Background Information:

What are the other Names for the Procedure?

• Catheter Insertion
• Vascular Access Techniques

What is Vascular Access Procedures? (General Explanation)

• Vascular Access Procedures are procedures that are performed to draw blood or to deliver medications into the patient’s bloodstream over a long time period by inserting a flexible, thin plastic tube or catheter into the blood vessel
• Intravenous (IV) lines are extremely useful in healthcare, but they are only effective for short-term use. When an IV line is necessary for a longer period of time, or when there is a need for a secure venous access, a catheter is preferred over IV lines
• A catheter can stay in the veins for a longer period of time, giving an easier access to the blood stream and avoiding multiple needle punctures

What part of the Body does the Procedure involve?

Depending upon the catheter being used, various parts of the body could be involved in Vascular Access Procedures.

Why is the Vascular Access Procedure Performed?

Vascular Access Procedures may be used for the following requirements:

• Hemodialysis
• IV antibiotic treatment
• Medication delivery
• Chemotherapy
• Nutrition support
• Drawing blood samples repeatedly
• Blood transfusion
• In patients who have difficulty receiving IV line
• When a long-term access to the blood stream is required

What is the Equipment used? (Description of Equipment)

The following equipment may be used during Vascular Access Procedures:

• Catheters: There are various types of catheters depending on its use. These include peripherally-inserted central catheter, non-tunneled central catheter, tunneled catheter, and port catheter
  • Peripherally-inserted central catheter (PICC): As the name suggests, these catheters are inserted peripherally from the arm or leg veins and are advanced into the largest veins near the heart, such as superior vena cava or inferior vena cava
  • Non-tunneled central catheter: These catheters are larger than the PICC line. These are inserted though the large veins, such as the jugular vein in the neck or the femoral vein in the groin
  • Tunneled catheter: Tunneled catheters are used when the vein access is required for an extended period of time, such as during a dialysis. These catheters have cuff and lumen, and are more secure than the PICC line. The risk of infection is much lower with these catheter types
  • Port catheter: A port catheter is a permanent catheter that includes a small reservoir. Port catheters are used in pain management, chemotherapy, or to store a drug within the small reservoir. The skin has to be punctured every time the catheter is used   
• X-ray:
  • The X-ray machine consists of an examination table, an X-ray tube, and a television monitor
  • Fluoroscopy uses X-rays and converts them into real-time images
• Ultrasound - the equipment for ultrasound imaging consists of:
  • An ultrasound transducer
  • A computer monitor
  • A central processing unit
  • A printer           

A transducer is used to send high-frequency sound waves in the body and the computer creates the image based on the echoes of that sound returning from the patient’s body.

What are the Recent Advances in the Procedure?

There have been no recent advances to Vascular Access Procedures.

What is the Cost of performing the Vascular Access Procedure?

The cost of Vascular Access Procedures depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding Vascular Access Procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple steps or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

http://www.ncbi.nlm.nih.gov/pubmed/25646197 (assessed on 3/6/15)

http://www.ncbi.nlm.nih.gov/pubmed/25694191 (assessed on 3/6/15)

http://www.ncbi.nlm.nih.gov/pubmed/25725272 (assessed on 3/6/15)

Prior to Vascular Access Procedures:

How does the Vascular Access Procedure work?

• With Vascular Access Procedures, the tip of the catheter is placed in the large vein, so blood can be accessed easily and repeatedly without puncturing the skin for a longer period of time
• X-ray or ultrasound is usually used to check the correct placement of the catheter.

How is the Vascular Access Procedure Performed?

Different catheter types are used for different Vascular Access Procedures.

