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112
V. L. Bishay et al.
devices [34]. Overall, closure devices that rely solely on
procoagulant material are signicantly more likely to be
associated with vascular complications, such as access site
bleeding and the requirement for blood transfusion, as compared to devices that suture closed the arteriotomy [35].
Although complications rates are similar, the invasive
devices that introduce a foreign body expose the patient to a
small risk of infection. Infections of the common femoral
artery can be clinically devastating, so use of invasive devices
should not be taken for granted.
Whatever method for hemostasis is chosen, it is imperative that the interventionalist have a good grasp of the benets and drawbacks of each and know how to effectively
perform MC as well as deploy a variety of closure devices.
References
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angiography. Catheter Cardiovasc Diagn. 1989;16(1):3–7.
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and plethysmography: comparison with the Allen's test in 1010
patients. Am Heart J.2004;147(3):489–93.
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19. Yoo BS, Yoon J, Ko JY, Kim JY, Lee SH, Hwang SO, et al.
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M. Risk of acute brain injury related to cerebral microembolism
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23. Dudrick S, Masland W, Mishkin M.Brachial plexus injury following axillary artery puncture. Further comments on management.
Radiology. 1967;88(2):271–3.
24. Gur S, Oguzkurt L, Gurel K, Tekbas G, Onder H.US-guided retrograde tibial artery puncture for recanalization of complex infrainguinal arterial occlusions. Diagn Interv Radiol. 2013;19(2):
134–40.
25. Palena LM, Manzi M.Antegrade pedal approach for recanalizing
occlusions in the opposing circulatory pathway of the foot when
a retrograde puncture is not possible. J Endovasc Ther. 2014;
21(6):775–8.
26. Binkert CA, Alencar H, Singh J, Baum RA. Translumbar type
II endoleak repair using angiographic CT.J Vasc Interv Radiol.
2006;17(8):1349–53.
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C, etal. Ultrasonic locating devices for central venous cannulation:
meta-analysis. BMJ. 2003;327(7411):361.
28. Knutstad K, Hager B, Hauser M.Radiologic diagnosis and management of complications related to central venous access. Acta
Radiol. 2003;44(5):508–16.
29. Kato F, Sato Y, Yuasa N, Abo D, Sakuhara Y, Oyama N, et al.
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from 4 hours to 2 hours: a randomized trial and a one-arm study.
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8 Vascular Access Techniques andClosure Devices
113
intervention: a prospective randomised study of the angio-seal
device vs. the femostop device. Int JCardiol. 2000;76(2–3):235–40.
31. Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention
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(PROPHET study): a randomized comparison of traditional versus
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32. Rijkée MP, Statius van Eps RG, Wever JJ, van Overhagen H, van
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35. Resnic FS, Majithia A, Marinac-Dabic D, Robbins S, Ssemaganda
H, Hewitt K, et al. Registry-based prospective, active surveillance of medical-device safety. N Engl J Med. 2017;376(6):
526–35.
Central Venous Access
DanielM.DePietro andScottO.Trerotola
Pathophysiology
Venous access can be divided into two categories– peripheral venous access and central venous access. Peripheral
venous access lines, including conventional peripheral
intravenous lines (PIVs) and midline catheters, terminate in
peripheral veins outside of the thorax. Central venous access
catheters terminate within the central veins of the thorax,
ideally at or belowwhere the superior vena cava and right
atrium meet at the cavoatrial junction [1]. This location
allows rapid mixing of infused solutions with the high volume of venous blood entering the right atrium, enabling the
safe administration of hyper- or hypo-osmolar solutions
(e.g., total parenteral nutrition) and other infusions that
could damage peripheral veins (e.g., chemotherapy and various antibiotics) as these are diluted to near iso-osmolality
in this high-ow environment [2]. Central venous access
also enables the delivery of high-volume therapies, such as
rapid uid resuscitation, blood transfusion, pheresis, and
hemodialysis [2]. The over ve million central venous catheters that are placed each year are used in both the outpatient and inpatient settings, and studies have shown that
nearly one in ten hospitalized patients will require central
venous access [3].
Key Point
The central veins are the superior vena cava, inferior
vena cava, brachiocephalic veins, subclavian veins,
external iliac veins, and common iliac veins [4].
