Pediatric Ultrasound-Guided Internal Jugular Central Venous Catheter (CVC) Insertion for Chemotherapy Delivery

Abstract

Central venous catheterization is a commonly performed procedure in pediatric surgery, requiring both appropriate device selection and meticulous technique to ensure long-term function and minimal complications. We report the technical considerations of tunneled central venous catheter placement in a pediatric patient with neuroblastoma.

A two-year and four-month-old boy with neuroblastoma required central venous access for chemotherapy. Preoperative evaluation confirmed patency of the right internal jugular vein and other central veins. A cuffed tunneled external catheter was selected, as it allows continuous access without repeated needle puncture and is suitable for multi-lumen use, including drug administration and blood sampling. Although routine blood sampling via central venous catheters is not generally recommended, our experience suggests that the associated risks are infrequent and clinically acceptable.

The catheter was inserted via the right internal jugular vein. The anterior chest wall exit site was determined using anatomical landmarks, specifically the triangle formed by the sternal notch, right acromion, and right nipple, with the entry point positioned near its center. Key technical considerations included creation of a broad, curved subcutaneous tunnel to prevent catheter kinking, secure fixation using a cuff with additional circumferential suturing to reduce early dislodgement, and accurate tip positioning at the junction of the superior vena cava and right atrium. In practice, the optimal tip location was estimated as approximately 1–2 vertebral body units below the carina. Careful hemostasis and postoperative compression were performed to minimize hematoma formation.

In conclusion, tunneled central venous catheter placement in pediatric patients is a safe and reliable procedure when appropriate device selection and technical considerations are applied. Attention to exit site selection, tunneling technique, catheter fixation, and tip positioning is essential to optimize long-term outcomes.

Keywords

Pediatric surgery; central venous catheterization; internal jugular vein; ultrasound-guided; chemotherapy.

Case Overview

Background

Central venous catheterization is a commonly performed procedure in pediatric surgery. Many patients require long-term central venous access for the administration of chemotherapy, as in the present case, or for parenteral nutrition in the setting of intestinal dysfunction or short bowel syndrome. Various types of central venous catheters (CVCs) are available, including totally implantable venous access devices (ports) and tunneled external catheters, such as Broviac and Hickman catheters (Figure 1).

Figure 1. Catheter Insertion Kits. A) 7-Fr Hickman catheter insertion kit. B) 4.2-Fr Broviac catheter insertion kit (Images courtesy of Medicon Co., Ltd., Japan).

To our knowledge, few reports have provided a comprehensive and practical description of tunneled CVC placement in pediatric patients, including device selection, anatomical landmark-based exit site determination, and reproducible technical strategies for preventing complications.

Focused History of the Patient

A two-year and four-month-old boy was diagnosed with neuroblastoma arising from the posterior mediastinum. The tumor extended cranially into the cervical region and caudally into the abdominal cavity, and was associated with a large pleural effusion (Figure 2). Computed tomography (CT) revealed tumor involvement of major vessels, including the aorta. Therefore, placement of a CVC was planned to facilitate the administration of chemotherapy.

Figure 2. Imaging studies. A) chest radiography and B) contrast-enhanced CT scan. The Symbols * and † indicate the right internal jugular vein and the supraclavicular mass, respectively. The left internal jugular vein is patent but compressed by the mass, as indicated by the arrowhead. The left thoracic cavity is occupied by a massive pleural effusion.

Physical Exam

Although the patient was diagnosed with neuroblastoma, the physical examination findings, as well as the subsequent imaging studies and clinical course, are described here primarily in the context of central venous catheterization. The planned insertion sites at the neck and anterior chest wall were intact, with no evidence of infection. Cervical range of motion was sufficient for surgical positioning; specifically, the patient’s head was rotated to the left to adequately expose the right side of the neck for catheter insertion via the right internal jugular vein, as demonstrated in the video.

Imaging

Chest radiography demonstrated markedly decreased translucency in the left lung field, along with mediastinal shift to the right, resulting in tracheal deviation (Figure 2a).