• The catheter insertion site is determined and it is cleaned, shaved, sterilized, and surgically draped
• The patient is positioned in a supine position on the examination table. An IV line is inserted in the patient’s arm vein to inject sedation medications
• If sedation is used during the procedure, the patient may feel sleepy and relaxed
• Catheter insertion site is numbed using a local anesthetic and a small skin incision is made

Peripherally-inserted central catheter (PICC) line:

• Ultrasound guidance or fluoroscopy is used to identify the vein
• A small needle is inserted into the arm vein
• A guide wire is advanced into the large central vein, such as the superior vena cava or the inferior vena cava, under fluoroscopy
• Once the guide wire is in the desired location, the PICC is advanced over the guide wire
• The guide wire is removed once the catheter reaches the desired position
• Chest X-rays are taken to confirm the location of the catheter tip

Tunneled catheter

• A tunneled catheter is inserted into a large vein, such as the jugular vein, located at the base of the neck
• A skin incision is made in the lower neck area
• The jugular vein is identified using ultrasound guidance and is punctured using the needle
• A guide wire is advanced through the jugular vein into a large central vein such as the superior vena cava
• A second skin incision is made just below the first skin incision and a tunnel is created under the skin
• The catheter is placed through the tunnel into the vein and advanced into the superior vena cava
• Stitches are placed at the end of the tunnel to secure the catheter

Non-tunneled catheter:

• Non-tunneled catheters are placed in larger veins, such as the jugular vein located at the base of the neck, or the femoral vein located in the groin area

Port catheter:

• A port catheter involves the catheter and a reservoir placed under the skin
• A small skin incision is made and a pocket created under the skin for the placement of the reservoir
• The catheter placement procedure is similar to tunneled catheter placement procedure. The catheter is then connected to the small reservoir
• Reservoir can be filled with medication by puncturing it several times, as it has a silicone covering
• Stitches are required to close the skin incision
• A chest X-ray is usually performed to check placement of the catheter

After the procedure is completed, the IV line is removed.

Where is the Procedure Performed?

Vascular Access Procedures are generally performed in a hospital.

Who Performs the Procedure?

Interventional radiologists, anesthesiologists, or hospitalists may perform Vascular Access Procedures.

How long will the Procedure take?

• Depending upon the type of Vascular Access Procedures being performed, it may take anywhere from 10-40 minutes for the procedure
• It may take longer depending upon the complexity of the anatomy and health of the patient

Who interprets the Result?

Interventional radiologists interpret the results of these studies.

What Preparations are needed, prior to the Procedure?

The following preparations are needed prior to Vascular Access Procedures:

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient, including information related to the medications that are currently being taken
• Do inform the medical professional if you have a history of any medical conditions such as a heart disease, asthma, diabetes, or kidney disease
• Do inform the medical professional about any allergies, especially related to barium or iodinated contrast material, which may be used in the procedure
• Patient may be asked to stop taking blood thinner medications, such as NSAIDs, aspirin, heparin, and warfarin, several days before the procedure
• It is advisable to wear comfortable and loose clothes. Avoid wearing any metal objects or jewelry, as it may interfere with the x-ray
• Women should notify the physician if they are pregnant or breastfeeding their child, as many such procedures may not be performed on pregnant women
• Depending on the procedure adopted, the patient may be asked for certain bowel or bladder preparations before the preparation sessions
• The patient may be asked to avoid eating or drinking several hours before the procedure

What is the Consent Process before the Procedure?

A physician will request your consent for Vascular Access Procedures using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What are the Benefits versus Risks, for this Procedure?

Following are the benefits of Vascular Access Procedures:

• Vascular Access Procedures save patients from pain of repeated needle sticks
• It is extremely useful to have access to bloodstream for long time periods during procedures such as chemotherapy or dialysis
• Vascular Access Procedures allow the delivery of medications and nutrition
• These procedures have lesser complications than using an IV line, such as local tissue damage, if the drug leaks out of the vein
• The medications delivered using a PICC line do not irritate the wall of veins

Following are the risks of Vascular Access Procedures:

