SUPERIOR VENA CAVAGRAM

TUNNELLED CVC INSERTION

DESCRIPTION OF PROCEDURE:

Realtime ultrasonography of the right neck was performend demonstrating
patency of the internal jugular vein which was then chosen for access;
ultrasound images were archived.

A large area of the right neck and upper chest was prepped and draped in
sterile fashion.

Using 1% lidocaine for local anesthesia and under real-time ultrasonic
guidance, a 21ga. micropuncture set was used to access the right internal
jugular vein at the base of the neck. Ultrasound images were archived.

A small incision was made at the puncture site. The wire could not be
advanced much into the vessel and for this reason a 4 French catheter was
advanced over the wire. Contrast material was injected and digital
angiograms were obtained demonstrating occlusion of the superior vena cava
just beyond the confluence of the azygos vein. Flow in the azygos vein is
retrograde.

Over a wire, the tract was dilated and an introducer sheath was advanced into
the vein.

A tract of subcutaneous tissue, leading from the incision at the puncture
site to the anterior right chest below the clavicle, was then infiltrated
with local anesthetic. A small incision was made at the chest end of the
tract. A flexible tunneler was then used to pull an 8 cm long dual-lumen
catheter through the subcutaneous tunnel. The tunneler was disconnected and
the catheter was then advanced through the sheath until its tip reached the
central portion of the patent superior vena cava ; as mentioned above the
catheter could not advance be advanced into the right atrium since the cava
is occluded more centrally.

Fluoroscopy of the air at demonstrated a kink in the catheter as it entered
the internal jugular vein. We were unable to resolve the kink and for this
reason the catheter had to be removed and the procedure restarted after re-
prepping and draping of the area.

Using sterile technique under real-time ultrasonic guidance a 21 gauge needle
was placed in the right internal jugular vein. An introducer sheath was
advanced into the vein.

A 6 French dual-lumen central venous catheter was then advanced through the
subcutaneous tunnel and into the internal jugular vein until its tip reached
the central portion of the patent superior vena cava. This time no kinks
were identified along the course of the catheter.

Both ports were capped and heparinized and the catheter was then secured to
the skin with 2-0 nylon sutures. The incision at the base of the neck was
closed with tissue glue and SteriStrips.

There were no complications.

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