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881

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Percutaneous Central Venous Catheter Placement: Use of the Blunt Needle for Subcutaneous Track Formation E. William

Akins,1

Irvin

F. Hawkins,

Jr.,

Paul

James

Mucciolo,

Percutaneous placement of central venous access cathehas recently been described [1 -3]. Fluoroscopic guidance makes venous entry safe and allows proper positioning of the catheter. One step in the procedure is the creation of a subcutaneous tunnel to prevent infection [4]. A variety of surgical instruments has been used to create this tunnel, including Kelly clamps and laryngeal biopsy forceps. We report the use of a blunt needle to create a subcutaneous track for percutaneous placement of indwelling venous catheters. ters

Materials

and Methods

The blunt needle (Cook, Bloomington. IN) consists of an 18-gauge outer cannula and inner blunt stylet [5] (Fig. 1). Needles are available in a variety of lengths (1 0-20 cm). After venous access is obtained, the blunt needle is inserted into the subcutaneous tissue at the expanded venotomy site. The needle is then advanced, by means of direct visual guidance and palpation, through the subcutaneous tissue toward the proposed catheter exit site. After a local anesthetic is applied, a nick is made in the skin down to the needle tip, and the blunt needle is extruded through this site. If the overlying tissue is tough at the site, the sharp stylus can be used to make the exit site for the needle. The blunt stylus is then exchanged for a 0.035-in. (0.089-cm) guidewire,

and

the

cannula

is removed.

A peel-away

sheath

of

appropriate size is inserted through the venotomy site over the wire. The wire is removed, and the Hickman catheter is inserted through the sheath. The catheter is then pulled manually through the dilated

D. Overmeyer,

track;

AprIl

1992 0361-803X/92/1584-0881

0 American

Roentgen

is taken

R. Kerns,

to keep

and Kevin

the Dacron

cuffs

well

K. Murray

secured

in the

track.

The distal end of the Hickman catheter is trimmed to the desired length and inserted in routine fashion via the same peel-away sheath. The skin at the puncture site is closed by two interrupted sutures;

no sutures

are required

at the catheter

entry

site.

Results The blunt needle has been used to create tunnel

in 22 patients

requiring

venous

access

a subcutaneous (1 8 subclavian

catheters and four translumbar vena cava catheters). Tracks were created successfully in all 22 cases. Local tenderness was encountered in two cases (9%), so the stylus was removed

related needle

and local

anesthesia

to the tunneling

was bent into a gentle

Subcutaneous

tracks

was

occurred. curve

that were

given.

No complications

In 10 cases

(45%),

to help form

the track.

longer

usual

than

the were

placed successfully in two patients. The first case was a 3year-old boy who had short-bowel syndrome after repair of midgut volvulus. All conventional venous access had been exhausted. A catheter for hyperalimentation was placed into

the suprarenal inferior vena cava through a translumbar route, and the catheter was tunneled to an exit site in the interscapular region of his back to prevent the patient from pulling on the catheter. The second patient was a 35-year-old woman with intestinal dysmotility syndrome who required long-term hyperalimentation

cess was possible.

Received August 12, 1991; accepted after revision October 7, 1991. This work was supported in part by National Institutes of Health grant 2-T35-HL07489. 1 All authors: Department of Radiology, Lkiversity of Florida College of Medicine, Box to I. F. Hawkins, Jr. AJR 158:881-882,

care

Scott

and in whom

To provide

no conventional

anterior

100374, JHMHC, Gainesville, FL 32610-0374.

Ray Society

abdominal

venous

access

ac-

to

Address reprint requests

882

AKINS

ET AL.

AJR:158, April 1992

devices

can be cumbersome

considerable

tracks

pain during

and increase

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The 1 8-gauge

to use and cause

insertion.

Errant

passes

the patient create

large

the risk of hematoma.

blunt

needle

offers

several

advantages

over

standard instruments [5]. Dilators are placed over a guidewire after the desired track has been created. With the blunt Fig. 1.-Close-up

of 18-gauge

cannula Is highly polished. In sonographic applications.

blunt

Cannula

needle tip. Blunt stylet within tip is roughened to improve visibility

a translumbar inferior vena caval Hickman catheter, we used a long, curved blunt needle to create a tunnel around the patient’s

flank to an exit site on her anterior

abdominal

wall.

