AJR 2002; 179:309-318
© American Roentgen Ray Society
Central Venous Access: A Primer for the Diagnostic Radiologist
Brian Funaki1
1 Department of Radiology, The University of Chicago Hospitals, 5841 S. Maryland
Ave., Chicago, IL 60637.
Received December 5, 2001;
accepted after revision February 13, 2002.
Address correspondence to B. Funaki.
Introduction
During the past 5 years, the growth of radiologic venous access has been
dramatic. With the benefit of sonography and fluoroscopy, interventional
radiologists can insert central venous catheters faster, safer, and better
than physicians who rely on anatomic landmarks
[1]. My purpose is to review
salient features of central venous catheters and to highlight concepts
relevant for the general diagnostic radiologist who does not insert these
devices.
Central venous catheters can be broadly categorized into four groups:
peripherally inserted central catheters, temporary (nontunneled) central
venous catheters, permanent (tunneled) central venous catheters, and
implantable ports. Each of these catheters may be used for specific
indications, but many indications are not mutually exclusive. In many
instances, catheters of more than one type may be inserted for similar
indications.
Peripherally inserted central catheters are essentially long IVs
(Fig. 1). These catheters
typically range from 4- to 7-French and are inserted in a forearm or upper arm
vein. The catheter may have one or two lumens and extends from the puncture
site to the superior vena cava. This type of catheter is ideal for
administration of intermediate-term medications such as antibiotics.
Temporary (nontunneled) subclavian, femoral, and internal jugular vein
catheters (Fig. 2) are commonly
used for medication delivery, central venous pressure monitoring, and
short-term hemodialysis. Many temporary catheters are constructed of
polyurethane. This material is relatively rigid at room temperature but
softens when placed in the body. Temporary catheters typically range from 6-
to 13-French and are most often used for several days to several weeks.
Permanent (tunneled) catheters (Fig.
2) are composed of Silastic (silicone elastomer) or thin
polyurethane. Silastic is compliant and easily passes through tortuous
vessels. Permanent catheters travel through a short (8- to 15-cm) subcutaneous
tunnel before entry into an accessed vein. A polyester cuff on the shaft of
the catheter becomes incorporated into the subcutaneous tissues and helps
secure the catheter in place. Although somewhat controversial, the theoretic
benefits of the tunneled catheter include decreased risk of infection compared
with nontunneled catheters and decreased risk of inadvertent removal
[2,3,4,5].
Unequivocal benefits of tunneled internal jugular vein catheters include
improved cosmetic appearance and patient comfort. In general, tunneled
catheters are preferred to nontunneled catheters in patients who require
central venous access for longer than 2 weeks.
Implantable ports consist of a single- or dual-lumen reservoir hub attached
to a catheter (Fig.
3A,3B).
The reservoir hub is implanted in the arm or chest, and the catheter is
tunneled to the accessed vein. These catheters are typically used for
long-term intermittent access such as that required for chemotherapy. The port
is accessed using a Huber (noncoring) needle. I favor chest ports because of
their lower rate of malfunction and symptomatic complications
[6]. Nonetheless, other
radiologists prefer arm ports, particularly in young women because of better
cosmetic appearance. Among central venous catheters, ports have the lowest
incidence of infection because they are completely buried beneath the
skin.
Choice of Vein for Access
Peripheral Veins
Peripherally inserted central catheters are typically placed in a forearm
vein when inserted by nurses or IV teams. Radiologists may also use these
veins but often also use upper arm veins, typically the basilic vein. Brachial
and cephalic veins may be used for access, but these veins have disadvantages.
Cephalic veins are prone to venospasm that can make peripheral central
catheter insertion difficult or impossible, and brachial veins are in close
proximity to the brachial artery and, therefore, must be punctured cautiously
using sonographic guidance. The basilic vein may be punctured using
sonographic or fluoroscopic guidance after injection of contrast medium.
Conventional Central Veins
Surgeons have traditionally used the subclavian vein for central access.
This vein has a predictable course compared with the internal jugular vein,
enabling reliable venipuncture using anatomic landmarks. Moreover, subclavian
vein catheters are located in a cosmetically acceptable, easily accessible
area. Unfortunately, the subclavian vein has distinct disadvantages that limit
its value for routine central access. Because this vessel provides venous
drainage for the arm, catheter-related venous thrombosis often results in arm
swelling and pain that require either anticoagulation, thrombolytic therapy
catheter removal, or both. The subclavian vein is also prone to becoming
stenotic because of venipuncture and should not be used in any patient
requiring hemodialysis unless the ipsilateral extremity is unsuitable for
graft or fistula creation [7].
