# Central Venous Access and Port Placement

## Introduction

Central venous access is one of the most commonly performed procedures by general surgeons. Indications range from hemodynamic monitoring and medication administration to long-term chemotherapy delivery and parenteral nutrition. Mastery of multiple insertion techniques, understanding of catheter types, and meticulous complication avoidance are essential competencies for the surgical resident.

## Indications for Central Venous Access

Short-term access needs include hemodynamic monitoring, vasopressor administration, rapid volume resuscitation, transvenous pacing, and inadequate peripheral access. Intermediate-term access is required for prolonged antibiotic therapy lasting 4 to 6 weeks, total parenteral nutrition, and repeated blood product transfusions. Long-term access serves chemotherapy administration, chronic TPN, chronic pain management, frequent blood sampling, and hemodialysis.

## Types of Central Venous Catheters

Non-tunneled central venous catheters, typically triple-lumen, are placed percutaneously for short-term use of less than 14 days. They carry the highest infection rate and are inserted via the internal jugular, subclavian, or femoral vein. Peripherally inserted central catheters (PICCs) are inserted via the basilic or brachial vein with the tip positioned in the SVC. They are used for intermediate durations of weeks to months and carry lower insertion complications but significant thrombosis risk of up to 5 to 10%. Tunneled cuffed catheters such as Hickman, Broviac, and Groshong lines have a subcutaneous tunnel with a Dacron cuff that promotes tissue ingrowth and serves as a bacterial barrier. They are used for long-term access lasting months to years, and the Groshong catheter features a pressure-sensitive valve tip. Implantable subcutaneous ports are completely implanted systems with a reservoir and attached catheter, accessed percutaneously with a non-coring Huber needle. They have the lowest infection rate and are ideal for intermittent long-term access such as chemotherapy, remaining in place for years.

<image>Comparison diagram of four types of central venous access devices: non-tunneled CVC, PICC line, tunneled cuffed catheter (Hickman), and implantable subcutaneous port, showing insertion sites, catheter paths, and catheter tip positions at the SVC-RA junction with labeled components of each device</image>

## Anatomy of Central Venous Access Sites

### Internal Jugular Vein (IJV)

The IJV is the preferred site for most central venous access, especially with ultrasound guidance. It lies within the carotid sheath, lateral and anterior to the common carotid artery, deep to the sternocleidomastoid muscle. The landmark technique targets the apex of the triangle formed by the two heads of the SCM and the clavicle, directing the needle toward the ipsilateral nipple at 30 to 45 degrees. Ultrasound-guided technique, now the standard of care, uses a short-axis (transverse) or long-axis (in-plane) approach, identifying the vein as compressible, non-pulsatile, and lateral to the artery.

### Subclavian Vein

The subclavian vein courses beneath the clavicle, anterior to the anterior scalene muscle, medial to the subclavian artery. The infraclavicular approach inserts the needle at the junction of the medial and middle thirds of the clavicle, directed toward the sternal notch. Advantages include greater patient comfort, lower infection rates compared to IJV and femoral sites, and suitability as the preferred site for tunneled catheters and ports. Disadvantages include higher pneumothorax risk, a non-compressible site (avoid in coagulopathy), and subclavian stenosis risk (avoid in dialysis patients to preserve venous capital).

### Femoral Vein

The femoral vein is located medial to the femoral artery in the femoral triangle (mnemonic: NAVEL, from lateral to medial: Nerve, Artery, Vein, Empty space, Lymphatics). Advantages include easy accessibility, no pneumothorax risk, and compressibility. Disadvantages include the highest infection rate, DVT risk, and unsuitability for ambulatory patients; it is reserved for emergencies or when upper extremity access is not possible.

## Seldinger Technique and Insertion Principles

The Seldinger technique involves needle puncture of the vein, guidewire insertion through the needle, needle removal, dilator passage over the wire, catheter advancement over the wire, and wire removal. Ultrasound guidance is strongly recommended for all central venous access, as it reduces complications and improves first-pass success rate. Critical safety steps include confirming venous blood (dark, non-pulsatile) versus arterial blood, always maintaining control of the guidewire to prevent embolization, confirming wire position in the IVC/SVC with ultrasound or fluoroscopy before dilation, and never forcing the wire or dilator if resistance is encountered. The ideal catheter tip position is at the cavoatrial junction or lower SVC, confirmed by chest radiograph or intraprocedural fluoroscopy.

