Central Venous Access

Venous Access Fundamentals

• US-guided access is standard of care — dramatically reduces complications vs landmark technique
• Common access veins: Internal jugular (preferred for tunneled catheters, ports), subclavian (ports, some tunneled), femoral (temporary, emergent), basilic/brachial (PICC)
• Seldinger technique: Needle access → guidewire → dilator → catheter/sheath
• Tip position: SVC–RA junction for most central catheters; confirm with fluoroscopy or post-procedure CXR
• Micropuncture access (21G needle + 0.018″ wire) reduces arterial puncture complications
• Always confirm venous access with US before dilation — arterial dilation is a serious complication

Planning & Safety

• Review prior imaging for venous stenosis/occlusion (especially with prior lines)
• Avoid placing lines through infected skin or into infected/thrombosed veins
• Left-sided IJ/subclavian: avoid if patient may need AV fistula (preserves vasculature)
• For tunneled catheters: plan tunnel tract, ensure adequate subcutaneous tissue, avoid breast tissue
• For ports: pocket over bony prominence for needle stabilization; comfortable and accessible
• ECG-guided tip positioning is an alternative to fluoroscopy for PICCs

General Contraindications

• Absolute: Uncorrectable coagulopathy (for tunneled/port), SVC occlusion (bilateral), overlying skin infection
• Relative: Anticoagulation, ipsilateral venous stenosis/thrombosis, prior radiation to access site, contralateral pneumothorax (avoid bilateral subclavian attempts)

SIR Bleeding Risk

Immediate

• Arterial puncture — most common serious complication; hold pressure; if dilated, may require surgical/endovascular repair
• Pneumothorax — IJ/subclavian access; US guidance reduces risk
• Air embolism — keep patient in Trendelenburg; occlude hub when open
• Arrhythmia — wire in right atrium; withdraw if sustained
• Catheter malposition — confirm with fluoroscopy; reposition as needed

Delayed

• Catheter-related infection / line sepsis — most common long-term complication
• Venous thrombosis / stenosis — especially with long-term catheters
• Catheter fracture / embolization (ports) — from pinch-off at costoclavicular space
• Fibrin sheath formation — impairs function; can strip with snare
• Port pocket infection / erosion

Key Guidelines

• SHEA/IDSA CLABSI Prevention Guidelines 2022
• SIR Standards of Practice for Venous Access
• CDC Guidelines for Prevention of Intravascular Catheter-Related Infections 2011

Primary References

• McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348(12):1123-1133.
• Sznajder JI et al. Central vein catheterization: failure and complication rates by three percutaneous approaches. Arch Intern Med. 1986;146(2):259-261.
• Troianos CA et al. Guidelines for performing ultrasound guided vascular cannulation. J Am Soc Echocardiogr. 2011;24(12):1291-1318.