Venipuncture of the subclavian vein is associated with the highest incidence
of pneumothorax compared with other central veins, even in radiologic series
[8]. Finally, catheter fatigue
and "pinch-off" may develop because of prolonged repeated
compression by the costoclavicular ligaments and subclavius muscle, leading to
catheter fracture and embolization.
Most radiologists favor the internal jugular vein for central access. It is
technically easier to puncture using sonographic guidance compared with the
subclavian vein and has a low incidence of pneumothorax. The right internal
jugular vein is preferred to the left because the right has a relatively
straight course, facilitating catheterization. Furthermore, the right internal
jugular vein has a negligible risk of symptomatic central venous stenosis and
thrombosis. A recent large retrospective review of 774 catheters compared
subclavian and internal jugular vein approaches and concluded that the
internal jugular vein is the preferred site for tunneled infusion catheter
placement [9]. Radiologists
have used both the subclavian and internal jugular veins for chest port
insertion [6,
10,
11]. The lowest incidence of
symptomatic central venous thrombosis (0%) was noted for internal jugular vein
devices [6].
Subclavian vein and internal jugular vein catheters may have a similar
appearance on chest radiographs because most internal jugular vein punctures
are performed low in the neck (
1 cm above the clavicle) to facilitate
tunneling [12]. If the
internal jugular vein is punctured more than 3-4 cm above the clavicle, a
tunneled catheter will often kink at the vein entry site, causing dysfunction.
The most cephalad aspect of the catheter usually differentiates the two types
of catheters. Subclavian vein catheters do not course above the clavicle,
whereas internal jugular vein catheters do. The femoral veins may also be used
for short- or long-term catheterization but have a slightly higher risk of
infection and dysfunction compared with the subclavian or internal jugular
veins [13].
Unconventional Central Veins
Patients requiring prolonged venous catheterization may develop stenoses
and occlusions that preclude central venous catheter placement. When these
complications occur, unconventional routes to the central veins are used,
including the translumbar inferior vena cava, external jugular veins, hepatic
veins, and even intercoastal veins
[14,15,16,17].
An important technique that preserves existing access is venous recanalization
or catheter placement in collateral neck or chest veins
[18,
19] (Fig.
4A,4B,4C,4D).
Catheters placed via these unconventional sites have an unusual course on
abdominal or chest radiographs but usually terminate in typical locations such
as the lower superior vena cava, right atrium, or higher inferior vena cava
near the right atrium. Patients who most commonly require this type of access
are those with a history of prolonged central vein catheterization from
long-term catheter hemodialysis or total parenteral nutrition.
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Fig. 4A. —Catheter placement into collateral vein in 37-year-old man
with central venous occlusion requiring hemodialysis. Venogram obtained
through end-hole catheter advanced from common femoral vein into superior vena
cava shows numerous small collateral veins in chest and neck. Jugular and
subclavian veins are occluded.
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Fig. 4C. —Catheter placement into collateral vein in 37-year-old man
with central venous occlusion requiring hemodialysis. Fluoroscopic image shows
needle puncture through loop of snare. Needle is exchanged for guidewire, and
snare is used to pull guidewire into superior vena cava, securing venous
access.
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Access in the Patient on Hemodialysis
The Dialysis Outcomes Quality Initiative
[7] outlines a number of
guidelines regarding venous access in patients who require hemodialysis. These
recommendations were instituted to preserve veins in the arms and chest for
fistula or graft creation and should be extended to patients with renal
insufficiency (e.g., creatinine levels > 3.0 mg/dL). Subclavian veins
should not be used for central venous catheter insertion unless the jugular
veins are inaccessible (i.e., avoid the subclavian vein if possible). Hand
veins instead of forearm and upper arm veins should be used for venous access.
This recommendation is important for any patient who receives IV contrast
material for CT or MR imaging. An antecubital IV should not be placed in these
patients.
Ideal Catheter Position
The optimal position for a central venous catheter tip is the right
atrial—superior vena caval junction. In practice, this ideal is not
always tenable. When catheters are inserted without the benefit of
fluoroscopy, precise placement may be difficult
[20]. Even with fluoroscopic
guidance, tip location may not always be perfect. Catheter position is
dynamic; the catheter tip often migrates several centimeters cephalad when
patients move from a supine to an upright position
[21,
22]. In women with chest ports
or tunneled catheters, downward retraction due to breast tissue may exaggerate
cephalad migration of catheter tips (Fig.
