Long-term central venous access

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Long-term central venous access Galloway S , Bodenham A British Journal of Anaesthesia Volume 92, Issue 5, Pages 722-734 (May 2004) DOI: 10.1093/bja/aeh109 Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 1 Magnified image of single-lumen Groshong catheter tip. (a) Valve closed. (b) Valve opened, fluid injected through catheter. (c) Valve open, blood aspirated from vein into catheter. Illustration courtesy of C. R. Bard. British Journal of Anaesthesia 2004 92, 722-734DOI: (10.1093/bja/aeh109) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 2 Port system with 8.4 Fr silicone catheter ready to be inserted by sliding over previously placed sutures into subcutaneous pocket on anterior chest wall (Portacath®; Deltec, St Paul, MN, USA). This patient had sickle-cell disease requiring recurrent blood transfusions. Note old scars from previous port procedures. The procedure was performed by the authors under local anaesthesia to avoid any need for exchange transfusion. British Journal of Anaesthesia 2004 92, 722-734DOI: (10.1093/bja/aeh109) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 3 (a) Adult female with difficult venous access. The patient had underlying haematological malignancy. Note bilateral old, healed scars from Hickman lines (small arrows). Healing recent left-sided puncture site from left subclavian access (arrow). New dual-lumen Hickman line inserted via left internal jugular vein. Prominent right chest wall venous collaterals secondary to right-sided great vein obstruction. (b) Right axillary–subclavian venogram on the patient shown in panel a. Contrast injected peripherally flows from the axillary vein into the start of the blocked subclavian vein and then passes through numerous collaterals into the stump of the blocked right internal jugular vein. Collaterals then drain into the azygos/superior vena cava confluence. This explains failed attempts to pass guidewires centrally after easy right subclavian and internal jugular vein puncture. (c) Chest X-ray from the patient shown in panel a. The dual-lumen Hickman line is seen to pass via the left internal jugular vein and left innominate vein so that its tip lies at the junction of the superior vena cava and right atrium. British Journal of Anaesthesia 2004 92, 722-734DOI: (10.1093/bja/aeh109) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 4 (a) Digital subtraction venogram of right subclavian and innominate vein. Contrast has been injected up from the right wrist. A Hickman catheter passes from the right subclavian area into a stent lying between the low superior vena cava and right atrium. There is narrowing of the right internal jugular vein above its junction with the subclavian vein. This patient had been on home total parenteral nutrition for 19 yr with multiple central venous access procedures. She required further venous access due to low-grade infection of the Hickman catheter. (b) X-ray from the patient shown in a. The narrowing in the right internal jugular vein is being widened by balloon angioplasty. Note X-ray contrast filling the balloon with characteristic waisting in which the vessel narrowing constricts the balloon during the dilation process. After these procedures, her original Hickman catheter was removed and a new catheter inserted a few days later. British Journal of Anaesthesia 2004 92, 722-734DOI: (10.1093/bja/aeh109) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 5 (a) Diagram to explain proposed mechanism of ‘pinch-off’. At the time of catheter insertion the angle between the clavicle and the first rib is wide (1). In the upright position, the angle narrows and pinches the catheter (2). Adapted from Aitken et al. (1984)3 with permission from Excerpta Medica. (b) Close-up view of left upper portion of chest X-ray. A single-lumen Hickman catheter has been inserted via the left subclavian route. The section of catheter lying under the first rib and clavicle (arrow) shows characteristic compression (scalloping) suggestive of pinch-off. Extravasation of infused fluid occurred and the damaged catheter required removal. British Journal of Anaesthesia 2004 92, 722-734DOI: (10.1093/bja/aeh109) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions