Unconventional venous access techniques

Abstract

For patients dependent on permanent venous catheters for survival, the progressive loss of venous access sites should prompt a systematic approach to alternative sites and techniques to maximize patient survival and minimize complications. Interventional radiologists should be familiar with the appropriate use of both conventional and unconventional types of venous access and their associated risks. This article discusses the use of venous access sites available as alternatives to occluded internal jugular veins, including the subclavian veins, the femoral veins, the inferior vena cava, and the hepatic veins. In addition, unconventional techniques for venous access are reviewed, including recannulization of occluded neck and chest veins, catheterization of small thyrocervical veins, and sharp recannulization of occluded central veins.

Keywords: Venous access; hemodialysis; translumbar; unconventional.

Figures

Figure 1

(A) Venous recannulization in a patient requiring permanent hemodialysis catheter placement. Sonography demonstrated bilateral occlusion of the jugular and subclavian veins. Venography from a right-sided collateral vein verified complete right-sided venous occlusion. (B) A long sheath was placed in the superior vena cava from the femoral venous approach, a glide catheter and wire were used to cross the occluded brachiocephalic vein into a small cervical collateral vein, and a loop snare was opened. This image shows fluoroscopically guided venipuncture using the loop snare as a target. (C) A wire is advanced through the loop snare. (D) The wire is pulled across the occluded veins into the right atrium. (E) A catheter is placed over the wire in standard fashion.

Figure 2

Attempted central venous recannulization with inadvertent pericardial access. A glide catheter and wire were advanced from the femoral vein with the intention of crossing the occluded bilateral brachiocephalic veins for chest catheter placement. Contrast injection (large arrow at catheter tip) shows spillage into the pericardium (small arrows). The catheter was removed without adverse sequelae.

Figure 3

(A) Patient with occluded right femoral hemodialysis catheter. Catheter tip is in the inferior vena cava. (B) After catheter removal over stiff angled glide wires, venography shows occlusion of the inferior vena cava. (C) A stent was placed to maintain caval patency and assure placement of a functioning catheter. Compared with permanent chest catheters, permanent femoral catheters are associated with an increased rate of malfunction and infection.

Figure 4

(A) Translumbar inferior vena cava (IVC) catheter placement in a dialysis patient with occluded jugular, subclavian, and femoral veins. In the prone position, a needle is advanced from the skin overlying the midpoint of the right iliac crest to the right lateral aspect of the L3 vertebral body. (B) Contrast is injected to verify access into the IVC. (C) A wire is advanced to the right atrium. (D) A permanent hemodialysis catheter is tunneled subcutaneously from the right side to the skin access site and advanced through a peel-away sheath until its tip is at the junction of the IVC and right atrium. Direct IVC catheters have a higher rate of catheter malfunction compared with chest catheters.

Figure 5

(A) Sharp venous recannulization in a patient with occluded jugular and subclavian veins. Contrast injection of a cervical vein shows occlusion of the right brachiocephalic vein and filling of a large mediastinal collateral vein (arrows). (B) The collateral vein eventually supplies a dilated azygous arch (arrow). (C) The azygous arch drains into a patent superior vena cava (arrow). (D) Using a 21-gauge needle through a sheath, direct puncture from the cervical collateral vein to a loop snare in the azygous arch was performed. The snare was used to pull a guide wire into the inferior vena cava (arrow). (E) Over the guide wire, a chest catheter was placed in standard fashion.