The internal jugular vein may be safer than subclavian venous access. The internal jugular vein is located posterior to the sternocleidomastoid mastoid muscle (Figure 1). It is usually accessed by a percutaneous route. The plate demonstrates a right internal jugular cannulation.
Preliminary ultrasound of the right side of the neck is done in order to document the patency of the internal jugular vein. With real-time ultrasound guidance and employing a modified Seldinger technique, a small incision is made in the skin of the neck with a 15 blade and the internal jugular vein is cannulated with a small diameter needle (Figure 2A). After removing the syringe, the surgeon places a flexible guidewire (Figure 2B). The needle is removed, and over this wire, a 5-French dilator is placed to create a track (Figure 3). A 3- to 4-cm transverse incision is made on the upper right thorax two fingerbreadths below the clavicle and a hemostat is passed to create a tunnel between the two incisions (Figure 4). Blunt dissection is done to create a subcutaneous pocket on top of the pectoralis muscle fascia for the reservoir (Figure 4). The Silastic catheter is advanced through the subcutaneous tissues from the upper thoracic subcutaneous pocket to the neck incision (Figure 4). The 5-French dilator is exchanged over a wire for an introducer with a peel-away sheath (Figure 5). The dilator and wire are removed from the introducer. The Silastic catheter is advanced through the peel-away sheath (Figure 6) and is positioned under fluoroscopy with its tip in the right atrium (Figure 7). Keeping the catheter in place with a forceps (Figure 6), the sheath is “peeled away” by pulling it apart laterally until it is completely split and out. The catheter is cut to length at the pocket and the slide-on boot is placed over the catheter. The catheter is pushed onto the chamber hubs (Figure 8A), and the boot is slid down over the catheter in order to secure its attachment to the hub (Figure 8B). Immediately following placement, each of the ports is aspirated and flushed to verify patency. If any resistance is encountered, then obstruction of the catheter in the vein insertion site, the tunnel, or at the junction of the catheter with the reservoir should be suspected. These sites should be inspected. The position of the catheter with its tip in the right atrium should be verified by fluoroscopy. The reservoir is then secured with nonabsorbable monofilament suture to the pectoralis fascia. The subcutaneous tissues of the reservoir pocket are closed using interrupted 3-0 absorbable suture. The port must be easily palpable, and in very obese patients, the subcutaneous fat may need to thinned directly above the port. The skin edges are approximated using a continuous subcuticular 4-0 absorbable suture. The neck incision is closed using a single subcuticular 4-0 absorbable suture and the port is checked for flow in both infusion and aspiration after which it is loaded with a dilute heparin solution. The final configuration is shown in Figure 9 and all personnel who access the port must remember to use the special needles that do not cut or core out a segment of the Silastic access dome as they are inserted into the port.
The central venous system may be accessed via the subclavian vein as shown in Plate 152. In this operation the subclavian skin entrance site is opened a few millimeters and a tunnel is created with a small hemostat to the port site pocket. The subcutaneous fat at the entrance may require some spreading so as to allow the Silastic catheter to round this corner without an obstructing angulation. The remainder of the procedure is the same except for the need to close this skin incision with a few absorbable subcuticular sutures followed by adhesive skin strips. The port is then aspirated, checked for free flow in both directions, and finally loaded with a dilute heparin solution.