Patients were followed up for 3 months after catheter placement. There were a variety of late catheter-related problems. In two patients (9%), infection developed at the entrance site. Subclavian

vein thrombosis

occurred

Three patients (1 4%) had sepsis that moval. These complication rates were observed

in a comparable

series

in one case (4.5%). required catheter re-

all less than those

of 23 patients

with

surgical

catheter average

placement at our hospital (unpublished data). The time between request for catheter placement and

insertion

was 1 day for percutaneous

vs 2.4 days for surgical

placement

placement

(22 patients)

(23 patients).

needle, the size of the skin incisions needed considerably, and only two sutures are required venous puncture site. Trauma to the subcutaneous fascia is reduced,

is reduced at the initial resulting

in

less discomfort for the patient. The blunt needle can be bent slightly to create a gentle curve, allowing the tunnel to follow body contours. Finally, long tracks can be created easily, which provides the option of placing catheter exit sites at the most convenient position for the patient. In uncooperative

patients cessible

or in children, sites.

In conclusion,

this study

a safe and effective track

the catheter

for percutaneous

The technique

suggests

means

can be tunneled that the blunt

of establishing

insertion

needle

is

a subcutaneous

of a central

is easy to perform

to mac-

venous

catheter.

and is nearly painless

for

the patient. The entire procedure for percutaneous placement of the Hickman catheter warrants further refinement in order to improve its safety. Modifications of the standard triple-

lumen

catheters

and delivery

improved safety placed indwelling

systems

and long-term efficacy central catheters.

will be needed

for

of percutaneously

Discussion Percutaneous placement of long-term central venous catheters has several advantages over surgical placement in the operating room [1 -3]. These include more accurate placement of the catheter tip under superior fluoroscopic control,

increased

accuracy

and safety

in accessing

the subclavian

vein, and potentially reduced cost of insertion. Regardless of the method of insertion, a subcutaneous track must be cre-

ated to position the exit site of the catheter so that it can be accessed easily with minimum inconvenience to the patient. A Dacron cuff is attached to the catheter and is pulled into the subcutaneous signed to promote

catheter During tunneling

tunnel during placement. The cuff tissue ingrowth to seal off the track

and create a barrier to infection. surgical devices

placement of Hickman catheters, are used, including laryngeal biopsy

[6] and Kelly clamps contain

is deof the

a large

[7]. Standard

“knitting

eter to be forcibly

needle”

pulled

surgical

device

through

catheter

that allows

the track.

various forceps

sets

the cath-

These

large

REFERENCES 1 . Robertson

LT, Mauro

MA, Jaques

PF. Radiologic

placement

of Hickman

catheters. Radiology 1989;170: 1007-1009 2. Page AC, Evans RA, Kaczmarski A, Mufti GJ, Gishen

P. The insertion of chronic indwelling central venous catheters (Hickman lines) in interventional radiology suites. Clin Radio! 1990;42: 105-1 09 3. Lameris JS, Post PJ, Zonderiand HM, Gerritsen PG, Kappers-Klunne MC, Schutte HE. Percutaneous placement of Hickman catheters: comparison of sonographically guided and blind techniques. AiR i990;155: 1097-1 099 4. Flowers RH, Schwencer KJ, Kopel RF, Fisch MJ, Tucker SI, Farr BM. Efficacy of an attachable subcutaneous cuff for the prevention of intravascular catheter-related infection: a randomized, controlled trial. JAMA

1989;261(6):878-883 5. Akins EW, Hawkins IF Jr, Mladinich CRJ, Siragusa RJ, Pry RJ. The blunt needle: a new percutaneous access device. A/A 1989;152:181-182 6. Davis SJ, Thompson JS, Edney JA. Insertion of Hickman catheters: a comparison of cutdown and percutaneous techniques. Am Surg

1984;50:673-676 7. LaBerge

MT,

Deppe

G, Malviya VK. A simplified technique of Hickman in gynecological oncology patients. Gyneco!

catheter insertion at bedside Oncol

1987;26:298-304