Ultrasound scanning facilities as well as patient monitoring equipment.

20. How long does it take to perform the procedure?

Depending on the type of vascular access, sedation, monitoring requirements, these procedures can last for about 15-60 minute. Some might take longer depending on the complexity of the case.

21. What are the risks?

Any intervention has got its own risks and it depends on the complexity of the case.
Few of the risks associated are classified into

Vascular injuries:

  • Arterial injury,
  • Venous injury,
  • Bleeding, and
  • Hematoma.

Pulmonary complications:

  • Pneumothorax,
  • Pneumomediastinum,
  • Chylothorax,
  • Tracheal injury,
  • Injury to the recurrent laryngeal nerve, and
  • Air embolus.

Cardiac complications:

  • Arrhythmia and
  • Cardiac arrest.

Device dysfunction:

  • Fibrin sheath formation,
  • Fracture,
  • Thrombosis,
  • Central venous stenosis, and
  • Infection.
  • Site of catheter placement, duration of catheterization, and underlying patient comorbidities all affect the rate of device dysfunction.

Infection:

  • Sepsis,
  • Shock, and
  • Death.

22. What medicines are given through central venous access?

  • Long term medications for pain, infection, or cancer, or to supply nutrition.
  • Medications that affect the heart, especially if a quick response to the medicine is wanted.
  • Blood transfusions.
  • To take frequent blood samples without having to "stick" someone with a needle.
  • Dialysis.

23. Will people see the catheter?

Most of the these are visible at their entry site, how ever these can be covered to avoid visualization.
Implanted catheters like portcath are not visible outside.

24. How long can the catheter stay in?

Depending on the type of the vascular access device and type of needs, these can stay for few days to months to years.

25. Is there anything I can’t do anymore while I have this catheter?

Aside from knowing that they have the catheter, these should normally not interfere with day to day activities.