Tunneled CVC with Extended Arch: Placement Recommendations
Primary Recommendation
For tunneled central venous catheters requiring extended arch configuration, the right internal jugular vein should be the primary access site, with the catheter tip positioned at the junction of the superior vena cava and right atrium. 1, 2
Optimal Access Site Selection
First-Line Approach
- Right-sided internal jugular vein access is preferable to left-sided approaches due to lower thrombotic complication rates 1
- The right internal jugular vein provides the most direct path to the superior vena cava-right atrial junction, minimizing the need for extreme catheter curves 2
- Subclavian vein access may be considered as an alternative upper body site, though it carries higher risk of pneumothorax 1
Sites to Avoid
- Femoral vein insertion should be avoided for long-term tunneled catheters due to significantly higher infection and thrombosis risks 1, 3
- Left-sided approaches create more acute angles and longer catheter paths, increasing thrombosis risk 1
Critical Technical Specifications
Catheter Tip Positioning
- The catheter tip must be placed at the level of the right atrial-superior vena cava junction 1
- This positioning minimizes thrombosis risk while ensuring adequate flow rates 1
- Tip position should be verified radiologically with intraoperative fluoroscopy or post-operative chest X-ray 1, 2
Exit Site Considerations
- The exit site must be easily visualized and accessible for patient self-care 1
- The preferred exit site should be marked by clinicians experienced with long-term venous access 1
- Consider proximity to wounds, prior exit sites, tracheotomies, stomas, or fistulae when planning the tunnel path 1
Insertion Technique Requirements
Sterile Precautions
- Maximal sterile barrier precautions are mandatory: cap, mask, sterile gown, sterile gloves, and sterile full-body drape 3, 2
- Skin preparation with 0.5% chlorhexidine with alcohol is required; if contraindicated, use tincture of iodine, iodophor, or 70% alcohol 3, 4
Image Guidance
- Ultrasound guidance should be used for venous access to reduce cannulation attempts and mechanical complications 3, 2
- Real-time ultrasound visualization reduces the risk of arterial puncture and pneumothorax 2
Device Selection for Long-Term Use
Appropriate Catheter Types
- Tunneled CVCs (Hickman, Broviac, or Groshong) are recommended for long-term parenteral nutrition or frequent daily access 1, 4
- Totally implantable devices (ports) may be considered for intermittent access with lowest infection rates (0.1 per 1,000 catheter-days) 1
Catheters to Avoid
- Peripherally inserted central catheters (PICCs) are not recommended for expected long-term use due to higher thrombosis risk and difficulty with self-administration 1
- Non-tunneled CVCs have infection rates of 2.7 per 1,000 catheter-days compared to 0.15 per 1,000 catheter-days for ports 1, 4
Multidisciplinary Planning
The choice of catheter type and exit site location must be made by a multidisciplinary team including an experienced interventional radiologist or surgeon and the patient 1
- Single versus multiple lumen selection should be determined by clinical needs, with minimum number of lumens necessary to reduce infection risk 3
- Patient body habitus, prior venous access history, and ability to perform self-care must be assessed 1
Common Pitfalls to Avoid
Positioning Errors
- Avoid catheter tip placement too proximal in the superior vena cava, which increases thrombosis risk 1
- Do not place tips in the right atrium proper, as this increases risk of cardiac perforation and arrhythmias 1
Access Site Mistakes
- Never use femoral access for long-term tunneled catheters despite easier initial placement, as infection rates are substantially higher 1, 3
- Avoid subclavian access in patients with advanced kidney disease or those who may need future hemodialysis access, due to risk of subclavian vein stenosis 3