9
Types ofCentral Venous Access
The many types of central venous access devices available
can be classied into four main categories: non-tunneled
central catheters, tunneled central catheters, implantable
ports, and peripherally inserted central catheters.
Non-tunneled Central Catheters (NTCCs)
Non-tunneled central catheters are inserted into a central
vein, such as the internaljugular vein, and the catheter tip is
advanced until it rests at the cavoatrial junction (Fig.9.1a, c).
NTCCs pass directly through the skin and subcutaneous tissue and enter the vein (see Fig.9.1b). The external portion of
the catheter directly overlies the venous access site. NTCCs
generally range in diameter from 3 French (F) to over 15F.
Key Point
1F=1/3mm. Catheter diameter in mm=F / 3.
Tunneled Central Catheters (TCCs)
Tunneled central catheters provide a means for safer and
more long term central venous access compared to NTCCs.
Tunneled catheters enter the vein at one location and exit the
skin at a different location (Fig. 9.2a, c). The catheter is subcutaneously tunneled between these two points, providing
separation between the external portion of the catheter and
where the catheter enters the vein (see Fig.9.2b). A subcutaneous polyester cuff is located near the skin entry site and
promotes the ingrowth of surrounding tissues, anchoring the
catheter in place and possibly providing a mechanical barrier
to bacterial migration [5]. TCCs generally range in diameter
from 3F to over 12F.
D. M. DePietro · S. O. Trerotola (*)
Perelman School of Medicine of the University of Pennsylvania,
Philadelphia, PA, USA
e-mail: Daniel.depietro@uphs.upenn.edu;
streroto@uphs.upenn.edu
© Springer International Publishing AG, part of Springer Nature 2018
N. A. Keefe et al. (eds.), IR Playbook, https://doi.org/10.1007/978-3-319-71300-7_9
Implantable Ports
Ports consist of a catheter attached to a mechanical reservoir (Fig.9.3a, c). The reservoir is placed entirely under
the skin within a subcutaneous pocket in the chest or arm
115
116
D. M. DePietro and S. O. Trerotola
Fig. 9.1 Non-tunneled central catheter. (a) Diagram of a NTCC placed
via the right internal jugular vein (IJV). (b) Diagram of a NTCC entering the skin and directly entering the vein. (c) Supine radiograph of a
and is connected to a tunneled catheter that is inserted into
a central vein (see Fig. 9.3b). The reservoir has a selfhealing silicone septum that can be repeatedly accessed
through specially designed noncoring (Huber) needles
[6]. Ports are an attractive option to those requiring infrequent or intermittent access, such as those undergoing
chemotherapy, but a less attractive to those who require
more frequent therapies, as a needlestick is required for
each use. Port catheter diameters generally range from 6F
to 10F.
Peripherally Inserted Central Catheters (PICCs)
PICCs are inserted into peripheral veins, such as the basilic,
brachial, or less commonly cephalic veins of the arm, and
the catheter tip is advanced until it terminates at the
right IJV NTCC with tip in the upper right atrium, so as to be at the
cavoatrial junction when erect
cavoatrial junction (Fig.9.4a–d) [7]. PICCs have increased
in popularity since their introduction due to their advantages over traditional central catheters, including safer
insertion in the arm (no vital organs nearby), increased
cost-effectiveness, and ease of self-care [8]. PICCs require
an accessible peripheral vein for placement. Catheter diameters are typically smaller, generally ranging from 3F to
6F, as the catheter must be small enough to pass through
the peripheral veins.
Catheters withMultiple Lumens
Central venous access devices can also be characterized by
the number of lumens they have. Non-tunneled and tunneled
central catheters are available as single, double, triple, or
quadruple lumen catheters (Fig.9.5a). Ports are available in
9 Central Venous Access
117
Fig. 9.2 Tunneled central catheter. (a) Diagram of a TCC placed via
the right IJV and tunneled to the right chest. (b) Diagram of a TCC
entering the skin with its catheter traveling through a subcutaneous
single or double lumen congurations. PICCs are available
as single, double, or triple lumen catheters. The presence of
separate lumens allows the delivery of non-compatible
infusates using one catheter; for instance, one lumen may be
used for TPN while another for heparin.
