This document discusses central venous access devices (VADs) used for long-term intravenous treatment. It describes different types of VADs including short-term central venous catheters, peripherally inserted central catheters, tunneled catheters, and totally implanted ports. It discusses factors in choosing a device, risks of complications, and techniques to reduce complications like ultrasound guidance and appropriate catheter size and position. Placement site, patient characteristics, and device care can affect risks of mechanical issues, infections, thrombosis, and extravasation injuries.

1. Leily Mohajerzadeh
Pediatric surgeon
Mofid Hospital

2. 1
• solutions with pH <5 or pH >9
2
• drugs with osmolarity >600 mOsm/L
3
• parenteral nutrition with solutions
containing 10% glucose or 5% amino acids

3. 4
• administration of vesicant drugs or other drugs associated with
vascular intimal damage
5
• Need for multiple-lumen intravenous treatment;
• Need for dialysis or apheresis;
• need for central venous pressure monitoring;
6
• venous access needed for more than 3 months.

4. Vascular Access
Devices
Short-term (1 to
3 weeks)
CVC, central
venous catheter
Medium-term
PICC,
peripherally
inserted central
catheter
Hohn catheters
Long-term
(Prolonged
intravenous
treatment (>3
months)
Tunneled
catheters
(Groshong,Hick
man, Broviac)
Ports (totally
implanted)

5. All centralVADs may
have
single or multiple
lumens
Multiple-lumen catheters are
advantageous in patients
undergoing stem cell
transplantation or
chemotherapy
that involves the simultaneous
infusion of a number of agents and
blood products.
and can be open-ended
or valved

8. PICC, peripherally
inserted central catheter
PICCs are usually inserted at the bedside by trained physicians
or nurses either resorting to the “blind” technique via the
antecubital vein or the cephalic vein or to ultrasound guidance
via a deep vein in the midarm (basilic or brachial vein)
In the United Kingdom, most chemotherapy treatments are
delivered through PICCs, which are increasingly inserted using
ultrasound guidance.

9. PICCs
PICCs are not advisable in patients with
renal failure and impending need for
dialysis,
in whom preservation of upper-extremity
veins is needed for fistula or graft
implantation

11. Hickman
catheter
Hickman catheter is part of a subclass of
central venous catheters which are tunneled,
since a segment of the catheter is tunneled
under the skin before exiting the chest.
The catheter will last anywhere from one-
12 months depending on its care

13. Totally implanted
ports
Reservoir ( made
of titanium
and/or plastic
polymers
connected to a
CVC (usually
made of silicone)

17. Ports have lower reported rates of catheter-related
bloodstream infections than both tunneled and
nontunneled CVCs.
Double-lumen ports are used for specific purposes, as in
patients undergoing bone marrow transplantation and in
patients who require infusion of noncompatible
medications and fluids, which necessitate a second
intravenous access.

18. • should be reserved for patients
who require long-term,
intermittent vascular access
totally
implantable
access
devices
• is preferable for patients
requiring continuous access
tunneled
CVC
Thus,oncology patients who need
chemotherapy treatment
scheduled on a weekly or monthly
basis should benefit from a totally
implanted port,
those who need daily infusions
of palliative treatment
analgesics ,hydration,nutrition,
etc.)should benefit from an
external catheter.

19. Although multiple-lumen catheters are
generally associated with increased
morbidity, particularly infections
small caliber should be employed to
minimize the risk of catheter-related
thrombosis

20. When a totally implanted
port is used, choosing a
catheter caliber larger than
6 to 7 French does not carry
significant advantages

21. most centralVADs are
made of silicone or
polyurethane, which
have different features.

22. CVCs with multiple lumens may be associated with
higher infection rates than single-lumen CVCs
Compared with central venous catheters,PICCs
appear to be associated with a lower risk of infection,
most probably because of the exit site on the arm,
• PICCs are not advisable in patients with renal failure and
impending need for dialysis, in whom preservation of upper-
extremity veins is needed for fistula or graft implantation

24. The CDC recommends not to use routinely venous cut-down
procedures as a method to insert catheters, even for long-term
ones, because percutaneously placed catheters are associated
with a lower infection rate than surgically implanted ones
However, in neonates and in children, not routinely but in
selected cases,venous cut-down might be the safest choice

25. conditions that
might increase
the difficulty of
catheter
insertion
Skeletal
deformity,
presence of
scars,
obesity,
or previous
surgery at
insertion site

