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 Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 2  |  Issue : 3  |  Page : 66-70

Central venous catheterization: An updated review of historical aspects, indications, techniques, and complications


1 Department of General Surgery, Hospital Nossa Senhora da Conceição de Porto Alegre, Porto Alegre, Brazil
2 Department of Oncogynecologyc Surgery, Hospital Nossa Senhora da Conceição de Porto Alegre, Porto Alegre, Brazil

Date of Submission13-Apr-2017
Date of Acceptance15-Jul-2017
Date of Web Publication15-Sep-2017

Correspondence Address:
Ricardo Pedrini Cruz
Department of Oncogynecologyc Surgery, Hospital Nossa Senhora da Conceicao de Porto Alegre, Avenida Francisco Trein, 596, Porto Alegre 91350-200, RS
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ts.ts_10_17

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  Abstract 

Central venous catheterization has become an indispensable procedure in various situations in the intensive care unit, emergency room and operation room. There are many applications such as invasive hemodynamic monitoring, parenteral nutrition support, dialysis, chemotherapy, fluid resuscitation and drug administration, though there are some complications associated with catheter placement. There are some articles that discuss the security and advantages of the anatomic landmark technique and ultrasound (US) guidance technique. In this non-systematic review article we searched the current data in Pubmed library.

Keywords: Central access, central venous access complications, central venous access techniques, central venous catheter, venous catheter


How to cite this article:
Pires RC, Rodrigues N, Machado J, Cruz RP. Central venous catheterization: An updated review of historical aspects, indications, techniques, and complications. Transl Surg 2017;2:66-70

How to cite this URL:
Pires RC, Rodrigues N, Machado J, Cruz RP. Central venous catheterization: An updated review of historical aspects, indications, techniques, and complications. Transl Surg [serial online] 2017 [cited 2017 Nov 23];2:66-70. Available from: http://www.translsurg.com/text.asp?2017/2/3/66/214805


  Introduction Top


Werner Forssmann, in 1929, was the first physician to introduce venous devices for central vein catheterization.[1] The applications and techniques have been improved progressively since then.[1] Dr. Sven-Ivar Seldinger introduced the central venous puncture technique known as “Seldinger technique” in the 1950s, and nowadays, it is the main method in use.[2] The use of central venous catheters (CVCs) became a routine procedure in the emergency rooms, Intensive Care Units (ICUs), and operation rooms, despite the evolution of central venous access techniques and the CVCs. A thorough knowledge of anatomy is required by the physician to reduce complications.


  Literature Search Strategy Top


The mesh terms “central venous access,” “central venous access” and “complications,” “central venous access” and “ultrasound” (US) and “central venous access” and “landmark techniques” were searched in PubMed library. Original, meta-analysis and review articles were included without considering the publication date. The total number of articles appeared was 1,664, details of which are summarized in [Table 1]. Other articles were found by searching the references of the selected articles. After analyzing the titles and abstracts, 38 articles were selected to be read in full.
Table 1: Description of references searched

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  Results Top


The most common indications of the central venous line include invasive hemodynamic monitoring (central venous pressure, pulmonary artery pressure), parenteral nutrition support, dialysis, chemotherapy, temporary pacemaker, venous line for caustic solutions, venous line for rapid fluid resuscitation, and inadequate peripheral veins.[3] Contraindications include infection of the puncture site and blood dyscrasia, and relative contraindication includes anatomic variations. Subclavian, internal jugular, and femoral veins are the main sites for central venous access puncture. The techniques of which are described below.

General procedure

  1. The position of the patient is the principal step in central venous catheterization. In general, to access subclavian, jugular or femoral veins, supine position is recommended
  2. Antisepsis and careful aseptic protection with sterile fields are mandatory.