Key Point
For a given catheter diameter, as the number of lumens
increases, the diameter of each lumen must become
smaller. Smaller lumens are more prone to blockage.
tunnel prior to entering the vein. (c) Supine radiograph of a right IJV
TCC with tip in the mid-right atrium
Dialysis and pheresis catheters are important types of
dual lumen catheters with a specialized design [4, 9]. The
two lumens of a dialysis catheter serve specic purposes–
one lumen is used to withdraw blood from the patient and
carry it to the dialysis/pheresis machine, while the other
lumen returns blood to the patient from the machine. The
lumens are separated from each other through the use of
multiple catheter tip designs (see Fig. 9.5b). This ensures
that the blood being withdrawn for dialysis is not the same
dialyzed blood that was just returned to the patient, i.e.,
recirculation. Dialysis and pheresis catheters require large
lumens capable of high ow rates and are therefore only
available for central as opposed to peripheral insertion [4, 5].
118
D. M. DePietro and S. O. Trerotola
Fig. 9.3 Chest port. (a) Diagram of a chest port placed via the right
IJV. (b) Diagram of a port within a subcutaneous pocket and its catheter traveling through a subcutaneous tunnel prior to entering the vein.
Clinical Indication
Central venous access is generally indicated when the
expected duration of access is greater than is recommended for peripheral access (see below), when the
required therapy cannot be delivered through peripheral
access, or if peripheral access is unattainable due to inadequate peripheral access sites. Central access allows the
administration of long-term therapies requiring extended
venous access and a number of therapies that cannot be
delivered through peripheral access [6]. A complete list of
the indications for central venous access can be found
below, noting this list varies considerably by institution
[1, 8, 10, 11].
(c) Supine radiograph of a right chest single lumen port with tip in the
mid- right atrium
General indications for central venous access:
• Administration of large volume therapy
– Rapid uid resuscitation
• Administration of long-term therapy and/or repeat therapy
– Prolonged antibiotic or medication delivery
– Frequent blood transfusion
– Frequent blood sampling
• Administration of medications harmful to peripheral
veins
– Chemotherapy
– Hyperalimentation (total parenteral nutrition)
• Hemodialysis or pheresis therapy
• Hemodynamic monitoring (Swan-Ganz catheter)
• Poor or inaccessible peripheral venous access
9 Central Venous Access
119
Fig. 9.4 Peripherally inserted central catheter. (a) Diagram of a PICC
placed via the right basilic vein. (b) Diagram of a PICC entering the
skin and directly entering the vein. (c) Supine radiograph of a right
Indications forDierent Central Venous
Catheters
As experts in central venous access, it is the responsibility
of IRs to determine the best access device for each patient.
Key points to consider include the duration of use, frequency of use, purpose of the catheter, and patient preference. These are included in Table 9.1, which provides a
summary of the types of central venous catheters and their
guidelines for use. Once a type of catheter is chosen to satisfy the patient’s needs, the smallest catheter size with the
basilic vein PICC with tip in the RA due to adducted arm position. (d)
Supine radiograph of a right basilic vein PICC with tip at the cavoatrial
junction due to abducted arm position
minimum number of lumens should be used to decrease
thrombotic complications.
When peripheral access is adequate (see Table9.1) [8]:
• <5days: PIV
• 6–14days: Midline catheter or PIV due to lower risk of
complications compared to PICCs in this time interval
• >15 days: PICCs preferred to midline catheters as the
failure rate of midline catheters increases in this time
period
• >30days: PICCs, TCCs, and ports
120
D. M. DePietro and S. O. Trerotola
Fig. 9.5 Images of different types of central venous catheters. (a)
Triple lumen non-tunneled dialysis catheter (Medcomp, Harleysville,
PA). (b) Dual lumen tunneled dialysis catheter with split tip
When peripheral access is contraindicated or unable to be
achieved:
• <14days: PICCs and non-tunneled catheters
• 15–29days: PICCs
• >30days: PICCs, TCCs, and ports.