Patency of the right internal jugular vein and the absence of thrombosis were confirmed by ultrasonography and contrast-enhanced CT. The CT scan had been obtained for diagnostic evaluation of neuroblastoma and was not performed routinely for the purpose of CVC placement. Nevertheless, it demonstrated patency of other central veins, including the left internal jugular vein and both external jugular veins, in anticipation of potential difficulty with catheter insertion via the right internal jugular vein. However, the left internal and external jugular veins were partially compressed by the tumor, resulting in luminal narrowing (Figure 2b).

Natural History

The inserted catheter is typically maintained throughout the entire course of chemotherapy unless replacement is required due to complications, such as insertion site infection, catheter-related bloodstream infection, intraluminal obstruction due to thrombus formation, or catheter dislodgement. The catheter is generally removed upon completion of chemotherapy.

In contrast, in patients requiring parenteral nutrition, the catheter is intended to be maintained for as long as possible, unless complications arise. Therefore, prevention of complications is of even greater importance in these patients than in those undergoing chemotherapy.

The catheter can be used immediately on the day of insertion. The insertion site at the anterior chest wall is covered with dressings for approximately one week postoperatively. The circumferential securing suture around the catheter is removed one month after surgery after confirming sufficient adhesion of the cuff to surrounding tissue.

Options for Treatment

Vascular Access Site:

1. Internal Jugular Vein:
   The internal jugular vein is considered the gold standard for vascular access. It is sufficiently large to allow safe percutaneous puncture from the skin surface and is unlikely to become occluded after catheter insertion, thereby preserving the possibility of reuse if needed. In addition, the cervical incision is small, typically measuring approximately 3–5 mm, resulting in minimal cosmetic impact.
   
   The right internal jugular vein is preferred over the left, as it provides a more direct anatomical course to the superior vena cava and right atrium, facilitating catheter insertion and allowing more precise adjustment of the catheter tip position. Therefore, in the absence of contraindications such as infection or thrombosis, the right side is selected as the first-line approach.
   
   
2. External Jugular Vein:
   In patients with thrombocytopenia and an increased risk of bleeding, the external jugular vein may be considered using a cut-down technique, which allows better control of hemorrhage compared with percutaneous puncture. However, this approach requires sacrifice of the vessel, precluding future use. The incision at the insertion site also tends to be larger, and the operative time is generally longer than that of the percutaneous approach based on our experience.
   
   In addition, the external jugular vein is typically smaller in caliber than the internal jugular vein and may follow a tortuous course to the superior vena cava, which can make catheter advancement and optimal tip positioning more challenging. For these reasons, this route is generally less favorable. If this route is selected, the right side is preferred for the same anatomical reasons as for the internal jugular vein.
   
   
3. Subclavian Vein:
   The subclavian vein is commonly used for central venous access in adults but is generally avoided in pediatric patients. Percutaneous access is technically more challenging due to the smaller vessel size and is associated with a higher risk of complications, such as pneumothorax and arterial puncture.¹

Central Venous Access Devices:

Several types of central venous access devices are available in pediatric patients, including tunneled external catheters and totally implantable venous access devices (ports). Device selection depends on the clinical indication, duration of use, and patient-related factors.

1. Tunneled External Catheter:
   Tunneled external catheters are generally preferred in pediatric patients. Children with malignancies often require multi-lumen access, and totally implantable venous access devices necessitate repeated percutaneous needle puncture, which may cause pain and psychological distress.
   
   Tunneled catheters are available in both cuffed and non-cuffed configurations.
   
   
   1. Cuffed Catheter:
      Cuffed catheters are widely used due to their ability to achieve long-term stability through fibrous ingrowth into the cuff. However, a certain period is required for firm adherence to the subcutaneous tissue, during which the risk of catheter dislodgement is relatively increased.
      