26. During internal jugular venous catheterization,ultrasound
guidance (both 2-dimensional [2D]ultrasound- and
Doppler-guided methods) clearly reduces the number of
complication
Ultrasound guidance reduces complications relative to
percutaneous accesses performed with the standard
“landmark” technique

27. Placement of the catheter tip high in the SVC results in
a higher incidence of thrombosis than low placement in
the SVC or at the atriocaval junction.
atriocaval junction appears to be the optimal position;
hemodialysis could require full atrial positioning of the
catheter tip, at least for cuffed devices

29. Thrombosis also seems to be more
common when catheters are inserted
entering the left subclavian vein
Many centers systematically verify
position by fluoroscopy after
implantation

31. Early
Complications
pneumothorax,
hemothorax,
primary
malposition,
arrhythmias,
air embolism,
arterial
perforation

32. Arterial puncture and hematoma are the most common
mechanical complications during the insertion of CVCs, with
similar rates for internal jugular and subclavian
catheterization
Pneumothorax is described as the most frequent
complication of percutaneous central venous cannulation.
Its prevalence is 0.5% to 12%,depending on differences in
clinical features
• With the ultrasound-guided approach, pneumothorax has become
extremely rare

33. A confirmatory x-ray is usually obtained after
implantation, immediately after the procedure,or a
few hours later, depending on the avail
first approach to a small asymptomatic
pneumothorax (one involving less than 30% of the
hemithorax) should be observation alone, with
repeated chest x-rays and supplemental oxygen.

34. The administration of oxygen is
able to accelerate by a factor of
the reabsorption of air by the
pleura, which occurs at the rate
of 2% per day in patients
breathing room air.

35. 1-mechanical
complications
pinch off,
fractures,
dislodgement,
migration)
2-Extravasation
injuries;
3-infections
(including phlebitis
of the cannulated
vessel);
4-catheter and vein
thrombosis/occlusion
deep vein
thrombosis,
pulmonary
embolism,
SVC syndrome

36. “pinch-off ”
syndrome
is due to compression of a large-bore silicone
catheter—tunneled or connected to an
implantable port—between the clavicle and the
first rib, typically secondary to “blind”
percutaneous placement of the catheter in the
subclavian vein via the infraclavicular route.

37. Immediate complications were more frequent in the
subclavian than in the internal jugular approach
(respectively, 5.0% versus 1.5%;P .001); catheter
malposition (2.3% versus 0.2%), venous thrombosis (2.0%
versus 0.6%),catheter malfunction (9.4% versus 4.3%),
And long-term morbidity (15.8% versus 7.6%) were also
significantly more frequent in the subclavian than in the
internal jugular group

38. Extravasation Injuries
CentralVADs have greatly reduced the
incidence of extravasation injury, but this
severe complication may still occur
in cases of catheter malfunction, such as rupture or tear
in the catheter or port septum, migration of the
catheter into a smaller vein, perforation of the SVC wall,
separation of the catheter from the reservoir, and
improper placement of the needle into the port septum.

39. Extravasation of drugs can result in
significant tissue damage.
Pain is the main warning sign. If pain
suggests extravasation injury, drug infusion
should be discontinued immediately,and the
site should be aspirated for residual drug

42. the incidence of venous thromboembolism is markedly
higher in patients with cancer than in patients without
cancer
thrombosis is a direct consequence of tumor growth and
host inflammatory responses and an indirect
consequence of cancer treatment,venous stasis, and
direct vessel trauma.

43. Within 24 hours of CVC insertion, a fibrin sheath,
always colonized by bacteria, forms around the
catheter, but its presence does not predict subsequent
thrombosis of the vessel in which the catheter is placed
Mechanisms of CVC induced thrombosis include acute
and chronic endothelial damage to the vein wall
produced by an intravascular foreign body.

44. Materials can also have an
effect on thrombosis rates.
superiority of silicone and second-third
generation polyurethane over more rigid
materials like polyvinylchloride,
tetrafluoroethylene,and polyethylene
a lower-diameter catheter and a single
lumen might be protective against the risk
of central venous thrombosis

45. and irreversible occlusion of the lumen.
Malposition of the tip (primary or secondary to
migration),
infected thrombus,

46. Chronic symptomatic cases
should be treated with a
combination of low-molecular–
weight heparin (LMWH) and
then oral anticoagulants or with
LMWH long-term alone

47. technique of placement
(ultrasound-guided versus blind),
cannulated vein (cephalic versus
brachial versus basilica),
position of the tip,
stabilization technique
(stabilization devices versus tape
versus stitches),
type of treatment,
patient, and disease characteristics

48. Thanks for your attention