Conventional Therapy
Non-tunneled Central Catheters
Central venous access was rst achieved in 1929 when
Werner Forssmann, a surgical intern, catheterized his own
cephalic vein and advanced a catheter into his right atrium
in what could be considered the rst PICC.Years later in
1952, the rst direct central venous access was described for
rapid blood transfusion in military personnel in which the
design(Medcomp, Harleysville, PA); note the polyester cuff for subcutaneous placement (red dotted line). (c) Triple lumen peripherally
inserted central catheter (Medcomp, Harleysville, PA)
subclavian vein was percutaneously accessed [12]. The
advent of TPN, which could not be delivered via peripheral
veins, and the growing importance of central venous pressure monitoring in cardiac surgery and critical care would
lead to an increase in central catheter placement in the
1960s. All early central venous catheters were non-tunneled
catheters and were placed without the aid of ultrasound or
uoroscopy in a “blind” fashion predominantly by surgeons
and anesthesiologists. NTCCs had a high rate of complications, between 30% and 50%, including pneumothorax,
arterial puncture, air embolus, thrombus formation, and
catheter tip malposition.
Tunneled Central Catheters
The rst tunneled central catheter, the Broviac catheter,
was described in 1973, followed in 1979 by the Hickman
catheter. The Hickman catheter featured modications on
Recommended
9 Central Venous Access
Table 9.1 Types of central venous access devices and guidelines for use [1, 6, 8]
121
Catheter
Type
Non-
tunneled
central
catheter
Tunneled
central
catheter
Port
Peripherally
-inserted
central
catheter
Entry Site
Percutaneously
inserted into the
jugular,
subclavian, or
femoral veins
Subcutaneously
tunneled then
inserted into the
jugular,
subclavian, or
femoral veins
Subcutaneously
placed in the chest
or arm with the
catheter inserted
into the jugular or
subclavian veins
Percutaneously
inserted into the
basilic, brachial,
or cephalic veins
and advanced into
the central veins
Duration of Use
Short
Medium
term
6-14
days
--
--
term
15-30
days
--
Long
term
>30
days
When to Use When to Avoid Comments
Short term access when a
peripheral IV is not suitable
Volume resuscitation
Central venous pressure
monitoring
Short-term dialysis
Long-term access with
frequent use (antibiotics,
TPN, transfusions, blood
sampling,dialysis, etc.)
When a PICC is
contraindicated or not
possible
Long term access with
infrequent use
(chemotherapy)
When a more aesthetically
appealing option is desired
For frequent access in the
short to long term
(antibiotics, TPN,
transfusions, blood
sampling, etc.)
When longer term
access is required
When shorter term
access is required
Infrequent access
(consider a port)
Frequent access
(needle stick required
for each use)
Dialysis or
predialysis patients
Easiest to place
and remove
Highest risk of
bloodstream
infections
Lower
infectious risk
compared to
NTCCs
Higher
infectious risk
compared to
ports
Lowest
infectious risk
Minimal local
site care
Expensive
More difficult
to place and
remove
Lower
infectious risk
than NTCC
Easiest to place
Requires patent
peripheral vein
Potential for
occlusion
the Broviac catheter including a larger catheter lumen
diameter and increased catheter wall thickness. This design
allowed for improved patency with blood products and for
multiple lumens within a single catheter [9, 13]. Tunneled
catheters proved to have a lower risk of catheter-related
infection compared to NTCCs, with later meta-analyses
reporting a greater than 50% reduction in infectious risk in
TCCs compared to NTCCs [14]. While “blind” percutaneous techniques were adopted early in NTCC placement, the
rst techniques for tunneled catheter placement required
surgical cutdown onto the cephalic, jugular, or subclavian
veins in the operating room. Surgical cutdowns would
prove difcult in patients who had undergone prior surgery,
radiation therapy, or other therapies to the access area.
Additionally,the required venous incision resulted in scar-
ring, making future access to the vein difcult [15]. In
response to these challenges, a surgical percutaneous technique was developed in the 1980s, whereby a surgeon
would access a vein via blind percutaneous puncture (rather
than surgical cutdown) and place a TCC using a vein dilator
and peel-away sheath for catheter insertion. The surgical
percutaneous technique for the placement of TCCs eliminated the need for surgical cutdown and resulted in
decreased operative time, better primary placement success, less morbidity, and more accurate catheter positioning
compared to open surgical techniques [15–18]. However,
the surgical percutaneous technique still required placement in the OR, which was time-consuming and expensive,
and was performed “blind,” making it difcult to account
for anatomic variants and catheter malpositioning.
