The central venous catheter (CVC) is a thin plastic tube that is usually introduced at the neck (or also at the shoulder or arm) into the venous system and positioned with the central end in the right atrium of the heart. It remains there.

CVCs make it easier to administer substances (e.g to provide medications) and take blood without having to puncture a separate vein for every sample. (Peripheral venous accesses, e.g. Flexules® or Braunules®, which are normally positioned in the forearm or hand, only allow this to certain degree.)

Thanks to the fast flow of blood in the superior vena cava close to the heart, central venous accesses can also be used to administer all medications or even nutrient solutions. Chemotherapy agents especially can be mixed in large quantities with the blood through central venous administration and distributed throughout the body without having to have large concentrations of the substance running through a peripheral vein, which can cause irritation and damage, especially in cases of prolonged or repeated use.

Another advantage is the fact that some versions of central venous access can be left in situ for several months or even years. Essentially, a distinction is made between short-term (up to 14 days), medium-term (14 days to 3 months) and long-term (longer than 3 months) central venous accesses. The first are also commonly referred to as acute central venous catheters, while the last are known as chronic central venous catheters. A summary can be found in the image in Figure 1.

Indication for venous access

Short-term
(≤ 7-14 days)

Medium-term
(< 2-3 months)

Long-term
(> 3 months)

Preference
doctor-
patient →

 

vein
status →

Peripheral access

  • Costs ↓*
  • ≤ 4 days

CVC

  • Multi-lumen
  • Acute administration
  • < 14 days

PICC

  • Costs ↓
  • Few complications
  • Specialist PICC team

Tunnelled CVC
e.g. Hickman, Broviac

  • Infection ↓
  • Multi-lumen
  • Large lumens
    (apharesis)

Port

  • Permanent
  • Few complications
  • Good cosmetic result

* After 4 days PICC cheaper (Ryder MA, Surg Oncol Clin N Am 1995)

Central venous
(pH ≤ 4 or pH ≥ 9 oder osmolarity > 5 mOsmol/l)

Figure 1: Summary of central venous accesses (after Gebauer et al. (4))

The indications:

There are several potential reasons for siting a CVC. They are sited especially

  • for the administration of chemotherapy and other medications, particularly those that cause irritation of the veins
  • for parenteral nutrition bypassing the gastrointestinal tract
  • for the administration of potent medications acting on the circulation and heart that require precise dosing and have short half-life times (e.g. catecholamines)
  • if inserting a peripheral access would be of limited value, is difficult or impossible, especially in cases of
    • long-term infusion-based treatments
    • otherwise repeated punctures being required of peripheral veins
    • low blood volume
    • states of shock
    • states of hypothermia
    • extensive burns
  • to measure the central venous pressure
  • in emergency situations, for example for massive transfusion

The catheter is usually inserted under local anaesthesia in the neck above the collarbone, or less commonly below the collarbone and in a few justified exceptions even in the groin. With a good knowledge of anatomy, the puncture can be performed “blind”, or with ultrasound guidance in an aseptic environment.

We insist on the following quality criteria when siting a CVC:

  • The CVC is always inserted under sterile conditions (maximum sterile barrier principle) following careful disinfection of the skin and draping with a sterile cover and gloves, including face mask and hood.
  • The CVC can be inserted under local anaesthetic or more extensive medication through to general anaesthesia by an anaesthetist.
  • The actual puncture of the vessel is always guided by ultrasound in order to avoid complications (see Figure 1 and video 1: more detailed video documentation on ultrasound-guided venepuncture which is worth watching can be found in the New England Journal of Medicine, for example (1, 2)).
  • The CVC is always sited using as safe and gentle a catheter placement technique as possible (Seldinger technique (3)) under X-ray guidance.
  • To complete the procedure, a check X-ray is carried out while the patient is still on the implant table in order to rule out any possible complications (such as a pneumothorax).

Construction of the CVC:

The plastic tube nowadays is largely made from polyurethane, but rarely also from silicone. The material is chosen to ensure it is a compatible as possible with the skin, has few kinking properties to ensure good flexibility, is as unattractive to potential bacteria colonisation as possible in terms of its surface properties and disrupts the normal (laminar) flow of blood as little as possible.

The external diameter of the CVC can vary and is usually between 2 mm and 4 mm. It is especially dependent on the number of individual lumens (channels) running separately inside it, and their diameter. CVCs can be used with anywhere from one to five or more lumens, as required: when several medications are being administered via a CVC simultaneously, using several lumens means that the medications can be prevented from mixing along the shared pathway. This can prevent the precipitation of dissolved components and the limitation of loss of effectiveness, while at the same time avoiding complications arising as a result of this. Each lumen can be closed off separately at the end outside the body. For safety reasons, they are usually closed off several times using different techniques. To protect it against inadvertent slipping (dislocation), for example during sleep, the CVC is secured to the patient (using a fixation suture and/or fixation plaster).

Figure 2: The illustration shows the moment of ultrasound-guided venepuncture on the right above the collarbone (the patient’s head is show on the left in the picture). The ultrasound monitor (right-hand side of the picture) shows the vein (long thin arrow in the monitor image) and a bright spot can be seen inside it. This spot represents the tip of the needle and indicates that the vessel has been pierced successfully. The correct positioning is also checked by drawing off a little blood before continuing with the catheter placement.

MdB

Video 1: Illustration of ultrasound-guided venepuncture on the right above the collarbone (the patient’s head is show on the left in the video). The interventional radiologist tracks the introduction of the needle on the ultrasound monitor. On this monitor, the vein appears dark while the tip of the needle is shown as a bright spot. Once the bright spot appears inside the vessel, the radiologist can see that the vessel has been punctured successfully. The correct positioning is also checked by drawing off a little blood before continuing with the catheter placement (video kindly provided by Dr de Bucourt).

CVCs are generally only used while patients are in hospital and removed before discharge. Consequently, our nursing staff will look after the catheter for you. This generally involves inspecting the puncture site, regular dressing changes and disinfecting the connecting pieces.

The combination of ultrasound-guided venepuncture and fluoroscopy-guided (with X-rays) placement of the CVC means that the potential risks can be reduced to a very low level. Potential risks include bleeding and bruising, the missed puncture of the jugular artery or subclavian artery, infection or the formation of an abscess, thrombosis of the vein or catheter, the introduction of air into the pleural fissure (pneumothorax) or injury to neighbouring organs.

The CVC is one of the non-tunnelled central venous catheters. This means that there is only a small amount of tissue between the incision in the skin and the entry into the vein. Since this short distance allows bacteria to enter the vessel more easily along the catheter and cause systemic infection, it is only recommended for use in short-term treatments of up to around 14 days (4).

Contact


Minimally Invasive Tumour Therapy (MITT)
Charité Campus Virchow-Klinikum (CVK)
Department of Radiology
Augustenburger Platz 1
13353 Berlin

Graham AS, Ozment C, Tegtmeyer K, Lai S, Braner DA. Videos in clinical medicine. Central venous catheterization. N Engl J Med. 2007 May 24;356(21):e21. PubMed PMID: 17522396.

Ortega R, Song M, Hansen CJ, Barash P. Videos in clinical medicine. Ultrasound-guided internal jugular vein cannulation. N Engl J Med. 2010 Apr 22;362(16):e57. doi: 10.1056/NEJMvcm0810156. PubMed PMID: 20410510.

Seldinger SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol. 1953 May;39(5):368-76. PubMed PMID: 13057644.

O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur H, McCormick RD, Mermel LA, Pearson ML, Raad II, Randolph A, Weinstein RA. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2002 Aug 9;51(RR-10):1-29. PubMed PMID: 12233868.