10.1245/s10434-006-9140-7
Annals of Surgical Oncology 14:937-941 (2007)
© 2007 Society of Surgical Oncology
A Modified Internal Jugular Vein Access for Long-Term Catheter Placement in Cancer Patients
Marcos Pires e Albuquerque, MD
Bone Marrow Transplantation Center of the National Cancer Institute (INCA), Ministry of Health, Rio de Janeiro, Brazil
Correspondence: Address correspondence and reprint requests to: Pires e Albuquerque Marcos, MD, Rua Jerson Pompeu Pinheiro, 270, Rio de Janeiro, Brazil, 22793-317; E-mail: mpires{at}marcospires.med.br
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ABSTRACT
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Background: Placement, handling, and maintenance of indwelling central venous access devices may be difficult due to anatomical, clinical, or hematologic conditions in many cancer patients needing chemotherapy. An alternative approach technique is suggested joining surgical dissection to venipuncture, assisted by fluoroscopy, as a secure way to avoid complications of long-term indwelling catheters. Although ultrasound guided puncture is a safe procedure, it is not always available or familiar to most surgeons.
Methods: At the National Cancer Institute (INCA) in Rio de Janeiro, Brazil, 1750 long-term catheter placements were performed between the years 1997 and 2005. Among those, 160 were done through an alternative technical procedure consisting of an anterior cervical cut-down approach to the internal jugular vein (IJV) followed by percutaneous visual puncture of the vein. This modified internal jugular vein access (MIJVA) was employed when other access techniques were not feasible or if other underlying conditions increase the risk of bleeding complications.
Results: The MIJVA procedure was successful in all 160 patients. Although it was used only as an exceptional option in difficult venous accesses, further prospective trials must be conducted, however, for comparison with other technical approaches.
Conclusion: The MIJVA is an option that provides successful IJV dissection and safe percutaneous visual puncture overcoming anatomical pitfalls in placement of long-term venous access for chemotherapy in cancer patients.
Key Words: Catheter-placement technique • Central venous catheter • Vascular access technique • Cancer chemotherapy
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INTRODUCTION
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Complex anatomical or clinical situations are frequently observed in cancer patients. An alternative technical procedure of long-term catheter placement is described as an option to overcome venous access complications and obtain successful catheterization.
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PURPOSE
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Complexity in placement, handling, and maintenance of chronic indwelling central venous access catheters has been reported,1–3 sometimes leading to serious complications.4–6 The choice of the venous access route will depend on anatomical, clinical, and hematological situations that are often challenging in cancer patients. Pre- and perioperative ultrasound and other imaging techniques have been suggested to overcome these difficulties.7 A variety of complex cancer conditions like tumor involvement, prior radiation or chemotherapy, variations in chest and neck anatomy, central venous thrombosis, venous stenosis, obesity, and hematological disorders in bone marrow transplantation (BMT) can lead to a very difficult long-term catheter placement procedure.
The purpose of this paper is to report a mixed (surgical-percutaneous) technique for approaching the internal jugular vein in order to obtain its successful catheterization as an alternative option in cancer patients.
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PATIENTS AND METHODS
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At the hospital of the National Cancer Institute (INCA) in Rio de Janeiro, Brazil, 1750 consecutive long-term catheter placements for chemotherapy treatment were performed between the years 1997 and 2005. A retrospective study was done according to the surgical approach utilized. Six venous access routes were used: subclavian, cephalic, external jugular, internal jugular, brachial, and femoral veins. Options for each approach depended on the anatomical patency of the chosen vein and hematological or clinical status of the patient at the moment.
The catheters used were the totally-implantable type (TI) and semi-implantable (double or single-lumen) type (SI). Of these, 833 (48%) were implanted for bone marrow transplantation and 121 (7%) for classic hematological cancer treatment, all SI type. Seven hundred ninety-six TI catheters (45%) were placed in patients needing monthly outpatient chemotherapy treatment for solid tumors.
A traditional safe access route was first tried. If this could not be accomplished, for clinical, technical, or anatomical reasons, an alternative technique of cervical dissection of the IJV and ipsilateral percutaneous puncture (MIJVA technique) was promptly performed.
This was done on 160 patients of the series (9%). The option for this technique depended on the surgeon’s experience when facing variations of neck anatomy and/or hematological disorders. All procedures were performed in an operating room, with fluoroscopic assistance, under local anesthesia for adults and general anesthesia for infants.
Ultrasound guidance, which can be very useful in such situations, was not available at the time of the study. We are considering a prospective randomized controlled trial for comparison of techniques of IJV puncture. However, as MIJVA was performed only in patients on whom other standard techniques of venous access were thought contraindicated by reasons indicated before, this circumstance could bring a bias to a prospective study.
Technical Description
1st step
The patient is placed on the operating table in a supine position with hyperextension of the neck. The entire neck and chest are prepared and draped in sterile fashion. A small transverse incision (1 or 2cm length) is made 2 cm above the clavicle and over the internal border of the sternocleidomastoid muscle (SCM) (Fig. 1
).
2nd step
Opening the platysma layer, the SCM appears and shall be used as anatomical reference to continue with deeper dissection. Abutting the internal border of SCM, assisted by a small Farabeuf retractor, the dissection continues until the omohyoid muscle (OHM) is found crossing this area. Herein, the surgeon draws the OHM upward exposing the infra omohyoid structures where the connective tissue covering the IJV permits visualization by transparency, which could be sufficient for venipuncture; however, if necessary, the dissection should continue until the surgeon feels it is safe to do so (Fig. 2).