      At our institution, cuffed catheters are preferentially used because the procedure is technically straightforward and does not require specialized equipment beyond the standard catheter kit. The risk of early dislodgement is mitigated by placing a circumferential suture around the catheter, which provides additional fixation by engaging the cuff in the event of inadvertent traction.
      
      
   2. Non-Cuffed Catheter:
      Recent studies have demonstrated that non-cuffed catheters secured with a subcutaneous anchoring system are associated with lower dislodgement rates and reduced costs compared with those secured using sutureless devices.²
      
      
2. Totally Implantable Venous Access Devices (Ports):
   Totally implantable venous access devices may be less suitable in children, as a discrepancy often exists between the size of the port reservoir and the limited thickness of the subcutaneous tissue, which can make port placement technically challenging.

Perioperative Safety Considerations

Informed consent for the procedure, filming, and publication was obtained from the patient’s parents. All procedures were performed under general anesthesia with continuous cardiopulmonary monitoring. Maximal sterile barrier precautions, including full sterile draping and sterile gown and glove use, were employed throughout the procedure. Correct guidewire position was confirmed fluoroscopically before dilation, and final catheter tip position was verified fluoroscopically at the completion of the procedure. Catheter patency was confirmed by free aspiration of blood and saline flushing. Postoperatively, patients were monitored for procedure-related complications, including arterial puncture, hematoma formation, pneumothorax, catheter malposition, thrombosis, catheter dysfunction, and catheter-related infection. 

Rationale for Treatment

Central venous access was required for the administration of chemotherapy in this patient with neuroblastoma. Given the need for reliable, long-term vascular access, a tunneled external catheter was considered most appropriate, as it allows continuous use without repeated needle puncture and is well suited for multi-lumen access in pediatric patients. In addition to drug administration, multi-lumen access enables blood sampling through the catheter, thereby avoiding repeated painful venipuncture. Although routine blood sampling via CVCs is not generally recommended due to concerns regarding catheter-related complications, our experience suggests that the associated risks, including catheter occlusion and infection, are infrequent and may be clinically acceptable in selected cases with appropriate catheter management.

At our institution, cuffed catheters are preferentially used due to their technical simplicity and stable long-term fixation. Although approximately one month is required for cuff integration into the subcutaneous tissue, early dislodgement is minimized by additional circumferential suturing.

Although other options such as implanted ports, external jugular venous access, subclavian venous access, and peripherally inserted central catheters (PICCs) may be appropriate in selected situations, a cuffed tunneled catheter via the right internal jugular vein was considered most suitable in this patient based on anatomical considerations, the anticipated duration of chemotherapy, and institutional practice. 

Discussion

In pediatric patients, catheter dislodgement represents the most common complication. Device failure prior to completion of therapy has been reported in approximately 30% of cases, with catheter dislodgement accounting for nearly half of these failures.^3,4 One contributing factor is the relatively short length of the subcutaneous tunnel in pediatric patients, which is attributable to their smaller body size compared with adults. Prevention of dislodgement is therefore critical, as both chemotherapy and parenteral nutrition depend on stable, long-term vascular access, and replacement of a CVC in children is generally more technically challenging than in adults. Although a period is required for the cuff to achieve firm adherence to the subcutaneous tissue—during which the risk of dislodgement is relatively increased—this risk can be mitigated by placing a circumferential suture around the catheter as an additional securing measure, as described above. The risk of infection with tunneled external catheters is also higher than that with totally implantable venous access devices (ports),⁵ as the catheter is externalized through the anterior chest wall, rendering it more susceptible to microbial contamination. Prophylactic antibiotics are not routinely required, whereas routine disinfection is, therefore, recommended.