## Subcutaneous Port Placement

### Surgical Technique

Site selection targets the anterior chest wall, typically 2 to 3 fingerbreadths below the clavicle over the pectoral muscle, avoiding breast tissue. Venous access is obtained through percutaneous puncture of the IJV or subclavian vein, or cutdown on the cephalic vein in the deltopectoral groove. Port pocket creation uses a 3 to 4 cm transverse incision to create a subcutaneous pocket superficial to the pectoral fascia; the pocket should be snug to prevent port migration or flipping. The catheter is tunneled from the venotomy or puncture site to the port pocket and trimmed to the appropriate length for the tip to reach the cavoatrial junction under fluoroscopic guidance. The port is secured to the pectoral fascia with 2 to 3 non-absorbable sutures through the port eyelets. Final verification includes aspirating blood from the port, flushing with heparinized saline, and obtaining completion fluoroscopy or chest radiograph.

### Cephalic Vein Cutdown

The deltopectoral groove landmark identifies the groove between the deltoid and pectoralis major muscles. The vein is identified in the fat within the groove after incision, isolated, and a transverse venotomy is performed to advance the catheter centrally under fluoroscopy. Advantages include no pneumothorax risk and no central vein puncture, making it useful when percutaneous access is difficult. The limitation is that the cephalic vein may be absent or too small in 10 to 15% of patients.

<image>Step-by-step surgical illustration of subcutaneous port placement showing the port pocket creation over the pectoral fascia, catheter tunneling from the internal jugular vein puncture site to the pocket, port fixation with sutures through eyelets, and the final catheter tip position at the cavoatrial junction on fluoroscopy</image>

## Complications

### Mechanical Complications

Pneumothorax occurs in 1 to 6% with the landmark technique and less than 1% with ultrasound guidance, more commonly with the subclavian approach. Small pneumothoraces may be observed, while larger ones require tube thoracostomy. Arterial puncture of the carotid (IJV approach) or subclavian artery is managed with direct pressure for IJV injuries, while subclavian arterial injury may require surgical repair or covered stent. Air embolism is prevented by placing the patient in Trendelenburg, occluding the needle hub, and having the patient perform Valsalva; treatment involves left lateral decubitus positioning and aspiration through the CVC. Guidewire embolization is prevented by always maintaining wire control; retrieval is performed via interventional radiology snare technique. Catheter malposition with the tip in the contralateral brachiocephalic, azygos, or IJV requires repositioning.

### Infectious Complications

Central line-associated bloodstream infection (CLABSI) occurs at 0.5 to 5 per 1,000 catheter-days depending on catheter type. Prevention bundles include hand hygiene, maximal barrier precautions, chlorhexidine skin preparation, optimal site selection, and daily assessment of line necessity. Management involves blood cultures from both peripheral and each lumen, empiric vancomycin plus gram-negative coverage, catheter removal for S. aureus, Candida, or tunnel/pocket infection, and consideration of salvage with antibiotic lock therapy for coagulase-negative staphylococci.

### Thrombotic Complications

Catheter-related DVT occurs in 2 to 25% depending on catheter type, with higher rates in PICCs, femoral catheters, and left-sided insertion. Treatment involves anticoagulation and catheter removal if no longer needed or if the thrombus progresses despite anticoagulation. Fibrin sheath encasing the catheter causes withdrawal occlusion and is treated with tPA instillation or catheter exchange over a wire with fibrin sheath disruption.

<image>Chest radiograph diagram showing correct and incorrect catheter tip positions for central venous catheters, including ideal position at the cavoatrial junction, and common malpositions in the contralateral brachiocephalic vein, azygos vein, and internal jugular vein, with anatomical landmarks labeled</image>

## Clinical Pearls

Ultrasound guidance is the standard of care for central venous access and significantly reduces complications. The ideal catheter tip position is at the cavoatrial junction; too high increases malfunction risk, and too low risks cardiac perforation and tamponade. Port pockets should be snug and secured to the pectoral fascia to prevent "twiddler syndrome" (port flipping). CLABSI prevention bundles have dramatically reduced infection rates, and daily reassessment of line necessity is critical. Subclavian vein access should be avoided in patients with renal disease to preserve venous capital for future dialysis access.

## References

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