3rd step
A cervical percutaneous sideway venipuncture, guided by anterior direct vision, allows a near-perpendicular angle to avoid kinking that may cause sluggish flow rate (Fig. 3). A guidewire is passed through the needle to the atrium and confirmed by fluoroscopic image at that moment.
4th step
Through a subcutaneous tunnel, joining the exit site of catheter with the puncture site, an adequate catheter length is prepared for indwelling into the central venous system (Fig. 4).
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FIG. 4. LTC placed subcutaneously, ready to be led by the sheath introducer into the central venous system.
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5th step
A vessel dilator and sheath introducer, as a unit, is inserted over the guidewire penetrating half-length into the endovenous system. Holding the two handles of the peel-apart sheath and pulling outward to the skin, we should withdraw the guidewire and vessel dilator at the same time, inserting the catheter into the lumen of the sheath until the desired endovenous position is achieved (Fig. 5).
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FIG. 5. The proximal length of LTC was passed through the peel-way introducer to endovenous system. A fluoroscopic image should confirm the catheter’s tip position.
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6th step
The procedure is completed after a fluoroscopic image checks the correct tip position of the catheter (Fig. 6).
Figure 7 shows an X-ray picture of the catheter in place, with a smooth curve that allows free flow. This is obtained through a lower cervical venipuncture and is extremely significant in large (>12 Fr.) double-lumen catheters’ insertion.8,9
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FIG. 7. An X-ray picture demonstrating the smooth curve of the catheter obtained through the perpendicular IJV puncture.
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RESULTS
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The MIJVA technique could be performed on an average of 80 minutes of operative time (range, 60–120 minutes). There was no operative bleeding, hematoma, or catheter kinking and it proved to be safe and efficacious on 100% of the patients. Prophylactic blood products were not routinely administered and this did not influence the results even in 333 patients with thrombocytopenia, 109 of them with platelet counts below 10,000/mm3. Severe thrombocytopenia was the main indication of the procedure on 35 patients.
Among the 160 MIJVA procedures, 115 (72%) were performed for BMT programs, ten (6%) for traditional leukemia programs, and 35 (22%) for solid tumor monthly-sessions programs.
Endovenous snaring-related anatomical disorders (thrombosis, stenosis, and compressions) and obesity or multi previous-catheter bearing were indications for MIJVA procedure in 125 patients (7% of the total number of patients).
There were no complications or deaths attributable to the method until the 30th postoperative day.
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DISCUSSION
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Long-term catheter (LTC) central venous accesses have become frequent and important surgical procedures in oncologic treatment of cancer patients. New therapeutic programs depend on central venous drugs administration, but the number of access sites is limited and, when lost or unfeasible, novel approaches must be considered as alternative technical solutions to overcome challenging and difficult venous accesses. This has lately been of concern as reported by many authors.7,10–14
The MIJVA technique can be considered an alternative surgical procedure, bringing a novel contribution to surgeons engaged in surgical management of LTCs in oncology. It should be indicated exceptionally as a subsequent surgical tactic when previous venous access attempt failed or chosen as a first option according to the surgeon’s judgment facing complex situations.
Its major advantage remains the fact that anatomical references conduct the dissection, assuring the identification of the IJV through a cutdown approach even in unshaped anatomical necks. It is a tactical approach without ultrasound assistance to be performed specifically by surgeons and not by invasive radiologists.
The adverse factors frequently observed in cancer patients increase complications rate,6,15–18 and should be dealt with through safe maneuvers like visual landmark venipuncture. Mainly through the right side, the IJV is accessed over a large venous structure with a straight pathway to the superior vena cava, which supports blind puncture, simple cutdown, or mixed approach (MIJVA). This broadens the options of surgical approach in difficult situations.
The MIJVA affords a lower and near-perpendicular cervical venipuncture as recommended to avoid catheter kinking19 through a safe landmark-guided approach. It is performed through a surgical pathway away from noble neck structures preventing inadvertent damages. It is also important in maintaining good endovenous flow rate and allowing a second approach at the same site if necessary later.
Smaller cutdown approaches such as external jugular vein or cephalic vein accesses allow lower morbidity and should be attempted first, but they are not always available,20–22 mainly in fat patients, multi previous catheter bearing, or children below 4 years of age.
According to Freytes,23 in a questionnaire review, only 2% of the surveyed medical institutions hold that the responsibility of the LTC-placements belongs to interventional radiologists. The majority of the answers agree with surgical responsibility, holding that the operating room is the appropriate location to manage LTC-placement in cancer patients.
Therefore, the MIJVA technique is appropriate to oncological surgeons engaged in LTC-placements assisted only by fluoroscopy. In our hands, it has been adequate to overcome difficult clinical or anatomic situations. Although it should not be regarded as a first-line option, it may be considered so in selected patients.
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ACKNOWLEDGMENTS
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The author wishes to acknowledge the help of A. Paulino-Netto MD, FACS, FACG in drafting the final revision of the manuscript.
Received for publication June 20, 2006.
Accepted for publication June 26, 2006.
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ABSTRACT
INTRODUCTION