• Since catheter is inserted directly in the vein, there is a chance of vein damage resulting in bleeding
• The skin is penetrated for insertion of the catheter, which may cause infection at the site
• Placement of catheters in the chest or neck may introduce air in the chest that can cause a lung collapse leading to pneumothorax. Pneumothorax is usually avoided by using ultrasound guidance or fluoroscopy for the placement of the catheter
• In some rare cases, the catheter may be inserted into an artery rather than a vein, which may cause severe bleeding. In these cases, the catheter is usually removed and the artery heals by itself
• If the catheter tip is inserted too far from the superior vena cava into the heart, it may cause a disturbance in the heart rhythm, however this is usually temporary

Following are the delayed risks of Vascular Access Procedures, which may occur during the lifetime of the catheter:

• Catheter or port insertion site may get infected, if the device is not handled with care, such as not washing hands before flushing or not cleaning the site. Infection rate is also common in patients with low white blood cell counts or in the immunocompromised
• If the catheter is not secured properly with the skin, it may come out and cause severe bleeding. In these cases, patients should apply pressure over the bleeding site and immediately call their physician
• Catheter may break and can cause leakage of fluid. The patient should make sure to clamp catheter at the same spot, to avoid creating a break in the catheter. If a break is suspected, clamp should be applied between the damaged part and the catheter insertion site on the skin
• If the catheter tip goes farther from superior vena cava into the heart, it may cause some irregular heartbeat. The patient should call their physicians immediately in such cases
• Swelling in the shoulder, neck, head, or arm may occur, if the vein in which the catheter lies gets closed-off or occluded. The physician should be called immediately in these cases. If the vein is occluded by a blood clot, blood-thinning medications may be required to break or dissipate the blood clot
• If a large amount of air is introduced into the catheter, it may cause shortness of breath or chest pain. If this incident happens, patient should clamp the catheter right away and lie down on the left side and call 911 (or the local emergency number). Patients should avoid introducing air into the catheter by screwing the cap tightly and clamping the catheter before and after inserting the syringe in the catheter
• Patients are recommended and taught to flush the catheter to avoid the risk of getting the catheter obstructed by a blood clot or fibrin sheath

What are the Limitations of the Vascular Access Procedure?

Following are the limitations of Vascular Access Procedures:

• In some cases, it is very difficult to find good vascular access for catheter placement. This usually occurs in patients where the veins are used for long time period, such as in intravenous feeding for a long time
• Even though catheters could be used for longer time periods, over time they may have to be replaced due to poor function

What are some Questions for your Physician?

Some of the basic questions that you might ask your healthcare provider or physician are as follows:

• What is Vascular Access Procedure?
• Why is this procedure necessary? How will it help?
• How soon should I get it done? Is it an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed?
• What are the risks while performing the procedure?
• What are the complications that might take place during recovery?
• What are the possible side effects from the procedure? How can I minimize these side effects?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any lifestyle restrictions or modifications required after the procedure is performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required after the procedure?
• Is there any medication that needs to be taken for life after the procedure?
• What are the costs involved?

During the Vascular Access Procedures:

What is to be expected during the Vascular Access Procedure?

The following may be expected during the Vascular Access Procedures:

• Patients may feel a slight pinprick when IV line is inserted into the patient’s arm vein and when local anesthetic is injected at the catheter insertion site
• Vital signs, such as blood pressure, pulse, and heart rate, are monitored using various devices
• If sedation is used during the procedure, patient may feel sleepy and relaxed
• The patient may feel slight discomfort and pressure when the catheter is inserted
• After the catheter is positioned correctly, it is secured using stitches
• Patient may feel discomfort during the procedure, as they may have to lie down for about 45 minutes during the whole procedure
• A chest X-ray is usually taken to ensure correct placement of the catheter tip

What kind of Anesthesia is given, during the Procedure?

Local anesthetic and moderate sedation could be used during Vascular Access Procedures.

How much Blood will you lose, during the Procedure?

Since these procedures are minimally invasive, the blood loss involved is generally minimal.

What are the possible Risks and Complications during the Vascular Access Procedure?

