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

CHAPTER 1

My name is Yuki Noguchi and I serve as the Chief Surgeon of Pediatric Surgery at Osaka Women's and Children's Hospital in Osaka, Japan. This case involves a two-year and four-month-old boy with a neuroblastoma arising from the posterior mediastinum. The tumor extended cranially into the neck and caudally into the abdomen, and was accompanied by a massive pleural effusion. Because the CT scan demonstrated that the tumor was involving major vessels, including the aorta, we plan to place a central venous catheter to facilitate chemotherapy administration. Central venous catheterization is a common procedure in pediatric surgery. Many of our patients require long-term chemotherapy, as in this case, or parenteral nutrition due to bowel dysfunction or short bowel syndrome. Several types of catheters are available for central venous access, including vascular access ports and tunneled external catheters such as Broviac and Hickman catheters. For pediatric patients, we generally prefer tunneled external catheters. Children with malignancies often require multiple lumens, and vascular access ports require needle access with every treatment, which is painful and traumatic. In infants in particular, there is often a mismatch between the size of the port reservoir and their thin subcutaneous tissue, making port placement technically challenging. Tunneled external catheters are available in both cuffed and a non-cuffed types. In pediatric patients, the most frequent complication is catheter dislodgement. This must be avoided as both chemotherapy and parenteral nutrition depend on secure, long-term vascular access, and replacing a central line in children is generally more difficult than in adults. Recent studies have shown that non-cuffed catheters secured with a subcutaneous anchor system have fewer dislodgements and lower cost compared with those secured with sutureless devices. At our institution, however, we primarily use cuffed catheters because the procedure is straightforward and it does not require equipment beyond the catheter kit. Also, it takes some time for the cuff to adhere firmly to the subcutaneous tissue, and the risk of dislodgment is higher during this period. We reduce this risk by placing a circumferential suture around the catheter. This suture acts as a secondary safety measure by catching the cuff if extent retraction is applied. Regarding the insertion site, we typically access the right internal jugular vein because it provides a direct route to the superior vena cava as demonstrated in the video. When platelet counts are critically low and the possibility of a hematoma is a concern, the external jugular vein via a cut-down approach may be considered. However, in most thrombocytopenic patients, percutaneous access to the internal jugular vein remains feasible. Platelet transfusion may be used to improve conditions for puncture, although previous reports have shown no significant difference in bleeding rates between transfused and non-transfused patients, even for tunneled catheters. The subcutaneous tunnel is typically created from the anterior chest wall towards the puncture site in the neck. To determine the appropriate chest entry point, we use a simple anatomical landmark triangle formed by the sternal notch, the right acromion, and right nipple, placing the entry site at its center, the most critical technical consideration is the direction in which the tunnel is created. A broad, curved path from the chest entry site to the neck puncture site is essential to prevent catheter kinking in the cervical region. As noted in the video, a straight tunnel connecting these two points frequently results in kinking, leading to impaired flow due to narrowing of the catheter lumen at the neck entry site. The target location for the tip of all tunneled central catheters is the junction of the superior vena cava and the right atrium. Suboptimal tip position affects catheter function and the longevity and may require repositioning. Tips that are too deep may cause arrhythmias, cardiac thrombus, or valvular injury if positioned intracardially. Tips that are too shallow are prone to retraction or migration into nearby vessels such as the innominate vein or the contralateral subclavian vein, leading to inadequate flow, risk of thrombosis, and catheter dysfunction. A reliable predictor for the junction of the superior vena cava and the right atrium in children is approximately 1.5 vertebral body units below the carina. Also, this varies slightly by age. We generally use one to two vertebral body units as a practical guideline. Many pediatric patients are at increased risk of postoperative hematoma because of thrombocytopenia either from the underlining disease or from treatment. Thus, percutaneous puncture into a large vessel such as the internal jugular vein or the creation of a broad subcutaneous tunnel may cause bleeding. To prevent hematoma formation, we routinely apply external pressure to both the neck puncture site and the tunnel path for about 24 hours. The catheter can typically be used on the same day it is placed, and the circumferential suture is generally removed about one month after surgery. In conclusion, pediatric central venous catheterization is a common and generally safe procedure in pediatric surgery. However, several important technical considerations are necessary to prevent complications and ensure long-term catheter function.

CHAPTER 2

This is two-year and four-months-old boy who came to medical attention with chronic cough that had persisted for about one month. His parents initially took him to a local hospital where a chest x-ray showed a decreased radiolucency in the left lung field, and also a mediastinum shift towards the light side. Contrast-enhanced CT scan where it's performed, which revealed that large masses, large tumor, arising from the posterior mediastinum extending upwards into the neck and downwards into the abdomen, and also accompanied by a massive pleural effusion. Therefore, he was referred to our medical center for further management. And at our institute, blood test showed an increased serum level of neuron-specific enolase or NSE. And based on this finding together with the characteristic imaging features, neuroblastoma was suspected. And at first, the thoracentesis was performed to remove the massive pleural effusion and correct the mediastinal shift. And the CT scan also revealed that the tumor was involving major vessels including the aorta, so we decided to start multidrug chemotherapy first before the definitive surgical resection, and the central venous catheter insertion was scheduled to facilitate the chemotherapy administration. And this is the catheter kit, and it basically contains the catheter itself. And a guidewire, and a tunneler, and a dilator. And as part of preparation, this catheter, and the guidewire, and the dilator are flushed with saline in advance. Okay. And there are basically two main vascular access methods, and one is percutaneous puncture, and the other is cut-down. And the internal jugular vein is most commonly used since it runs straight to the heart, and in this case, the percutaneous puncture is employed. And if there is an increased risk of hematoma formation, such as in the patient with thrombocytopenia, then the external jugular vein may be accessed via the cut-down method, but in most cases, platelet transfusion is performed and then the internal jugular vein is still accessed percutaneously. And for this technique, the patient is placed in the Trendelenburg position, I mean, the head-down tilt, to distend the internal jugular vein, and it makes the puncture easier. And also, the patient's head is turned to the left and the endotracheal tube or laryngeal mask is positioned to the left side to ensure the better exposure of the right neck, okay? And the puncture site is determined under ultrasound guidance, identifying both internal jugular vein and carotid artery. And the internal jugular vein usually lands just above the carotid artery, so by rotating the head to the left, then these two vessels can be separated to avoid vertical overlap, so...