Puncture techniques

Internal jugular vein

Trendelenburg position, contralateral rotation of the neck and extension of the ipsilateral arm is advised for jugular catheterization.[4],[5],[6] The internal jugular vein is found anterolaterally to the internal carotid artery. The distal half is located in the triangle formed by the clavicular and sternal heads of sternocleidomastoid muscle, and the upper border of the clavicle [Figure 1]. The jugular veins drain to the subclavian vein in the proximal third of the clavicle.
Figure 1: Anatomic landmarks for jugular vein puncture

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Anatomical landmarks are important to internal jugular vein catheterization. The apex of the jugular triangle is the puncture landmark point. Internal vein catheterization is achieved using the ipsilateral nipple to guide the needle. Maintaining negative pressure on the syringe, the needle is inserted about 2–3 cm deep into the skin. It is important to alleviate the skin pressure and recede the needle to avoid vein from collapsing. After confirmation of venous reflux, the passage of the guidewire is performed. Skin dilation must be performed by the appropriate cannula, inserting not more than 1–2 cm through the skin.

Unfortunately, in some patients, the anatomical landmarks are difficult to identify, as in obese patients. A tip to internal vein cannulation in such patients is to prepare the patient as previously describe, and imagine a line between ipsilateral mastoid and sternal furcula. Then, this line must be divided into three regions; superior, middle, and inferior. The needle must be inserted in the junction of middle and inferior regions, with the same needle guidance.

Subclavian vein

Trendelenburg position, contralateral rotation of the neck and extension of the ipsilateral arm are advised for subclavian catheterization. Some physicians use a cushion placed between shoulder blades to facilitate the access to the subclavian vein, though it reduces the cross-sectional area of the vein hindering the needle insertion.[7] The subclavian vein originates from the axillary vein, extends from the side edge of the first rib to the sternal end of the clavicle, joining the internal jugular vein to form the brachiocephalic vein.

The preferred anatomical landmark for subclavian vein catheterization is 1 cm caudal to the junction of the medial and middle thirds of the clavicle, directing the needle to sternal furcula. A tip to subclavian vein catheterization is to identify the triangle formed by applying a gentle digital pressure on the inferior border of the clavicule [Figure 2]. The puncture site (the apex of this triangle) and the patient position are illustrated in [Figure 3]. The needle and syringe should be parallel to the bed. Vein is accessed when the venous reflux is achieved by maintaining a negative pressure on the syringe. After the introduction of the guidewire, the skin dilation is performed with the appropriate cannula dilator to enable catheter insertion as previously described.
Figure 2: Anatomic landmarks for subclavian vein catheterization

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Figure 3: Correct position for subclavian vein catheterization

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Femoral vein

Little abduction, external rotation of the ipsilateral leg and inverse trendelenburg position is advised for femoral vein catheterization. The femoral vein is the most medial structure of the femoral canal. It starts at the hunter canal, formed by the popliteal vein, and receives various tributary muscle veins; the deep femoral vein and great saphenous vein. It ends at the bottom of the inguinal ligament, becoming the external iliac vein.

The femoral artery pulse serves as a landmark to femoral vein identification, being just medial to it. After identifying the femoral pulse below the inguinal ligament, the needle is inserted about 0.5 cm medially to it and directed cranially in a 45° angle. Maintain negative pressure on the syringe until the venous reflux is achieved. Complete the procedure with guidewire passage, skin dilatation, and catheter introduction.

Ultrasound guidance technique

Internal jugular vein

An assistant may be necessary to handle the probe (preferably a 7.5–9 MHz vascular transducer). Using sterile cover for the probe, the major vessels can be identified as two circles when the probe is used in a transverse position in relation to the neck [Figure 4]. The artery appears as a pulsatile hypoechoic circle, and the jugular vein can be safely differentiated when external pressure is applied, being collapsed [Figure 5]. The syringe is advanced (maintaining negative pressure until venous reflux is achieved) under ultrasound guidance.[8],[9]
Figure 4: Ultrasound image of the left jugular vein

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Figure 5: Ultrasound image of compressed left jugular vein

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Femoral vein

The probe must be positioned inferiorly to the inguinal ligament. The femoral vein is identified medially to the femoral artery. Valsalva maneuver can be used to enlarge the vein diameter and the vein can be collapsed applying external pressure. After the syringe is advanced (maintaining negative pressure until venous reflux is achieved) under ultrasound guidance.[10],[11]

Subclavian vein

The static technique is advised for subclavian vein instead of dynamic US guidance technique due to the clavicular acoustic shadow.

Complications

Complications of CVC can be classified into three categories: mechanical (hematoma, arterial puncture, pneumothorax, hemothorax, catheter misplacement, and stenosis), infectious (insertion site infection, CVC colonization, and bloodstream infection) and thrombotic (deep vein thrombosis). These three categories occur in 5%–19%, 5%–26% and 2%–26% of patients, respectively.[12],[13] Complications vary according to insertion route [Table 2], technique used number of attempts and personal experience.
Table 2: Complications of central venous catheterization using anatomical landmark technique

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In a prospective study conducted in the ICU with 707 patients submitted to subclavian placement of CVC, arterial punctures were reported in 7.8% of patients, while pneumothorax and misplacements of the catheter tip were 3.1% and 4.2%, respectively.[18] A systematic review including 17 prospective trials that compared jugular and subclavian access concluded that arterial puncture is more common in jugular access, while misplacement of the catheter tip was less common in the jugular CVC.[17] This study did not find differences in pneumothorax and hemothorax incidences between puncture sites.

The femoral access technique is associated with a higher risk of catheter-related thrombosis.[14],[19] A randomized controlled trial involving 289 ICU patients, compared femoral and subclavian catheterizations and evidenced 21.5% of catheter-related thrombosis in the femoral venous line, whereas only 1.9% in the subclavian venous line (P < 0.001).[19] A systematic review compared the use of heparin and 0.9% sodium chloride flushing to prevent catheter thrombosis and showed no statistically significant difference.[20]

Infection of CVC leads to increased morbidity and costs in health-care systems. According to Graham et al.,[14] infection with subclavian, jugular and femoral approach is associated to 4, 8.6, and 15.3/1,000 catheter-days, respectively. Femoral access has been shown to be associated with an increased risk of infection,[4],[14],[19] but some authors suggest that there is no difference among the three puncture sites when the strict sterile technique is followed.[21],[22] Many types of dressing (gauze, transparent material, frequency of change) and care systems are described,[23],[24] although the optimal type cannot be recommended due to the lack of evidence. The use of medication-impregnated dressing (chlorhexidine gluconate and silver-alginate) reduces catheter colonization and catheter-related bloodstream infection, however, further research is necessary to assess the impact of these measures in CVC infectious complications.[25],[26],[27]

Surgical experience is inversely proportional to the number of attempts of vein catheterization. Some authors have shown that more than two attempts for central vein catheterization are associated with higher complication rates.[16] Other authors demonstrated 50% reduction in the risk of mechanical complications after fifty or more catheterizations performed.[4]

The use of the US to guide central vein catheterization has become popular among physicians. A systematic review showed that US is associated with lower complication rates, higher success rates and lesser attempts.[28] A meta-analysis conducted by Hind et al.,[29] showed that the use of US for jugular vein catheterization is associated with lower failure rate (hazard ratio [HR] 0.14, 95% confidence interval [CI] 0.06–0.33) and success on the first attempt (HR 0.59, 95% CI 0.39–0.88). The landmark technique was shown to be more successful for subclavian vein catheterization than the US-guided approach (1.48, 95% CI 1.03–2.14). A prospective randomized trial comparing the US guidance and the landmark technique for internal jugular vein catheterization evidenced success rates of 93.9% and 78.5% (P = 0.009, 95% CI 3.8%–27.0%), and complications rates of 4.6% and 16.9%, respectively (95% CI 1.9%–22.8%).[30] Although they demonstrated a tendency of lower complication rates in the US technique, no significant difference was found.

Keenan et al.[31] conducted a systematic review with 18 trials and found that US guidance reduced the number of attempts (risk reduction, 1.41, 95% CI, 1.15–1.67) and arterial puncture rates (risk difference, −0.07, 95% CI, −0.10–−0.03). Some studies have shown a reduction in the procedural time required for US-guided central venous catheterization.[32],[33],[34],[35] However, these studies did not evaluate the time necessary to prepare the equipment.


  Conclusion Top


Central vein catheterization is an important invasive procedure often performed to administer the medication, hemodynamic monitorization, and total parenteral nutrition. It can be associated with significant mechanical complication rates, which can be reduced by considering appropriate indications, knowledge of anatomical landmarks and personal experience in central venous catheterization. Complications vary according to the puncture site chosen. The subclavian route is associated with highest rates of mechanical complication, while femoral route with thrombotic complication.

