Chapter 139: Venous Access, Port Placement, Internal Jugular Vein

INDICATIONS

The most common indication is for the administration of chemotherapy or long-term parenteral nutritional support. For these purposes, a port is usually used. For short-term therapies, alternatives include a tunneled central venous catheter and a peripherally inserted central catheter.

PREOPERATIVE PREPARATION

The procedure is usually performed as an outpatient. Electrolytes and clotting studies should be checked prior to the procedure. If the patient has had previous central catheters, a careful history should be obtained because this will help with site selection. Transcutaneous ultrasound can assist with vein localization. A single dose of preoperative antibiotics provides for prophylaxis.

ANESTHESIA

Moderate sedation and local anesthesia are preferred.

POSITION

Patients are placed in the supine position. Fluoroscopy should be available. The arms are tucked at each side.

OPERATIVE PREPARATION

The hair is removed with clippers. The chosen side of the neck/upper thorax is prepped and draped using the maximum sterile barrier technique. Then a time-out is performed.

DETAILS OF THE PROCEDURE

The internal jugular vein may be safer than subclavian venous access. The internal jugular vein is located posterior to the sternocleidomastoid muscle (FIGURE 1). It is usually accessed by a percutaneous route. This chapter demonstrates a right internal jugular cannulation.

Preliminary ultrasound of the right side of the neck is done 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 no. 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 finger breadths below the clavicle. Blunt dissection is done to create a subcutaneous pocket on top of the pectoralis muscle fascia for the reservoir (FIGURE 4). The Silastic catheter attached to a metal stylet is advanced through the subcutaneous tissues from the incision in the right upper thorax to the incision in the neck (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 forceps (FIGURE 6), the sheath is peeled away by pulling it apart ...