What are Vascular Access Procedures?
A vascular access procedure involves the insertion of a flexible thin plastic tube, or catheter, into a blood vessel to provide an effective method of drawing blood or delivering medications and nutrients into a patient’s bloodstream over a period of weeks, months or even years. A simple intravenous (IV) line is effective for short-term use, but is not suitable for long-term use. When an IV line is necessary for a longer period of time and/or a more secure venous access is necessary, a special catheter that is generally longer, called a central access catheter, or a similar device can be used. The catheter can remain in place either temporarily (days) or long-term (weeks to years) so that it can be easily and repeatedly accessed over the necessary period of time without the need for repeat punctures to the patient. In a vascular access procedure, a special catheter is inserted inside a major vein (generally in one of the large veins in the neck, arms or legs) with the tip of catheter positioned into a large central vein that terminates near the heart.
What to Expect
A midline catheter and some peripherally inserted central catheter (PICC) lines may be inserted at your bedside without image guidance. These are inserted through a vein near the elbow and threaded through a large vein in the upper arm. Other vascular access procedures are most often performed by a specially trained interventional radiologist in an interventional radiology suite or occasionally in the operating room. These procedures are often performed on an outpatient basis.
You will be positioned on your back. A nurse or technologist may insert an intravenous (IV) line into a vein in your hand or arm so that sedative medication can be given intravenously. PICC placement usually does not require sedative medications. The area of your body where the catheter is to be inserted will be shaved (typically the upper chest for tunneled catheters and in the arm for PICCs), sterilized and covered with a surgical drape. Your physician will numb the area with a local anesthetic. A very small nick is made in the skin at the site.
PICC
To place a PICC line, the physician or nurse will identify the vein using ultrasound or x-ray guidance and insert a small needle into the arm vein and advance a small guide wire into the large central vein, called the superior vena cava, under x-ray (fluoroscopy). The catheter is then advanced over the guide wire and moved into position. The guide wire is then removed. If this is done without x-ray guidance, a chest x-ray is needed to confirm the catheter position.
NON-TUNNELED CENTRAL CATHETER
These catheters are placed via a relatively larger vein such as the jugular vein in the neck or femoral vein in the groin.
TUNNELED CATHETER
For a tunneled catheter, the physician will make one small incision in the skin commonly in the lower neck. Using ultrasound guidance, the vein is punctured with a needle (usually the jugular vein at the base of the neck), and a small guide wire is advanced into the large central vein, called the superior vena cava, under x-ray guidance (fluoroscopy). A second small skin incision may be made below the first, and a tunnel under the skin is then created. Using x-ray guidance, the catheter is placed through the tunnel into the vein, and the tip of the catheter is placed into the largest vein, the superior vena cava. The cuff, which is typically made of Dacron®, is located under the skin in the tunneled path of the catheter. Finally, the physician will place stitches at end of the tunnel to help keep the catheter firmly in place. The stitches do not typically need to be removed until the catheter is taken out.
PORT-CATHETER
Implanting a subcutaneous port generally requires two incisions (except in the arm where a single incision may suffice). The port reservoir is placed under the skin. A small skin incision slightly longer than the diameter of the device itself is made, and a small pocket for the port is created under the skin. The rest of the procedure is similar to the tunneled central catheter placement. A small, elevated area remains on your body at the site of the reservoir at the conclusion of the procedure. The port, which passes from an access site in a vein of your arm, shoulder or neck, ends in a large central vein in the chest. The reservoir has a silicone covering that can be punctured with a special needle.
An x-ray may be performed after the procedure to ensure the catheter is positioned correctly but is frequently not necessary if x-ray (fluoroscopy) was used during the placement procedure. The implanted vascular access catheter is then ready for use.
Patient Prep
Prior to your procedure, your blood may be tested to determine how well your kidneys are functioning and whether your blood clots normally.
You should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to local anesthetic medications, general anesthesia or to contrast materials containing iodine (sometimes referred to as “dye” or “x-ray dye”). Your physician may advise you to stop taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or blood thinners for a specified period of time before your procedure.
You will receive specific instructions on how to prepare, including any changes that need to be made to your regular medication schedule. Other than medications, you may be instructed to not eat or drink anything for several hours before your procedure. You should plan to have a relative or friend drive you home after your procedure.