CHAPTER 3

And also, by compressing the ultrasound probe and confirming that the target vessel becomes flattened, one can confirm that it is a vein. And if a thrombus is detected within the vessel, then there is an increased risk of embolization into the heart, then the choosing an alternative vascular access site would be safer. And especially in the pediatric patients, these two vessels, I mean, the internal jugular vein and the carotid artery, are usually very close together, and puncturing the posterior wall of the internal jugular vein may result in accidental arterial puncture. So it is safer to insert guidewire once the needle tip is confirmed to be within the vessel under ultrasound like this, and without penetrating the posterior wall of the internal jugular vein. Okay, go ahead.

CHAPTER 4

Okay. So we need to focus on the needle tip, and it should be confirmed to be within the vascular, within the vessel.

CHAPTER 5

Under ultrasound guidance, and then, insert the guidewire into the vessel. And advance the guidewire sufficiently, but when it reaches the heart, as you can see, a brief arrhythmia may appear on the electrocardiogram indicating that the wire has advanced far enough, and at that point, no further insertion is needed.

CHAPTER 6

And after that, use a portable fluoroscopy to confirm the correct intravascular placement of the guidewire. Okay, looks good. Okay, remove it, so I can keep this. Okay. Go back.

CHAPTER 7

And the next step, in adult case, in adult cases, port-type central venous catheters are generally used, which requires repeated needle puncture and can cause pain, but in pediatric patients, we usually use catheters that are externalized from the anterior chest wall and therefore can be directly connected are generally used, yeah. And, the puncture site is usually determined by forming a triangle using the sternal notch here, and the right acromion here, and the right nipple, like this. And choosing a point near the center of this triangle, okay? And the subcutaneous tunnel is next created in a broad, curved path from the anterior chest entry site toward the neck insertion site. Okay, good. And then make a small incision on the chest wall, necessary for inserting the tunneler, and also get a bit of the puncture point. Okay. And then dissect the subcutaneous layer for smooth advancement of the tunneler. Then insert the tunneler into the subcutaneous layer. And again, the tunnel should be created in a broad, curved path from the chest entry site toward the neck puncture site. Okay, good. Okay, and after inserting the tunneler into the subcutaneous layer like this, then a circumferential 2-0 nylon suture is placed around the tunneler to prevent accidental dislodgement of the catheter. Okay, keep this.

CHAPTER 8

And then the catheter is connected to the tunneler tip and pulled through from the chest entry site toward the neck puncture site. Okay, good. And of note, a straight tunnel connecting to the two points, which can cause the catheter to bend sharply around the neck puncture site, which results in lumen narrowing, leading to the peripheral. So this is really important to create the tunnel in a broad, curved path like this. And after that, the catheter is pulled like this, and the cuff should be pulled slightly deeper than its final position at the fixation suture. So now, the cuff is around here, and after tying the fixation suture, then the catheter is gently pulled back until the cuff catches on the fixation suture. Hmm, okay.

CHAPTER 9

And the next step is to determine the length of the catheter, and use the fluoroscopy again to confirm the course of the guidewire. And then the catheter is laid over the body surface like this, following the same course of the guidewire to determine the appropriate insertion length. Over here, okay? And as a general guide, the catheter tip should be positioned about one or two vertebral bodies below the tracheal bifurcation. Okay. Okay, around here, and cut the catheter. But especially in patients requiring long-term total parenteral nutrition such as those with the intestinal failure, the gradual outward migration of the catheter may occur with growth, so this must be kept in mind, okay? Hmm. Okay, so... And after the length is determined, then the catheter is sufficiently pulled toward the neck puncture site like this, and then, insert the dilator next.

CHAPTER 10

And the dilator is inserted over the guidewire into the vessel, advancing it beyond the clavicle, under the fluoroscopy. Okay. Like this.

CHAPTER 11

And then remove the, could you wait? Remove the inner dilator and the guidewire together. And then the catheter is gonna be inserted through the outer sheath of the dilator into the vessel next, but if the catheter has not been pulled sufficiently toward the neck, then the next step can be more difficult. And it is also important to synchronize the catheter advancement through the outer sheath of the dilator with the peeling motion. Okay. So, okay, remove them.

CHAPTER 12

Okay, peel it out. Okay. Synchronize the peeling motion with the catheter advancement. Okay. Okay, okay, okay. Go ahead, go ahead. Go ahead, go ahead. And after the catheter is completely inserted, then the sheath is fully peeled away.

CHAPTER 13

Okay, and after that, the catheter is gently pulled back from the chest entry site until the cuff engages the fixation suture that was placed earlier. Okay, like this. And then use the fluoroscopy again, okay, to straighten any kinking of the catheter in the neck region, but this time, we don't, we wouldn't have such findings. And also confirm that the catheter tip is located below the tracheal bifurcation as intended. So it looks good.

CHAPTER 14

Then close the incision sites. And at the same time, these two lumens are heparinized. And also, check the smooth flow. Okay, good. Okay. Okay, good, good. Okay, perfect. So now, heparinize these lumens next. And also, the catheter should be secured to the skin. Good. Okay. Okay, and apply dressings on these wounds. And this completes the procedure. Okay, all done.