Where can I use a blood vessel for medical treatment, such as dialysis or chemotherapy, in a patient with cardiovascular disease or at risk of thrombosis?

Vascular Access Site Selection for Medical Treatments in Patients with Cardiovascular Disease

Primary Recommendation for Peripheral Venous Access

Upper extremity veins—specifically the hand and forearm—are the strongly preferred first-line sites for peripheral intravenous access in all patients, including those with cardiovascular disease or thrombosis risk. 1

Hierarchical Approach to Vascular Access Selection

First-Line: Upper Extremity Peripheral Access

• The hand and forearm veins should be used as the initial access sites for peripheral IV therapy, dialysis preparation, or chemotherapy administration 1
• Upper limbs have significantly lower complication rates compared to lower extremity access 1
• For medium-term access (1-4 weeks), midline catheters in upper extremity veins are appropriate 1

Second-Line: Central Venous Access (When Peripheral Access Inadequate)

For central venous access, the right internal jugular vein is the optimal first choice due to its direct anatomical pathway and lowest complication rates 2, 3

Central Access Site Hierarchy:

1. Right internal jugular vein (preferred)

   • Provides straightest path to superior vena cava 2
   • Requires shorter catheter length (15 cm) 2
   • Lowest mechanical complication rates 2, 3
   • Use real-time ultrasound guidance for placement 2

2. Subclavian vein (alternative for most indications)

   • Lowest infection risk among central sites 2
   • CRITICAL CONTRAINDICATION: Never use in patients with chronic kidney disease stage 3 or worse due to high stenosis risk that permanently compromises future dialysis access 4, 2

3. Left internal jugular vein (avoid when possible)

   • Associated with poor blood flow rates, higher stenosis, and thrombosis 2
   • May compromise venous return from left arm 2

4. Femoral vein (emergency/last resort only)

   • Highest infection risk 2
   • Increased deep vein thrombosis risk 2
   • Reserved for emergency situations or when upper body access contraindicated 2

Duration-Based Catheter Selection

Short-term access (days to weeks):

• Non-tunneled polyurethane catheters via internal jugular vein 2

Medium-term access (up to 3 months):

• PICCs, Hohn catheters, or tunneled catheters 4, 2

Long-term access (>3 months):

• Tunneled catheters (Hickman, Broviac, Groshong) or totally implantable ports 4, 2

Special Population Considerations

Hemodialysis Patients

• Preserve arm veins for future arteriovenous fistula creation 4
• Use small-bore catheters via internal jugular vein only 4
• Absolute contraindication: subclavian vein access (causes irreversible central venous stenosis) 4, 2
• If temporary dialysis access needed, femoral vein is preferable to subclavian 2

Chemotherapy Patients

• Single-lumen ports are ideal for long-term intermittent bolus chemotherapy in solid tumor patients 4
• Ports have lowest catheter-related bloodstream infection rates (0.23 per 1,000 days) 4
• Double-lumen ports required for patients needing blood transfusions or bone marrow transplantation 4
• PICCs have higher thrombosis risk than ports in oncology patients 4

Parenteral Nutrition Patients

• Catheter tip must be positioned in lower third of superior vena cava or upper right atrium for high osmolarity solutions 4
• For home PN >3 months, tunneled catheter or port preferred over PICC 4
• PICCs may not be suitable for self-caring home PN patients as they disable one arm 4

Catheter-Related Thrombosis in Cancer Patients

• Treat with LMWH alone for minimum 3 months 4
• Do not remove functioning, well-positioned catheter if: tip is at SVC-right atrium junction, good blood reflux present, catheter is vital, and no signs of infection 4
• Thrombolytic therapy reserved only for superior vena cava syndrome or when catheter maintenance is imperative 4

Critical Pitfalls to Avoid

Absolute Contraindications

• Never use subclavian vein in any patient with chronic kidney disease stage 3-5 4, 2
• Never use lower extremity IV access except in true emergencies when no upper extremity access available 1
• Avoid left internal jugular when right side is accessible 2

Lower Extremity Access Risks

• Significantly higher superficial vein thrombosis risk in lower limbs 1
• If unavoidable, use smallest cannula size and remove within 24 hours once alternative access established 1
• Monitor closely for thrombosis signs; lower limb SVT requires different management than upper limb 1

Technical Considerations

• Select catheter diameter ≤ one-third of vein diameter (confirmed by ultrasound) 2
• Position patient in Trendelenburg when clinically appropriate 2
• Catheter tip should be at cavo-atrial junction for optimal flow 2, 3

Anticoagulation for Vascular Access

For prophylaxis of catheter-related thrombosis:

• Prophylactic-dose heparin shows trend toward reduction in symptomatic DVT (RR 0.54,95% CI 0.28-1.05) in cancer patients with indwelling CVCs 4
• Warfarin provides 85% RR reduction in VTE (RR 0.15,95% CI 0.02-1.2) but increases major bleeding risk (RR 4.24) 4
• The bleeding risk with warfarin outweighs VTE reduction benefit 4

For treatment of established catheter-related thrombosis:

• LMWH monotherapy for minimum 3 months is recommended 4
• Continue anticoagulation until catheter removed, then at least 3 months total 4