• Medications

  • Anesthesia

    • Local anesthetic: 1% lidocaine

    • Conscious sedation: Fentanyl, midazolam

    • General anesthesia (if needed)

  • Heparin

  • Heparinized saline

  • Prophylactic antibiotics

    • Based to local protocol

  • Management of co-morbidities  (allergy, blood glucose, blood pressure, nausea, etc)

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• Trolley/Equipment​

  • Micropuncture access kit

  • Tunneled line kit:

    • Cuffed line

    • Peel-away sheath

    • Dilators

    • Microwire (0.018”)

  • Sheaths

  • Wires 

    • 0.018”

    • 0.0035” (standard, hydrophilic, Amplatz superstiff)

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• Checklist

  • CIRSE (IR Patient Safety Checklist)

  • LocSSIPs (Local Safety Standards for Invasive Procedures)

  • NatSSIPs (National Safety Standards for Invasive Procedures)

  • WHO (World Health Organization Surgical Safety Checklist)

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• Access

  • Supine position for internal jugular, subclavian or common femoral vein access

    • In rare occasions: translumbar, transhepatic access

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• Technique

  • Cleanse the access sites of the neck and upper chest wall 

  • Cover with sterile drapes

  • Venous access:

    • Administer local anesthetic at the skin and subcutaneous tissues, up to the vein

    • Perform a skin nick that will fit the peel-away sheath and the tunneling device

    • Use the micropuncture kit to access the vein under ultrasound guidance

    • Use the microwire to measure the length from the access to the SVC/RA level, under fluoroscopy

    • Exchange the microwire with an 0.0035” wire

    • Dilate the track and insert the peel-away sheath

  • Tunnel preparation:

    • Use the microwire, that was used to measure the venous length, to calculate the total length of the line from the beginning of the tunnel to the tip at the SVC/RA level

    • Administer local anesthetic subcutaneously from the tunnel’s entry site to the neck access

    • Perform skin incision at the entry site of the tunnel

  • Tunnel line insertion:

    • Flush all lumens to ensure no leakage

    • Attach the tip of the line to the tunneler

    • Advance the tunneler through the tunnel to the exit site on the neck, parallel to the peel-away sheath

    • Pull the cuff into the tunnel

    • The cuff should be positioned at the middle of the tunnel

    • Detach the tunneler

    • Remove the wire and the dilator from the peel-away sheath

    • Advance the line into the peel-away sheath

    • Peel and remove the sheath

    • Confirm fluoroscopically that the tip of the line is at the SVC/RA level

    • Flush/aspirate the lumens

    • Lock the lumens with heparin

      • Check manufacturer’s specifications

  • Completion chest image

  • Secure the line with non-absorbable sutures 2-0 or 3-0

  • Cover the entry with sterile dressing

  • At the neck apply steri-strips and a dressing

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• Tips​

  • Tunneled line can be used immediately

  • Keep in mind that the tip of the line will rise as the patient stands

  • If the tip of the line is into the RA can cause arrhythmia

 

• Report

  • Describe the technique

  • Mention venous patency

  • Post-procedure instructions if needed