Central venous access devices

What type of central venous access device does my patient have?

Seen in a variety of clinical settings from critical care to outpatient, central venous access devices (CVADs) are catheters that are inserted into a central or peripheral vein and extend into the superior vena cava (SVC) or cavoatrial junction (CAJ), where the SVC meets the right atrium (RA)^1,2. Used for the administration of medication, fluid, blood products or nutrition and for phlebotomy sampling, there are three distinct types of catheters^3,4. 

CVCs are inserted into the subclavian or jugular vein and can be sub-divided into two categories^5,6. Also referred to as a Hickman catheter, tunnelled CVCs are inserted away from the heart, and travel under to skin towards the SVC or RA⁶. They are used for long-term therapy such as chemotherapy or dialysis⁷. Non-tunnelled CVCs are used for short-term therapy, often in a critical care setting, and are generally inserted into the neck, with the catheter travelling to the RA or SVC⁸.

Peripherally inserted central catheters (PICCs) are inserted into the cephalic or basilic vein in the arm, extending to the SVC near the CAJ⁹. PICCs are generally associated with a lower risk of central line-associated bloodstream infection (CLABSI) and venous thromboembolism (VTE) than CVCs and can be accessed for weeks to months¹⁰. Complications include localised or central infection, venous thrombosis, and extravasation caused by malpositioning¹¹. 

Totally implantable central venous catheters are indicated in patients who will require central access for months to years¹². The device sits under the skin and can be intermittently accessed, which is more comfortable and less limiting to the patient’s daily life¹². Complications related to insertion include catheter embolism, malposition, and pneumothorax, while maintenance complications include extravasation, infection or thrombosis¹³. When compared to other CVADs, implantable devices are recognised as having a significantly lower risk of infection or complications⁴. 

References

1.       Gorski L, Hadaway L, Hagle M, Broadhurst D, Clare S, Kleidon T, et al. Infusion Therapy Standards of Practice. Journal of Infusion Nursing 2021;44(1):S66.

2.       Baskin K, Jimenez R, Cahill AM, Jawad A, Towbin R. Cavoatrial Junction and Central Venous Anatomy: Implications for Central Venous Access Tip Position. Journal of Vascular and Interventional Radiology 2008;19(3):359-65.

3.       Patel A, Patel A, Singh S, Singh S, Khawaja I. Central line catheters and associated complications: a review. Cureus 2019;11(5): e4717.

4.       Hord J, Lawlor J, Werner E, Billett A, Bundy D, Winkle C, et al. Central Line Associated Blood Stream Infections in Pediatric Hematology/Oncology Patients with Different Types of Central Lines. Pediatric Blood and Cancer 2016;63(9):1603-067.

5.       Smith R, Nolan J. Central venous catheters. BMJ 2013;11(347): e6570.

6.       Vats H. Complications of catheters: tunneled and nontunneled. Advances in Chronic Kidney Disease 2012;19(3):188-94.

7.       Ash S. Advances in tunneled central venous catheters for dialysis: design and performance. Seminars in Dialysis 2008;21(6):504-15.

8.       Wall C, Moore J, Thachil J. Catheter-related thrombosis: A practical approach. Journal of the Intensive Care Society 2016;17(2):160-7.

9.       Queensland Health. Peripherally inserted central venous catheters (PICC); 2015; Available from: https://www.health.qld.gov.au/__data/assets/pdf_file/0032/444497/icare-picc-guideline.pdf.

10.   Patel N, Petersen T, Simpson P, Feng M, Hanson S. Rates of venous thromboembolism and central line-associated bloodstream infections among types of central venous access devices in critically ill children Pediatric Critical Care 2020;48(9):1340-8.

11.   Grau D, Clarivet B, Lotthe A, Bommart S, Parer S. Complications with peripherally inserted central catheters (PICCs) used in hospitalised and outpatients: a prospective cohort study. Antimicrobial Resistance and Infection Control 2017;6(18).

12.   EviQ. Central venous access devices. NSW Health; 2021; Available from: https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads/112-central-venous-access-devices#types-of-cvads.

13.   Granic M, Zdravkovic D, Krstajic S, Kostic S, Simic A, Kovcin V. Totally implantable central venous catheters of the port-a-cath type: complications due to its use in the treatment of cancer patients. Journal of the Balkan Union of Oncology 2014;19(3):842-6.