5A,5B).
Patients receiving hemodialysis require high blood-flow rates through
large-bore catheters; prolonged catheterization often leads to central
stenosis and fibrin sheath formation that limit inflow and egress of blood
into indwelling catheters. Catheter tips are occasionally positioned in the
upper right atrium to improve blood flow. However, right atrial placement
should be regarded with caution because arrhythmias and valvular vegetations
may occur if the tip is placed too low in the right atrium.
Diagnostic Evaluation
When interpreting diagnostic studies, radiologists should be familiar with
and comment on catheter position, catheter type, and the presence or absence
of complications. Catheters tend to be less obvious on cross-sectional images,
so it is helpful to evaluate CT scans with either radiographs or CT scout
images. Catheters placed with and without imaging guidance should be
approached differently. If catheters have been placed using imaging guidance,
malpositioning is rare because it is usually recognized at the time of
placement and the catheter is adjusted accordingly. An atypical course may
reflect insertion using collateral veins or recanalized veins rather than
great vessel perforation. Hemodialysis catheters that appear to be located too
low in the right atrium are often positioned there intentionally to maximize
flow rates for dialysis. In my hospital, routine postprocedural radiographs
are no longer obtained for catheters inserted in the radiology department
because complications are exceedingly low with sonographically guided
venipuncture and fluoroscopic determination of catheter tip position
[23].
Procedural Complications
Malpositioning
Knowledge of normal and variant venous anatomy is crucial for catheter
positioning. If fluoroscopy is not used during catheter insertion, a
malpositioned catheter may lie in the internal jugular vein
(Fig. 6), contralateral
subclavian or axillary vein, or azygous vein
(Fig. 7). Less commonly, a
catheter may terminate in the pericardiophrenic vein, internal mammary vein,
or left superior accessory vein. In a patient with variant anatomy, a
malpositioned intravascular catheter may lie in a left superior vena cava
(Fig.
8A,8B)
or coronary sinus or project over the lung in partial anomalous pulmonary
venous return (Fig.
9A,9B,9C,9D).
Rarely, arterial placement may be unrecognized at the time of catheter
insertion (Fig.
10A,10B).
If the catheter is too long, it may lie coiled in the right atrium or in the
inferior vena cava. When peripherally inserted central catheter lines are
placed at beside, malpositioning is common. Typically, the catheter terminates
short of the superior vena caval—right atrial junction and may be
misdirected into the chest wall or neck veins. Because these catheters are
small and not particularly radiopaque, chest radiographs must be scrutinized
to locate tip position.
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Fig. 9A. —Partial anomalous pulmonary venous return in 54-year-old man.
Chest radiograph obtained after bedside insertion of left internal jugular
vein temporary catheter shows tip (arrow) projecting over left
lung.
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Fig. 9B. —Partial anomalous pulmonary venous return in 54-year-old man.
Venogram obtained through catheter shows tip in left vertical vein (anomalous
pulmonary vein). Blood drawn from catheter had arterial-oxygen partial
pressure confirming that structure was anomalous pulmonary vein rather than
left pericardiophrenic vein, which has similar course.
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Fig. 9D. —Partial anomalous pulmonary venous return in 54-year-old man.
Venogram obtained through chest port shows tip in right anomalous pulmonary
vein. Blood aspirated from catheter also had arterial-oxygen partial
pressure.
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Fig. 10A. —Arterial insertion of central catheter in 72-year-old woman.
Postplacement chest radiograph shows left subclavian catheter
(arrows) that assumes slightly more medial course than is
typical.
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Fig. 10B. —Arterial insertion of central catheter in 72-year-old woman.
Digital subtraction angiogram confirms that tip terminates in aorta. Contrast
material was rapidly diluted by high flow in ascending aorta.
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Pneumothorax
Pneumothorax occurs more commonly with subclavian vein puncture than with
internal jugular vein puncture
[8]. Most pneumothoraces
associated with central venous catheters remain asymptomatic, particularly if
the visceral pleura is less than 2-3 cm from the parietal pleura. Usually,
this complication is apparent on postprocedural chest radiographs but
occasionally may be manifest several days after catheter placement
[24]. In general, a small
asymptomatic pneumothorax does not require treatment. Symptomatic or large
pneumothoraces may be successfully treated with a smallbore pigtail chest tube
and a Heimlich valve.