Following are the possible risks during Vascular Access Procedures:

• Since the catheter is directly inserted into the vein, there is a chance of damaging the vein and causing bleeding
• The skin penetration for insertion of the catheter may cause an infection at the insertion site
• Placement of catheters in the chest or neck may introduce air in the chest, which may cause lungs to collapse resulting in pneumothorax. This condition may be avoided by using ultrasound guidance or fluoroscopy for catheter placement
• Sometimes, catheters may be wrongly inserted into an artery instead of a vein. This may cause severe bleeding. On removal of the catheter, the artery heals by itself
• If the catheter tip is inserted too far from the superior vena cava into the heart, it may temporarily lead to heart rhythm disturbances

What Post-Operative Care is needed at the Healthcare Facility after the Vascular Access Procedure?

Chest X-ray is usually performed to check the correct placement of the catheter tip after Vascular Access Procedures.

After the Vascular Access Procedure:

What is to be expected after the Vascular Access Procedure?

The following may be expected after Vascular Access Procedures:

• The patient may be admitted to the hospital, if necessary. However, most of the patients are discharged after the procedure
• Some swelling and tenderness in the chest, neck, shoulder, or groin area may be experienced after the procedure, which may last for a few days. Over-the-counter NSAIDs may be taken to relieve pain
• It is very important to keep the catheter site clean and dry for the first week following the procedure
• Some physicians may also recommend cleaning the catheter insertion site with peroxide and applying antibiotic ointment around the area
• Patients should avoid soaking the incision under water. They may instead put a plastic wrap over the catheter insertion site to avoid wetness
• It is recommended to flush the catheter with heparin, to breakdown any blood clots that form and block the catheter
• After catheter use, it is removed by healthcare professionals

When do you need to call your Physician?

Patients may need to call their physician in the following situations after Vascular Access Procedures:

• If the catheter is not secured properly to the skin, it may come out and cause severe bleeding. In such cases, patients should apply pressure over the bleeding site and immediately call their physician
• Catheters can break and can cause fluid leakage. Thus, it should be ensured that catheters are clamped at the same spot to avoid catheter breakage. If a break is suspected, a clamp should be applied between the damaged part and the catheter insertion site on the skin
• If the catheter tip moves farther from the superior vena cava into the heart, it may cause irregular heartbeat. Patients must immediately call their physicians in such cases
• If the vein in which catheter lies gets closed-off or occluded, it may cause swelling in the shoulder, neck, head, or arm. If the vein is occluded by a blood clot, blood-thinning medications can be used to break-off the clot. In all these cases, the physician should be immediately notified
• If the large amount of air is introduced in the catheter, it may cause shortness of breath or chest pain. If such a condition takes place, the catheter should be clamped right away and the patient should lie down on their left side and call 911 (or the local emergency number). Patients should avoid introducing air into the catheter by ensuring that the cap is tightly screwed on and the catheter is clamped before and after inserting the syringe into the catheter
• If patient notices any redness, warmth, swelling, tenderness, or fluid drainage at the site of catheter insertion
• If patients develop high fever

What Post-Operative Care is needed at Home after the Vascular Access Procedure?

• It is very important to keep the catheter site clean and dry for the first week after Vascular Access Procedures
• Patients should avoid taking shower during the first week
• Some physicians may also recommend cleaning the catheter insertion site with peroxide and applying antibiotic ointment around the area
• The incision site should not be soaked underwater. A plastic wrap may be placed over the catheter insertion site to avoid wetness
• It is recommended to flush the catheter with heparin, in order to breakdown any blood clots that are form and block the catheter

How long does it normally take to fully recover, from the Procedure?

• It may take few days to recover completely from Vascular Access Procedures
• Patient may resume their normal activities after 1-2 days
• Patient should avoid lifting any heavy objects for a few days after the procedure

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

Vascular Access Procedures do not involve the removal of any body tissue.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

Since no tissue is removed during the procedure, a pathologist does not get involved in the care of the patient.

Who will you receive a Bill from, after the Vascular Access Procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The hospital, where the procedure is performed
• Healthcare providers, physicians, and radiologists, who are involved in the process

The patient is advised to inquire and confirm the type of billing, before Vascular Access Procedures are performed.