1. Physiologic Anomalies and Challenges to CVAD Insertion
James C. Andrews, MD, FSIR
Professor of Radiology
Division of Vascular and Interventional Radiology
Mayo Clinic College of Medicine
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2. Disclaimers No conflict of interest to disclose
Off label use of drugs/devices ?

3. Objectives Review the anatomy relevant to central venous access
Review the anatomic and acquired barriers to central venous access device placement
Review alternatives to the commonly used access sites/techniques

4. Interventional Radiology
Subspecialty of Diagnostic Radiology
Training
Internship (1 year)
Diagnostic Radiology residency (4 years)
IR fellowship (1-2 years)
New IR residency
6 years
Match right out of med school

5. Interventional Radiology
Patient centric (vs technology centric)
Outpatient/inpatient clinical consultation
Inpatient/outpatient procedures
Admitting service

6. Non-Vascular Procedures
Biliary drainage
Urinary drainage
Abscess drainage
Feeding access
Percutaneous biopsy
Percutaneous tumor ablation
Lymphangiography

7. Vascular Procedures Angiography Venography Venous sampling Angioplasty
Vascular stents
TIPS
Thrombolytic Rx
Embolization
Chemoembolization
Radioembolization
Vascular access

8. Goals of VAD Placement Correct device Correct number of lumens
Correct tip position

9. Appropriate Tip Position
Controversial
Many opinions, but little real data
Radiologists who place VADs may find themselves in conflict with the FDA’s guidelines, and the practice guidelines of the nursing organizations who may use the VADs

10. JVIR 2003; 14:

11. Catheter Tip Position
“….the tip of a CVAD should terminate in the central vasculature, such as the superior vena cava (SVC) or inferior vena cava (IVC). Dialysis catheter tips may terminate in the right atrium.”
Infusion Nursing Standards
of Practice, 2011

12. Implications of a short catheter
Loss of blood return
Loss of ability to infuse
Venous thrombosis/stenosis
Arm swelling
SVC syndrome
Loss of access for future lines

13. Normal Venous Anatomy

14. Impediments Successful Line Placement
Anatomic issues
Left SVC
Aberrant radial or ulnar arteries
Cephalic vein access
Acquired conditions
Venous occlusion
Pacer/AICD leads
Pending dialysis
Surgery for congenital heart disease
Patient preference

15. “Normal Central Line Position”

16. Location of catheter? Left SVC Aorta Internal mammary vein
Superior intercostal vein
Mediastinum

17. Left SVC Rare May be associated with congenital heart disease
10% isolated
90% bilateral or “duplicated” SVC
Of no real significance other than confusion interpreting CXR

18. Location of catheter?
ORIGINAL REPORT - 16-May :40:00 Chest; 1 view: Interval removal of the right IJ Port-A- Cath with placement of left subclavian Port-A-Cath with tip in the RA. Low lung volumes with bibasilar atelectasis. No pneumothorax.

19. Internal Mammary v. PICC

20. Azygos v. Catheter

21. Aortic Catheter

22. Pleural Space Catheter

23. Non-SVC Catheter Position
Left SVC
Internal mammary vein
Superior intercostal vein
Azygos vein
Arterial
Extravascular

24. Chest; 2 views:
Central line in the proximal SVC. Mild cardiac enlargement and pulmonary vascular congestion. Infiltrate or atelectasis left base is new.
Indications : check Hickman placement
Exam : Chest-- PA & Lateral NORM

25. Review CXR Yourself if Possible
Review of 262 surgically placed CVCs
Tip position
Ideal /262 (32%)
Acceptable 62/262 (24%)
Innominate v. confluence 110/262 (42%)
Incorrect radiology report 152/262 (58%)

26. Catheter “Pinch-Off”
Catheter compressed between clavicle and first rib
Only seen with subclavian punctures
Pre-disposes the catheter to fracture
Should be replaced

27. Why didn’t this line work?

28. Movement with Position Change
Upright
Supine

29. Impediments Successful Line Placement
Aberrant radial/ulnar arteries
Cephalic vein puncture
Thrombocytopenia
Coagulopathy

30. Aberrant Radial/Ulnar Arteries
Uncommon anatomic variant
Radial or ulnar arise from the axillary artery
May course with the basilic or cephalic veins
Incidental finding of no clinical significance

31. Ultrasound for PICC Placement

32. Cephalic v. Puncture

33. Impediments Successful Line Placement
Venous stenosis/occlusion
Prior lines
Tumor encasement
Fibrosing mediastinitis
Pacer/AICD leads
Pending dialysis
Surgery for congenital heart disease
Patient preference

34. Dialysis Patients K-DOQUI 2009 guidelines:
1.2 In patients with CKD stage 4 or 5, forearm and upper-arm veins suitable for placement of vascular access should not be used for venipuncture or for the placement of intravenous (IV) catheters, subclavian catheters, or peripherally inserted central catheter lines (PICCs). (B)

35. Access for Future Dialysis Patients
Tunneled IJ or EJ “PICC”

36. Pacer Leads

37. Congenital Heart Disease

38. Patient Preference Importance cannot be underestimated
The VAD may be the patient’s “life line”, and they may require access for protracted periods of time
Get the patient involved in choosing
The device
The device position or exit site

39. Impediments to Successful Line Placement
Venous stenosis/occlusion
Prior lines
Tumor encasement
Fibrosing mediastinitis
Most common issue we face in line placement
May be asymptomatic/unsuspected

40. Unsuspected Subclavian Stenosis
Asymptomatic patient referred for PICC placement for 6 week course of antibiotics
Had PICC for similar indication several years ago

41. IR Options for Venous Occlusions
Cross obstructed segment
Use collaterals as a route for line placement
Alternative access sites

42. 55 year old male needing a Hickman catheter for TPN

43. Recanalize Occluded Segment

44. Recanalizing Occluded Veins for Catheter Placement
Generally only need a channel large enough to accommodate the catheter
patients with these chronic occlusions are usually asymptomatic due to collateral flow
Reserve venous stenting for patients with obstructive symptoms

45. SVC Syndrome

46. Options for Access with Extensive Central Occlusion
Catheter placement through collaterals
Alternative access sites
Trans-lumbar
Trans-hepatic
Trans-renal
Saphenous
Femoral

47. External Jugular Access

48. Innominate Vein Occlusion

49. Central Venous Occlusion

50. Translumbar Catheter Placement
Catheter directly enters IVC
Tunneled to the right anterior axillary line
Performed under local anesthesia with IV sedation
Place catheter into the IVC as a target
Position patient in the prone-oblique position

51. Transhepatic Access

52. Trans-Renal PICC

53. Summary True, pre-existing obstacles to line placement are rare
Most of the problems we encounter are acquired, usually from prior lines
Review your patient’s chest x-rays yourself if at all possible
Catheter tip position is crucial
There are multiple options available for patients with access issues