122
D. M. DePietro and S. O. Trerotola
Ports
The rst subcutaneous infusion ports were also developed in
the 1980s. These allowed central venous access without the
need for an external component [19]. Ports were surgically
placed in the anterior chest for patients requiring chronic
venous access and proved to have a lower complication rate
of 10–20% compared to TCCs and NTCCs [20, 21].
PICCs
PICCs were originally developed for placement in the palpable veins of the arm within the antecubital fossa, at or below
the elbow, by specialized medical and nursing teams at the
bedside. While these “lower-arm” PICCs proved to be a good
option for those requiring medium-duration central venous
access, limitations to this approach included patient tolerance
of a catheter in the antecubital fossa and the inability to place
a catheter in patients with thrombosed antecubital veins [22].
Interventional Therapy
Radiology initially played little role in the placement of central
venous access devices. In fact, an analysis for the year 1992
showed that nearly 99% of all central venous access devices
were placed by non-radiologic specialties (primarily surgeons,
followed by anesthesiologists) [3]. However, as evidence built
to support the radiologic placement of central venous catheters
throughout the 1990s, IR’s role in this important aspect of
patient care would increase exponentially [3].
Tunneled andNon-tunneled Catheters
In 1989, Robertson et al. published the rst report of the
radiologic placement of tunneled catheters. The use of uoroscopy in the IR suite demonstrated signicant advantages
over surgical placement in the OR, including the ability to
assess central venous anatomy, conrm percutaneous access
within the venous system, and more accurately position the
catheter tip. Robertson etal. showed that radiologic placement resulted in reduced catheter placement times (30min
for the radiologic group versus 90–120min for the surgical
group) and decreased costs when compared to surgical placement while achieving equivocal success and complication
rates [23]. In a later study, McBride etal. provided the rst
single institution comparison of surgical and radiologic techniques in adults. The surgical group was found to have a primary placement failure rate of 4.5%, required multiple
placement attempts in 13%, and malpositioned catheters in
3.7%. None of these issues were observed in the radiologic
group [18]. A signicant decrease in infection rates was also
found, with 1.9 infections per 1000 catheters days in the
radiologic group compared to 4.0 infections per 1000 catheter days in the surgical group [18]. The use of ultrasound to
attain venous access would further decrease the rate of acute
complications such as pneumothorax and arterial puncture
[24]. Further studies continued to support radiologic placement of tunneled catheters, providing evidence that radiologic placement was faster, cheaper, safer, and more reliable
than surgical placement with fewer complications [18, 23,
25, 26]. This translated into an increasing role for IR in the
placement of tunneled central venous catheters. Eventually
IR became the primary provider for such devices. As IR
placed more TCCs, the advantages of IR placement for nontunneled central catheter placement were also realized,
although the placement of NTCCs continues to be spread
over a number of different specialties [3].
Ports
IR continued to expand its role in central venous access
placement in 1990 with the implementation of a device specically designed for placement in the IR suite – the arm
port. These ports were placed in the upper arm with a catheter entering the basilic or brachial vein and terminating in the
central veins. Ports are accessed via palpation of the reservoir and subcutaneous access using a Huber needle. Initial
studies found radiologically placed arm ports to be extremely
effective, with successful primary placement achieved in all
patients. Image guidance again provided the added benets
of more accurate venous puncture and visualization of the
catheter course and tip position. Once placed, the port proved
reliable, with blood draws successful in 99% of attempts
[27]. In those where blood could not be aspirated, patients
beneted from the radiologic diagnosis and treatment of
issues such as brin sheath formation or thrombus, enabling
continued use of the port [27]. In addition to comparable primary placement rates and reliability, the complication rates
of radiologically placed arm ports were found to be similar
or better to surgically placed chest ports, with some studies
reporting signicantly lower infection rates compared to surgery [21, 27].
IRs built on their experience with arm ports to develop
new techniques for the radiologic placement of chest ports.
Chest ports are generally preferred over arm ports as they
are easier to access and have superior blood withdrawal and
infusion capabilities. As a result, they are placed much
more commonly than arm ports [28]. IR chest port placement differs from surgical placement in that venous access
is always attained percutaneously with imaging guidance,