US guidance for CVC is becoming more popular in the medical practice because of its advantages, such as lower complication rates and higher rate of successful attempts, safety in patients with disorders of hemostasis and the possibility of not performing routine chest radiography after the procedure.[36],[37] Even with the US popularization, the anatomic landmark technique can be safely taught in teaching hospitals, with acceptable complication rates.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Beheshti MV. A concise history of central venous access. Tech Vasc Interv Radiol 2011;14 (4):184-5.  Back to cited text no. 1
    
2.
Buckley CJ, Buckley SD. Evolution of endovascular therapy: Where are we now? In: Khanna NN, Henry M, editors. Handbook of Interventions for Structural Heart and Peripheral Vascular Disease. New Delhi: Jaypee; 2016. p. 95-8.  Back to cited text no. 2
    
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Moureau N, Chopra V. Indications for peripheral, midline and central catheters: Summary of the MAGIC recommendations. Br J Nurs 2016;25 (8):S15-24.  Back to cited text no. 3
    
4.
McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348 (12):1123-33.  Back to cited text no. 4
    
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Gok F, Sarkilar G, Kilicaslan A, Yosunkaya A, Uzun ST. Comparison of the effect of the Trendelenburg and passive leg raising positions on internal jugular vein size in critically ill patients. Int J Clin Exp Med 2015;8 (10):19037-43.  Back to cited text no. 5
    
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Moayedi S, Witting M, Pirotte M. Safety and Efficacy of the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access. J Emerg Med 2016;51 (6):636-42.  Back to cited text no. 6
    
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Rodriguez CJ, Bolanowski A, Patel K, Perdue P, Carter W, Lukish JR. Classical positioning decreases the cross-sectional area of the subclavian vein. Am J Surg 2006;192 (1):135-7.  Back to cited text no. 7
    
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Soni NJ, Reyes LF, Keyt H, Arango A, Gelfond JA, Peters JI, Levine SM, Adams SG, Restrepo MI. Use of ultrasound guidance for central venous catheterization: a national survey of intensivists and hospitalists. J Crit Care 2016;36:277-83.  Back to cited text no. 8
    
9.
Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev 2015;1:CD006962.  Back to cited text no. 9
    
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Powell JT, Mink JT, Nomura JT, Levine BJ, Jasani N, Nichols WL, Reed J, Sierzenski PR. Ultrasound-guidance can reduce adverse events during femoral central venous cannulation. J Emerg Med 2014;46 (4):519-24.  Back to cited text no. 10
    
11.
Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev 2015;1:CD011447.  Back to cited text no. 11
    
12.
Kander T, Frigyesi A, Kjeldsen-Kragh J, Karlsson H, Rolander F, Schött U. Bleeding complications after central line insertions: relevance of pre-procedure coagulation tests and institutional transfusion policy. Acta Anaesthesiol Scand 2013;57 (5):573-9.  Back to cited text no. 12
    
13.
Bowdle A. Vascular complications of central venous catheter placement: evidence-based methods for prevention and treatment. J Cardiothorac Vasc Anesth 2014;28 (2):358-68.  Back to cited text no. 13
    
14.
Graham AS, Ozment C, Tegtmeyer K, Lai S, Braner DA. Videos in clinical medicine. Central venous catheterization. N Engl J Med 2007;356 (21):e21  Back to cited text no. 14
    
15.
Bernard RW, Stahl WM. Subclavian vein catheterizations: a prospective study: I. Non-infectious complications. Ann Surg 1971;173 (2):184-90.  Back to cited text no. 15
    
16.
Eisen LA, Narasimhan M, Berger JS, Mayo PH, Rosen MJ, Schneider RF. Mechanical complications of central venous catheters. J Intensive Care Med 2006;21 (1):40-6.  Back to cited text no. 16
    
17.
Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: internal jugular versus subclavian access-a systematic review. Crit Care Med 2002;30 (2):454-60.  Back to cited text no. 17
    
18.
Lefrant JY, Muller L, De La Coussaye JE, Prudhomme M, Ripart J, Gouzes C, Peray P, Saissi G, Eledjam JJ. Risk factors of failure and immediate complication of subclavian vein catheterization in critically ill patients. Intensive Care Med 2002;28 (8):1036-41.  Back to cited text no. 18
    