Air Embolus
An air embolus most commonly occurs during the insertion procedure of
tunneled catheters or ports immediately before intravascular catheter
deployment. Because these catheters are flimsy and must travel through a
subcutaneous tunnel before vein entry, they are advanced into the accessed
vein using a peel-away sheath. This two-piece device consists of a rigid
plastic dilator encased by a thin outer plastic sleeve. It is analogous to a
drinking straw around a hollow pencil. The peel-away sheath is advanced over a
guidewire into the accessed vein; then the guidewire and inner dilator are
removed, leaving the thin outer sleeve (drinking straw portion) in the vein.
The catheter is then quickly advanced through the sleeve into the vein. Once
the catheter is completely advanced into the vein, the hub of the sleeve is
cracked, and the sleeve is peeled out of the patient in two parts, leaving the
catheter in the vein. An air embolus occurs between dilator removal and
catheter insertion if intrathoracic pressure drops (as occurs during
inspiration) and sucks air into the sleeve. Various maneuvers can be performed
to minimize this risk, such as crimping the sleeve before catheter insertion
or asking the patient to hum. Tiny air emboli probably occur commonly and far
more often than is recognized. Large air emboli may be fatal. When
symptomatic, a patient with an air embolus typically experiences coughing and
respiratory distress. The patient should be placed in the left lateral
decubitus position and given 100% oxygen.
Great Vessel or Cardiac Perforation
The mechanism of great vessel or cardiac perforation has not been proven,
but this catastrophic event likely occurs during peel-away sheath insertion
[25]. If the intravascular
guidewire is either kinked or not advanced into the inferior vena cava, the
peel-away sheath may function like a spear and perforate the brachiocephalic
vein or right heart. Catheters inserted from the right subclavian vein are
more prone to developing this complication because the sheath is advanced
along a course nearly perpendicular to the superior vena cava. In the absence
of fluoroscopy, this complication may not be immediately apparent until a
postprocedural chest radiograph is obtained (Fig.
11A,11B,11C)
because the catheter will be deployed in the normal fashion through the sheath
(and vascular perforation) and will at least partially occlude the laceration.
This complication usually results in hemothorax, mediastinal hematoma, cardiac
tamponade, or a combination of these. It can be fatal if unrecognized. Clues
to this complication on chest radiographs include an atypical catheter course
and tip position, mediastinal widening, or a pleural effusion. Chest CT is
diagnostic.
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Fig. 11A. —Great vessel perforation in 48-year-old man. Chest radiograph
shows widening of mediastinum and atypical leftward course of indwelling right
subclavian vein dual-lumen chest port (arrow).
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Fig. 11C. —Great vessel perforation in 48-year-old man. Lower image of
chest CT scan shows catheter tip in extravascular space of mediastinum
anterior to trachea (arrow) with adjacent hemorrhage.
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Late Complications
Infection
Infection is the most common complication of central venous catheters.
Coagulase negative Staphylococcus species and Staphylococcus
aureus are the most common
[26]. Infections are reported
in number per 100 or 1000 days and are related to the type of catheter. A wide
range of infection rates is reported among different types of catheters, but
in general, ports have the lowest incidence of infection, followed by tunneled
catheters, then nontunneled lines. In one large study, the infection rate of
ports was 0.21/1000 catheter days, whereas the infection rate for tunneled
lines was 2.77/1000 catheter days
[27]. Although practice
patterns vary regarding treatment of infected catheters, in general, exit site
infections can be treated with antibiotics, and site care can be performed
with the catheter in place, whereas tunnel and port pocket infections require
catheter removal and antibiotics. Similarly, catheter-related bacteremia may
be treated with antibiotics and catheter exchange or antibiotics and catheter
removal. Sepsis usually mandates catheter removal and treatment with
antibiotics unless another source of infection is implicated.
Fibrin Sheath Formation
The most common cause of catheter dysfunction is fibrin sheath formation. A
fibrin sheath is a proteinaceous coat composed of eosinophilic material and
scattered inflammatory cells that envelop the catheter from insertion site to
tip [28]. It may have
associated thrombus and usually functions as a one-way valve (i.e., the
catheter may be flushed but blood cannot be aspirated). Fibrin sheath
formation is a common problem for patients undergoing catheter hemodialysis.
Infusing tissue plasminogen activator into the catheter is the first treatment
for catheter dysfunction associated with fibrin sheaths
[29,
30]. If this treatment is
unsuccessful, patients are referred to interventional radiology for catheter
exchange over a guidewire
[31,32,33],
a procedure that disrupts the sheath. Occasionally, it may be necessary to
obliterate the sheath by performing balloon angioplasty or stripping the
sheath off the catheter using a loop snare.
