Central line placement

Tunnelled catheters (can be left for months to years)

Permcath
Hickmann line

Non-tunnelled catheters (can be left for days to up to 3 weeks)

Vascath

Totally implantable catheters (can be left for months to years)

Portacath
- For long-term placement (e.g. cancer patients), ports are best option

Pre-op workup

Coagulopathy/anticoagulants
Consider USS to confirm good calibre veins
II

IJV (usual site for haemodialysis catheters)

Anatomy
- Right side preferred - straighter course to RA
- Under SCM, and obliquely down neck on a line from the pinna to sternoclavicular joint
- In lower neck, just anterior and lateral to carotid artery
Preparation
- Head down 15 degrees (distends large veins by 25%)
- Turn head 30 degrees to opposite side to straighten the course of the vein
- Use ultrasound - increases success rate and reduces risk of carotid puncture
USS technique: Locate vein with USS in between the two heads of SCM, anterolateral to carotid pulse, and perform micropuncture.
Landmark technique:
- Anterior: Insert micropuncture needle at apex of SCM triangle with bevel up, advance towards ipsilateral nipple at 45 degrees, and continue for 5cm. If vein not encountered, withdraw and try a more lateral traverse.
- Posterior: insert 1cm above the point where EJV crosses over the lateral edge of SCM, aiming under SCM towards the suprasternal notch for 5-6cm.
Insert wire to level of RA
Tunnel catheter from chest wall - do it in two goes to make sure it's a nice curve, and not kinked
Dilate up the vein
Insert catheter, wire out, position check (aim tip at carina)
Flush
Suture
Complications:
- Carotid puncture - if just needle, withdraw and press for 5 minutes; if catheter, leave in situ and consult vascular.
- Pneumothorax 1.3% with landmark technique
- Infection
- Air embolus - see topic under Vascular

Subclavian

Reliable for permanent access, but should not be used for haemodialysis access (risk of stenosis)
Short distance between subclavian vein and chest wall - catheter less prone to kinking
Hard to visualise with USS, and not usually helpful
Anatomy
- At some points only 5mm above the apical pleura of the lungs
- Subclavian artery and brachial plexus are just deep to the vein
- Diameter 7-12mm
- Lies just underneath the clavicle at the point where the SCM inserts onto clavicle
Preparation
- Head down 15 degrees (distends large veins by 25%)
- Some say arching the shoulders or placing a rolled towel under the shoulder also helps, but this is disputed by Marino's
Approach
- Supraclavicular - use the needle to bisect the angle formed by SCM and clavicle; advance along underside of clavicle towards opposite nipple; enter at 1-2cm from skin
- Infraclavicular - below
Technique
- Check the heparin
- Remember to secure guidewire at all times
- Positioning: prefer GA. Patient flat with head-ring, ideally with a little Trendelenburg. Both arms tucked and prep on both sides.
- Set-up: needle on 10mL syringe with 2mL saline. Then guidewire, with tip pointing away from coil, as it will be fed in with tip towards heart. Then trochar (needs to be set up). Then port, with catheter attached (feed it onto port then click the ring in place, with black part away from me, I think); need an artery on the end for measuring. Lock port with hep saline, and do it with port angled to ensure no bubble.
- Technique:
  - Mark sternal notch, clavicle, ACJ, and SCM rectangle where it inserts onto clavicle.
  - Micropuncture Seldinger access to subclavian vein
    - Stab incision at the lateral border of part of clavicle where SCM inserts, then needle inserted with bevel at 12 o'clock, and advanced along the underside of the clavicle, in a direction that would bisect the SCM rectangle on the clavicle (from picture above) into two triangles.
    - Should meet vein within a few centimetres from the surface. Keep right on underside of clavicle to avoid the artery.
    - Rotate bevel to 3 o'clock on insertion, insert guidewire, remove needle, confirm placement with II..
    - Micropuncture sheath over guidewire and upsize to the larger guidewire; confirm with II.
    - Place peel-away catheter over guidewire; remove guidewire.
  - Create pocket for port with a transverse incision and dissection onto chest wall
    - Measure catheter to level of tracheal bifurcation at T4 (usually 15-20cm from venotomy to right atrium, plus the tunnelling distance)
    - Tunnel catheter and cut off trochar
    - Remove inner dilator from peel-away sheath and feed catheter down
    - II again
    - Peel sheath while holding catheter in place
  - Apply port-locking device to catheter end; secure it to port; suture port in place
  - Check port working
  - Close in layers
  - CXR in recovery
- Complications
  - Subclavian artery puncture
  - Pneumothorax
  - Brachial plexus injury
  - Phrenic nerve injury
  - Air embolus - see topic under Vascular

Cephalic

Approach for port-a-cath
- Incision along deltopectoral groove about 5cm long, with upper end close to clavicle
- Dissect down through fat to delto-pectoral groove
- Dissect cephalic vein over length of 2cm
- Ligate distally with 2-0 vicryl
- Loop proximally
- Venotomy and insert catheter with aid of vein pick
- X-ray - position catheter at junction of SVC and RA
- Length will be 15-20cm on right and 20-25cm on left
- Secure with suture
- Flush with saline
- Create pocket for port - suture in place x3
- Close

Femoral

Avoid unless no other good options
Leg in abduction
USS useful
Landmark method: insert 1-2cm medial to femoral artery pulse, hitting the vein at 2-4cm from the skin. If femoral pulse not palpable, draw a line from ASIS to pubic tubercle and use the junction of medial and middle thirds.
Complications
- Femoral artery puncture
- Femoral vein thrombosis
- Infection (maybe higher risk than other sites, although this is disputed by Marino's)

Choice of site:

Non-contaminated area that will stay clean
Avoid altered local anatomy
Avoid previous access device
If significant lung disease is present, use the same side, to minimise risk of ruining good lung with a PTX

Advantages and disadvantages of central vein approaches

Approach	Advantages	Disadvantages
External jugular	Superficial vessel that is often visible Coagulopathy not prohibitive Minimal risk of pneumothorax (especially with US guidance) Head-of-table access Prominent in older adult patients Rapid venous access	Not ideal for prolonged venous access Poor landmarks in patients with obesity High rate of malposition Catheter may be difficult to thread
Internal jugular	Minimal risk of pneumothorax (especially with US guidance) Head-of-table access Procedure-related bleeding amenable to direct pressure Lower failure rate with novice operator Excellent target using US guidance	Not ideal for prolonged access Risk of carotid artery puncture Uncomfortable Dressings and catheter difficult to maintain Thoracic duct injury possible on left Poor landmarks in patients with obesity/edematous patients Potential access and maintenance issues with concomitant tracheostomy Vein prone to collapse with hypovolemia Difficult access during emergencies when airway control being established
Subclavian	Easier to maintain dressings More comfortable for patient Better landmarks in patients with obesity Accessible when airway control is being established Associated with lower incidence of catheter-related infection*[1]	Increased risk of pneumothorax Procedure-related bleeding less amenable to direct pressure Decreased success rate with inexperience Longer path from skin to vessel Catheter malposition more common (especially right SCV) Interference with chest compressions Risk for stenosis/occlusion, which impacts future hemodialysis arteriovenous access
Femoral	Rapid access with high success rate Does not interfere with CPR Does not interfere with intubation No risk of pneumothorax Trendelenburg position not necessary during insertion	Delayed circulation of drugs during CPR Prevents patient mobilization Difficult to keep site sterile Difficult for PA catheter insertion Increased risk of iliofemoral thrombosis