Vascular Access - Vein Anatomy and Clinical Considerations PDF

## Vein and Anatomic Route Information ### Internal Jugular Vein **Anatomic Route:** - A deep vein, draining much of the head and neck. - Descends with the internal carotid and then the common carotid artery in the neck. - Joins with the subclavian vein posteriorly to the sternal end of the clavi...

## Vein and Anatomic Route Information ### Internal Jugular Vein **Anatomic Route:** - A deep vein, draining much of the head and neck. - Descends with the internal carotid and then the common carotid artery in the neck. - Joins with the subclavian vein posteriorly to the sternal end of the clavicle, forming the brachiocephalic vein. - Because of its size and relatively straight pathway to the brachiocephalic veins, the internal jugular vein is the first choice for VAD placement in the neck. - Largest vein in the neck. **Clinical Considerations:** - Often used for tunneled CVADs and implanted ports when tunneled over clavicle and inserted into base of U. - An easily compressible site for consideration in hypercoagulable patients. - Vein of choice for insertion of short-term dialysis catheters as it avoids problems of stenosis that could impede creation of AVF on the ipsilateral arm. - The axillary/subclavian vein is recommended over the U site in an attempt to reduce infections, an U is the recommended insertion site for patients with chronic kidney disease. - It avoids pinch-off that can occur with subclavian insertions. "Pinch off" occurs when the catheter is compressed between the clavicle and the first rib. ### Axillary and Subclavian Vein **Anatomic Route:** - Each subclavian vein is a continuation of the axillary vein and runs from the outer border of the first rib to the medial border of anterior scalene muscle. - Joins with the internal jugular vein to form the brachiocephalic vein (also known as innominate vein). **Clinical Considerations:** - There is overwhelming evidence that ultrasound guidance improves patient safety, and insertion CVAD success. - Lateral to the traditional landmark subclavian site is the axillary vein which can be visualized with ultrasound for safer chest insertions. - Subclavian vein is often used for 'blind' CVAD placement. - Subclavian joins the internal jugular lying anteriorly and inferiorly to the subclavian artery. - Insertion of CVADs using a landmark approach have traditionally inserted into this area in order to avoid hitting the subclavian artery, but a subclavian approach increases the risk of catheter "pinch-off" and catheter fracture. - Risks include pneumothorax, hemothorax, subclavian arterial puncture, and catheter pinch-off. ### Axillary and Subclavian Vein (continued) **Clinical Considerations:** - Subclavian should NOT be used for CVAD insertion in patients with CKD Stage 3 or higher, or ESRD. - IHI recommends subclavian approach over internal jugular site for lowering risk of CLABSI; infraclavicular sites have lower bioburden compared with neck sites. ### Brachiocephalic (innominate) Vein **Anatomic Route:** - Either of the two veins that drain blood from the head, neck, and upper limbs, and unite to form the SVC. - Each is formed at the root of the neck by union of the ipsilateral internal jugular and subclavian veins. - The right vein passes almost vertically downward in front of the brachiocephalic artery, and the left vein passes from left to right behind the upper part of the sternum. **Clinical Considerations:** - Catheter tips that terminate in these veins have an increased risk of causing venous thrombosis. - Left brachiocephalic vein is longer compared with the right brachiocephalic, and enters the SVC at a near 90-degree angle. ### Femoral Vein **Anatomic Route:** - Lies within the femoral triangle in the inguinal-femoral area. - The superior border of the triangle is formed by the inguinal ligament, the medial border by the adductor longus, and the lateral border by the Sartorius muscles. **Clinical Considerations:** - Femoral site should be avoided and is generally used for short-term VAD placement when there are contraindications for placing a device in the neck or chest. - When used for short-term access, the femoral vein is associated with a higher rate of CRBSI than other sites. - The common femoral vein (CFV) may be used for VAD placement in both acute and chronic settings. - There is little data on the use of long-term tunneled catheters or implanted ports via the CFV; anecdotally these devices may have substantial longevity in patients with cancer, chronic kidney disease, and short bowel syndrome. - Device exit site may be tunneled on the thigh, usually in a lateral area for case of access or tunneled in a retrograde fashion retrograde fashion up the abdomen.