204 Section V ■ Vascular Access

m.Cut the catheter length to the premeasured distance

between the neck incision and a point midway

between the center of the nipple line and the suprasternal notch.

n. Perform transverse venotomy (Fig. 32.8).

FOR EXTERNAL JUGULAR OR FACIAL VEIN

(1) Tie cephalad-venous ligature, and exert traction

on both ligatures in opposite directions with aid

of appropriately prepared assistant.

(2) Make short, transverse incision in anterior wall

of vein, and enlarge gently by inserting and

spreading tips of fine vascular forceps.

FOR INTERNAL JUGULAR VEIN

(3) To avoid ligation of the vessel, use purse-string

suture of 6-0 polypropylene, placed in vessel

wall around point of catheter entrance.

(4) Make incision in vessel as for external jugular vein.

o. Bevel intravascular end of catheter (optional).

p. Grasp catheter gently with blunt nontoothed tissue

forceps, introduce catheter tip, and insert into the

vein.

q. Leave loop of catheter in neck wound to dampen

effect of head movement (Fig. 32.11).

r. Close wound with subcuticular 5-0 absorbable

suture, taking care not to penetrate the catheter.

s. Secure the catheter to the skin with at least one

nylon suture to hold it until the cuff has created

enough tissue ingrowth.

t. Use selected method for fixation and dressing.

2. Proximal saphenous vein cutdown

a. Scrub and prepare as for major procedure.

b. Prepare as for cutdown on jugular vein. Make sure

that the patient is in the reverse Trendelenburg position to minimize the risk of an air embolism.

(1) Choose right or left groin area for insertion.

(2) Prepare groin and abdomen on same side.

c. Make incision 1 cm long: 1 cm caudad and 1 cm

lateral to pubic tubercle (Fig. 32.12).

d. Spread incision into subcutaneous tissues, using

curved mosquito hemostat.

(1) Incise superficial fascia.

(2) Identify saphenous vein lying medial and inferior to its junction with femoral vein at foramen

ovale (Fig. 32.12).

e. Move 0.5 to 1 cm distally before

(1) Passing curved mosquito hemostat behind vein.

This avoids inadvertent damage to femoral vein.

(2) Placing two 4-0 absorbable suture ligatures

loosely around vein

f. Create a tunnel, using a small hemostat or tunneling instrument, in subcutaneous plane laterally

onto abdomen, just above or lateral to umbilicus or

on lateral thigh.

g. Flush catheter with heparinized saline and replace

cap.

h. Pull catheter through tunnel into groin wound so

that the Dacron cuff is just within the skin incision.

Estimate the length of the catheter to be inserted so

that the tip will be in inferior vena cava at junction

with right atrium.

i. Cut catheter to appropriate length, and bevel intravascular end (optional).

j. Dissect saphenous vein to junction with common

femoral vein.

Visualizing the junction prevents inadvertent

direction of catheter into lower extremity.

k. Apply traction to vein, using caudad suture. Lateral

tension may also be applied by a scrubbed assistant,

using fine nontoothed vascular forceps.

l. Make transverse venotomy.

m.Dilate vein, if necessary, with blunt dilatator.

n. Moisten catheter with saline to ease passage into

vein.

o. Maintain back-traction on caudad suture to control

bleeding.

A

B

Fig. 32.9. Formation of a subcutaneous tunnel with a VimSilverman needle. A: Tunnel on the anterior chest wall.

B: Alternative route under the scalp.

Fig. 32.10. Broviac catheter with transparent dressing.