Central Venous Access: Keep These Options on the Table

Purpose: Exhaustion of conventional central venous access sites, although common, presents with its own challenges to treating physicians. Nontraditional alternative approaches for central venous access have been well described in the literature and are critical for interventional radiologists to be informed about so that long-term reliable, complication-free access can be delivered to patients in need of their use. Here, we examine alternative approaches for central venous access used by our institution since 2015.

Materials and Methods: We conducted a retrospective analysis of 13 patients who required nontraditional venous access at our institution from 2015 to 2021. Data abstracted included sex, age, reason for hospital admission, indication, length of time previously requiring access, catheter insertion procedure, technical success rate, and time to first exchange.

Results: After reviewing 13 cases (7 male, 6 female; mean age, 59.4 years) of nontraditional venous access, it was found that the most common approaches used at our institution since 2015 were (1) translumbar (n = 6), (2) transhepatic (n = 4), (3) transrenal (n = 2), and (4) brachiocephalic (n = 1). Indication for using these varied approaches was determined after it was confirmed by ultrasound scan that conventional access sites were exhausted, including failure of arteriovenous grafts or fistulas, occlusion of bilateral internal jugular veins, and occlusion of bilateral femoral veins. The reason for hospital admission ranged between the need for dialysis (n = 6), sepsis (n = 3), COVID pneumonia (n = 2), cardiac arrest (n = 1), and nutritional support (n = 1). Length of time requiring venous access was longer than 5 years (n = 6), 6 months to 5 years (n = 4), and less than 6 months (n = 3). Technical success rate was 100% overall. The average time to first exchange was 27.4 days.

Conclusions: Nontraditional central venous access via these approaches, although technically more difficult, provide patients with alternative means to achieve desired goals in their medical management, whether for renal replacement therapy or intravenous administration for medical treatment. Although the risk of complication needs to be considered, these approaches may allow for prompt care to take place. Upon our review, our outlook remains steady in that patients who have exhausted all conventional access sites may benefit from alternative approaches. Ultimately, these approaches should be a consideration when interventional radiologists are called upon.