The right internal jugular vein is the preferred site for access, as it provides a relatively direct route to the superior vena cava. In cases of severe thrombocytopenia, where the risk of postoperative hematoma is a concern, the external jugular vein may be accessed via a cut-down approach. However, percutaneous cannulation of the internal jugular vein is generally feasible even in thrombocytopenic patients. Platelet transfusion may be administered to optimize conditions for vascular access, although previous studies have reported no significant difference in bleeding complications between transfused and non-transfused patients, including those undergoing tunneled catheter placement.⁶

The subcutaneous tunnel is typically created from the anterior chest wall to the cervical puncture site. The chest entry point is determined using anatomical landmarks, specifically the triangle formed by the sternal notch, the right acromion, and the right nipple, with the entry site positioned at its center, as demonstrated in the video. The direction of tunneling is a critical technical consideration; a broad, smooth, curved trajectory between the chest entry site and the neck puncture site is intentionally created to avoid acute angulation and catheter kinking. After catheter placement, free aspiration of blood and unobstructed saline flushing are routinely confirmed to verify catheter patency and appropriate function before completion of the procedure. In contrast, a straight tunnel between these points is associated with a higher risk of kinking, potentially leading to luminal narrowing and impaired catheter flow.

The optimal tip position for tunneled CVCs is at the junction of the superior vena cava and the right atrium. Malposition of the catheter tip can adversely affect both function and longevity and may necessitate repositioning. Excessively deep placement may result in arrhythmias, intracardiac thrombus formation, or valvular injury, whereas a shallow position increases the risk of catheter retraction or migration into adjacent vessels, such as the innominate vein or the contralateral subclavian vein, potentially leading to inadequate flow, thrombosis, and catheter dysfunction.⁷ Catheter malposition and the need for replacement were more frequently observed in younger children and in cases where the catheter tip was positioned less than 1.5 vertebral body units below the carina.⁸ In addition, the junction of the superior vena cava and right atrium can be estimated as approximately 1.5 vertebral body units below the carina;⁹ in clinical practice, a range of 1–2 vertebral body units is commonly used as a practical guideline. This vertebral body-based estimation provides a practical and reproducible intraoperative reference, particularly in pediatric patients in whom body size variability may limit the utility of fixed distance measurements.

One disadvantage of cuffed catheters, however, is that the position of the cuff must be determined in advance, which can make subsequent adjustment of the catheter tip difficult if malposition occurs after insertion. This is particularly relevant when the patient’s position changes from neck extension with leftward rotation during insertion to a neutral position, potentially altering the catheter tip location. Therefore, this positional change should be anticipated when determining the catheter length. In contrast, with non-cuffed catheters, the catheter tip position can be assessed and readily adjusted even after insertion, making correction of malposition easier.

Many pediatric patients are at increased risk of postoperative hematoma due to thrombocytopenia, either related to the underlying disease or its treatment. Both percutaneous puncture of large vessels, such as the internal jugular vein, and the creation of a subcutaneous tunnel may contribute to bleeding. To reduce the risk of hematoma formation, external compression is routinely applied to the cervical puncture site and along the subcutaneous tunnel for approximately 24 hours postoperatively. The catheter is typically available for use on the day of placement, and the circumferential securing suture is generally removed approximately one month after the procedure.

In conclusion, central venous catheterization in pediatric patients is a commonly performed and generally safe procedure in pediatric surgery. However, careful attention to several key technical considerations is essential to minimize complications and ensure optimal long-term catheter function. These technical considerations provide a simple and reproducible framework that may help improve catheter durability and reduce complications in pediatric practice.

Equipment

• 7-Fr Hickman catheter insertion kit (including catheter, guidewire, dilator, and tunneler) (Figure 1).
• 2-0 and 4-0 nylon sutures.
• 5-0 absorbable monofilament suture (e.g., PDS).
• Heparinized saline for flushing.
• Heparin for catheter locking.
• Standard wound closure instruments (needle holder, forceps, scissors).
• Sterile dressings.

Disclosures

The authors report no conflicts of interest, financial relationships, funding, sponsorship, equipment support, or other relationships that could be perceived to influence the content of this article.

Statement of Consent

Informed consent for filming and online publication of the images and clinical information was obtained from the patient’s parents and documented in the medical record.

Acknowledgments

The authors would like to express sincere gratitude to Medical Engineer Akihito Inoue for his invaluable assistance and cooperation throughout the filming process.