A fibrin sheath with a small amount of thrombus around the tip of a central
venous catheter is occasionally noted as an incidental finding on CT. The
proper course of action in this situation is unclear. In my experience, most
patients with this finding remain asymptomatic and probably do not need to be
aggressively treated. However, if the clot appears to be bulky or enlarging,
disturbs blood flow, or is associated with pulmonary embolism, treatment
should be pursued. This usually consists of anticoagulation therapy with or
without catheter removal. Thrombolytic therapy may also be helpful in some
patients.
Catheter-Related Central Venous Thrombosis
In patients with indwelling central venous catheters, acute arm swelling or
head and neck swelling (i.e., superior vena cava syndrome) should be regarded
as catheter-related central venous thrombosis until proven otherwise. Often
patients with prolonged catheters will also have some degree of preexisting
venous stenosis that is exacerbated by clot formation. Anticoagulation therapy
is the treatment of choice, often with catheter removal. Pulmonary embolism is
not rare in these patients and may occur despite adequate anticoagulation
therapy [34]. As stated
previously, thrombolytic therapy may be beneficial for some patients,
particularly if the clot is acute.
Catheter Pinch-Off
Subclavian catheters may be compressed near the junction of the first rib
and clavicle by the costoclavicular ligament and subclavius muscle
[35]. Repetitive compression
in this area may cause catheter fatigue and subsequent fracture
[36] (Fig.
12A,12B,12C,12D).
A fragment may then, in some instances, embolize to the right heart. Catheters
at particular risk for this complication are long-term implantable ports that
enter the medial portion of the subclavian vein. Fractures may be subtle, and
radiologists should pay attention to this portion of the catheter when
evaluating chest radiographs. A fragment that embolizes to the right heart or
pulmonary artery may often be retrieved using a loop snare if recognized
early. If not, the fragment may become "endothelialized" into the
right heart or pulmonary artery and preclude percutaneous removal. This
complication does not occur with internal jugular vein catheters.
Filter Displacement
A guidewire used for catheter insertion can become entangled in an
indwelling inferior vena cava filter leading to displacement
[37,
38]. This complication occurs
most commonly during bedside central venous catheter insertion when the
physician inserting the catheter is unaware of the presence of the filter.
When resistance to wire removal is encountered (i.e., the wire is stuck in the
filter), the physician responds by increasing tension on the wire that in turn
dislodges the filter. Some displaced filters can be retrieved using a loop
snare.
Power Infusion of Central Catheters
No established guidelines exist for using catheters to infuse contrast
material for CT, although a number of studies have addressed this issue
[39,40,41].
In general, most central venous catheters and the larger peripherally inserted
central catheters (4- to 5-French) may be infused at rates of 1.5-2.0 mL/sec
[41]. More rapid injection
rates could potentially result in catheter perforation. It is important to be
familiar with the catheters used in your hospital and to establish protocols
for their use. For example, in my hospital, ports are not used for power
infusion, although this practice is common in other medical centers
[39]. Ports are slightly more
difficult to access properly, and if the access needle is not well positioned
in the diaphragm of the device, contrast material could extravasate into the
subcutaneous tissues of the chest. If any central venous catheter is used for
power injection, personnel familiar with catheter maintenance should be
available. Most catheters are loaded with heparin to reduce the incidence of
thrombosis; this indwelling anticoagulant should be aspirated before
connection to a power injector. After the examination, heparin should be
reintroduced according to hospital protocol.
In conclusion, because imaging guidance eliminates all the guesswork
associated with central venous catheter placement, as interventional
radiologists continue to increase their role in central venous access, the
incidence of early and late complications will continue to decrease. Many
complications described in this article are easily avoided using procedural
fluoroscopy and sonographically guided venipuncture. In fact,
procedure-related complications have become virtually nonexistent for
imaging-guided central venous access. Nonetheless, a large number of central
venous catheters continue to be placed using anatomic landmarks without
procedural fluoroscopy. It is therefore incumbent for radiologists to remain
familiar with venous access devices because radiologists are often the first
physicians to recognize untoward occurrences. In addition to allowing safer
and faster catheter placement, imaging guidance has enabled interventional
radiologists to expand the scope of central access by using alternative access
sites and techniques. These contributions have increased the options for
patients requiring central venous catheters and have improved patient
care.
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Introduction
Choice of Vein for...
