Editorials

Insertion of long term central venous catheters: time for a new look

Central venous catheters and ports are used to administer chemotherapy, antibiotics, parenteral nutrition, blood products, and cardiovascular pressor agents. Catheters are being used more commonly as more patients are being treated for leukaemia, solid tumours, infection, and AIDS.¹ The prototype central venous catheter inserted via a subcutaneous tunnel for long term use is the Hickman catheter.² At present such catheters may be inserted in three ways: by a surgical venous cutdown or by percutaneous puncture with or without imaging guidance.

Traditionally central venous catheters for long term use have been inserted by surgeons using a cutdown technique in the operating theatre under general anaesthesia. The catheter was inserted into the subclavian vein and advanced along the superior vena cava to the right atrium. The drawbacks of this method include a relatively low success rate (75%), a long operating time, and the fact that the vein is compromised for future use.³

In many hospitals these disadvantages have led to the cutdown technique being replaced by percutaneous methods.^{3 4 5} The procedure is still often commonly carried out in the operating theatre under general anaesthesia--probably because surgeons and anaesthetists are accustomed to that setting. Local anaesthesia is being used increasingly often, but in most cases imaging guidance is not used for the venous puncture. Instead the catheter is advanced "blindly" to the superior vena cava. A relatively large calibre needle, usually 18 gauge, is used for the initial puncture. Placement relies on simple anatomical landmarks, and the subclavian or carotid arteries are at risk of puncture. In patients with thrombocytopenia or a defective coagulation mechanism--not uncommon in those who need a central catheter--inadvertent arterial puncture may result in a large mediastinal haematoma or haemothorax, especially if it is not recognised immediately and is followed by insertion of the catheter. Pneumothorax is another risk associated with "blind" puncture of the subclavian vein, as this is usually performed quite medially. If imaging guidance is not used misplacement of catheters occurs in 6% of patients.⁶ Misplaced catheters can be repositioned by interventional radiologists, but any additional procedure causes discomfort and inconvenience. Overall, the success rate of the blind percutaneous method is around 96%, and the same vein can be reused if necessary. The puncture-related complication rate is 1-7%.^{3 7}

Imaging guidance simplifies the insertion of central venous catheters and allows the procedure to be carried out under local anaesthesia and light sedation. The creation of a subcutaneous tunnel need not be uncomfortable provided the site has been adequately infiltrated. Interventional radiologists can use standard percutaneous techniques to gain central venous access, using fluoroscopic or ultrasound guidance.^{8 9 10} If a little contrast medium is injected into a peripheral vein in the arm this allows visualisation and puncture of the axillary or the subclavian vein. Inadvertent arterial puncture is unlikely if fluoroscopy is used, and the risk is almost eliminated if real time ultrasound guidance is also used, since this allows simultaneous visualisation of both the subclavian artery and the subclavian vein and guidance of the needle into the vein.¹⁰ If venography is being used the initial diagnostic information it provides will prevent any attempt at insertion of the catheter in patients with occlusion of the subclavian or innominate veins or the superior vena cava.¹¹ Imaging guidance also allows the puncture to be made peripherally, so minimising the risk of a pneumothorax.⁹ In fact, in most cases, the axillary rather than the subclavian vein is used. Peripheral venous puncture also avoids the problem of compression of the catheter between the clavicle and the first rib. Fluoroscopic screening also has great advantages during the procedural steps which follow the venous puncture: a wire is advanced to the inferior vena cava, thus enabling the interventional radiologist to be certain that the venous and not the arterial system has been entered. A long sheath advanced over the guidewire to the right atrium ensures final correct placement of the catheter.

A complete venous access service

The most appropriate specialists to insert long term venous catheters are interventional radiologists--not only because of their familiarity with fluoroscopic and ultrasound guidance but also because of their experience with advanced catheter and guidewire techniques and equipment. The initial puncture can be made with a 21 gauge or 22 gauge needle followed by a coaxial system, which allows a gradual increase in the size of the instruments used.¹² The final catheter is identical with those used in the surgical cutdown or blind percutaneous techniques, but the early steps use small calibre equipment. Should the carotid or subclavian arteries or the lung be punctured during the procedure this is most unlikely to lead to complications.¹³ Interventional radiologists also have the skills to carry out direct percutaneous puncture of the hepatic veins or inferior vena cava in patients in whom the jugular and subclavian veins cannot be used; they are, therefore, capable of offering a complete venous access service.

Time for re-evaluation

The time has come for all hospitals to re-evaluate the methods they use to insert these catheters. The surgical cutdown should be abandoned; the blind percutaneous method should be considered to be very much a second best. The interventional radiological method is easy to learn; uses equipment that is widely available commercially; and has many advantages, including lower overall costs--a catheter can be inserted on an outpatient basis in about 30 minutes, with the patient being allowed to go home after a short period of observation. Gaining access to angiographic suites is much easier than scheduling catheter insertions in operating theatres, allowing the procedure to be carried out at short notice. Even implantable ports may be inserted by radiologists. Referring clinicians occasionally question the risk of infection if placement of a catheter is done in the angiography suite instead of the operating theatre; the published evidence shows that the rates are much the same whether the procedure is done in the radiology department or in the operating theatre.^{13 14 15 16 17 18 19 20 21}

The only real problem with the interventional radiological method of insertion is that there are too few radiologists to cope with the demand for interventional radiological procedures. Many are reluctant to provide a new, high volume service. This problem should be recognised and addressed. The Royal College of Radiologists is currently exploring ways of providing specific training in interventional radiology.

The method of inserting long term central venous catheters should no longer be dictated by tradition and habit. On-cologists and other clinicians whose patients need these catheters should question the practice in their hospitals, and interventional radiologists should learn these techniques. Patients requiring Hickman lines have enough problems to cope with already and should not be subjected to a higher risk or greater inconvenience than is necessary.

Professor of interventional radiology Department of Radiology, United Medical and Dental Schools of Guy's and St Thomas's Hospitals, London SEI 9RT

Andy Adam 

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