Vascular Access Guide PDF
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This document details the anatomy and clinical considerations of various veins, including femoral, superior vena cava, inferior vena cava, and azygos, highlighting their roles in vascular access in different clinical situations. It emphasizes how these veins are utilized in different scenarios, particularly in patients with special circumstances such as those suffering from severe respiratory issues or coagulopathy. It also discusses alternative veins like hepatic and posterior auricular veins for difficult access scenarios.
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# Table 3. Alternative Veins for Difficult Access <sup>1,54</sup> | VEIN | ANATOMIC ROUTE | CLINICAL CONSIDERATIONS...
# Table 3. Alternative Veins for Difficult Access <sup>1,54</sup> | VEIN | ANATOMIC ROUTE | CLINICAL CONSIDERATIONS | | :------- | :--------------------------------------------------------------------------------------------- | :--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Hepatic | - Middle hepatic vein is typically accessed<br> - It ultimately drains into the inferior vena cava | - Transhepatic access is an alternative approach into the IVC; It can be used in the setting of SVC occlusion, and in patients with intra-renal vena cava occlusion<br> - Catheter tip terminates in the IVC | | Posterior | - Superficial vein on the side of the head<br> - Descends behind the ear to join the posterior temporo-maxillary vein terminating in the external jugular | | | Auricular | | | | Saphenous | - Lesser Saphenous Vein begins at the medial aspect of the arch on the dorsum of the | - May be palpated or visualized above the ankle<br> - May also be assessed/ visualized using US<br> - Considerations for lower-extremity | # Vein ## Femoral cont. - In patients with profound respiratory failure, femoral access avoids the risk of development of a hemothorax or pneumothorax, which are potential complications of supraclavicular venous access. - Is an easily compressible site for consideration in patients with severe coagulopathy. - The disadvantage of the femoral site is that it presents a field that is potentially contaminated because of the proximity of the perineal area. - Non-tunneled CVCs may be inserted in the femoral vein in critically ill pediatric patients. ## Superior Vena Cava (SVC) - Formed by the confluence of the left and right brachiocephalic veins below the right border of the sternum, lies a bit to the right of the midline of the body, entering the top of the right atrium near the level of the third costal cartilage. - Largest vein in the upper body. - Relatively straight with no valves allowing catheter tips to reside parallel to the vessel walls if properly placed in the lower third. - Approximately 2 liters of blood flow per minute through SVC which allows for rapid hemodilution of infusates. - Lowest reported rates of venous thrombosis with CVND tips located in the lower third of the SVC, near the juncture with the right atrium. ## Inferior Vena Cava (IVC) - Formed by the confluence of the common lliac veins and receives blood from all organs and tissues below the diaphragm. - Runs posterior to the abdominal cavity along the right side of the spinal column and enters the right atrium. - CVADs placed in the hepatic or thoracic veins or in the lower extremities should have their catheter tips located in the inferior vena cava above the level of the diaphragm. - In the setting of SVC occlusion, the IVC may be used for VAD placement. - The IVC may be accessed directly (via a trans-lumbar approach) or indirectly via the common femoral veins or hepatic vein (known as the Transhepatic approach) for CVAD placement. ## Azygos - Azygos vein ascends from the abdomen and arches anteriorly to enter the posterior wall of the SVC. - Catheter tips can malposition in the azygos and must be repositioned or replaced (except after assessment and planning (where there is an SVC occlusion) and the azygos is the intended tip position). - When using any collateral vein for access, be cognizant of potential complications of occlusion of a dominant collateral, leading to venous outflow obstruction. - While not typically used for CVAD tip placements, the azygos offers an alternative before other sites (such as direct VC placement) are entertained.