19.
Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre E, Rigaud JP, Casciani D, Misset B, Bosquet C, Outin H, Brun-Buisson C, Nitenberg G; French Catheter Study Group in Intensive Care. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 2001;286 (6):700-7.  Back to cited text no. 19
    
20.
López-Briz E, Ruiz Garcia V, Cabello JB, Bort-Marti S, Carbonell Sanchis R, Burls A. Heparin versus 0.9% sodium chloride intermittent flushing for prevention of occlusion in central venous catheters in adults. Cochrane Database Syst Rev 2014,8(10): CD008462.  Back to cited text no. 20
    
21.
Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med 2012;40 (8):2479-85.  Back to cited text no. 21
    
22.
Deshpande KS, Hatem C, Ulrich HL, Currie BP, Aldrich TK, Bryan-Brown CW, Kvetan V. The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population. Crit Care Med 2005;33 (1):13-20.  Back to cited text no. 22
    
23.
Schiffer CA, Mangu PB, Wade JC, Camp-Sorrell D, Cope DG, El-Rayes BF, Gorman M, Ligibel J, Mansfield P, Levine M. Central venous catheter care for patient with cancer: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 2013;31 (10):1357-70.  Back to cited text no. 23
    
24.
Gavin NC, Webster J, Chan RJ, Rickard CM. Frequency of dressing changes for central venous access devices on catheter-related infections. Cochrane Database Syst Rev 2016;2:CD009213.  Back to cited text no. 24
    
25.
Ullman AJ, Cooke ML, Mitchell M, Lin F, New K, Long DA, Mihala G, Rickard CM. Dressings and securement devices for central venous catheters (CVC). Cochrane Database Syst Rev 2015;(9):CD010367.  Back to cited text no. 25
    
26.
Hill ML, Baldwin L, Slaughter JC, Walsh WF, Weitkamp JH. A silver-alginate-coated dressing to reduce peripherally inserted central catheter (PICC) infections in NICU patients: a pilot randomized controlled trial. J Perinatol 2010;30 (7):469-73.  Back to cited text no. 26
    
27.
Lai NM, Taylor JE, Tan K, Choo YM, Ahmad Kamar A, Muhamad NA. Antimicrobial dressings for the prevention of catheter-related infections in newborn infants with central venous catheters. Cochrane Database Syst Rev 2016;3:CD011082.  Back to cited text no. 27
    
28.
Atkinson P, Boyle A, Robinson S, Campbell-Hewson G. Should ultrasound guidance be used for central venous catheterization in the emergency department? Emerg Med J 2005;22 (3):158-64.  Back to cited text no. 28
    
29.
Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, Thomas S. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003;327 (7411):361.  Back to cited text no. 29
    
30.
Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study. Ann Emerg Med 2006;48 (5):540-7.  Back to cited text no. 30
    
31.
Keenan SP. Use of ultrasound to place central lines. J Crit Care 2002;17 (2):126-37.  Back to cited text no. 31
    
32.
Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein. A prospective, randomized study. Anesth Analg 1991;72 (6):823-6.  Back to cited text no. 32
    
33.
Slama M, Novara A, Safavian A, Ossart M, Safar M, Fagon JY. Improvement of internal jugular vein cannulation using an ultrasound-guided technique. Intensive Care Med 1997;23 (8):916-9.  Back to cited text no. 33
    
34.
Hilty WM, Hudson PA, Levitt MA, Hall JB. Real-time ultrasound-guided femoral vein catheterization during cardiopulmonary resuscitation. Ann Emerg Med 1997;29 (3):331-6.  Back to cited text no. 34
    
35.
Miller AH, Roth BA, Mills TJ, Woody JR, Longmoor CE, Foster B. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Acad Emerg Med 2002;9 (8):800-5.  Back to cited text no. 35
    
36.
Tercan F, Ozkan U, Oguzkurt L. US-guided placement of central vein catheters in patients with disorders of hemostasis. Eur J Radiol 2008;65 (2):253-6.  Back to cited text no. 36
    
37.
Hourmozdi JJ, Markin A, Johnson B, Fleming PR, Miller JB. Routine Chest Radiography Is Not Necessary After Ultrasound-Guided Right Internal Jugular Vein Catheterization. Crit Care Med 2016;44 (9):e804-8.  Back to cited text no. 37
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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