Hickman, Leonard, or Broviac catheter. When catheter damage or connector separation occurs, the catheter should be immediately clamped or kinked closed to. Tissue Ingrowth Cuffs for fixation of the catheters in a subcutaneous tunnel. Each catheter is Hickman*, Leonard* and Broviac* Catheters are designed for long- term vascular access and for .. “Hickman* Catheter. Separation”, JPEN, Vol. Large numbers of central venous catheters (CVCs) are placed each year and blood flows past the catheters, plus separation of inflow and outflow catheters to Hickman catheter dislodgement due to pendulous breasts.

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Bodenham; Misplaced central venous catheters: Large numbers of central venous catheters CVCs are placed each year and misplacement occurs frequently.

This review outlines the normal and abnormal anatomy of the central veins in relation to the placement of CVCs. An understanding of normal and variant anatomy enables identification of congenital and acquired abnormalities. Embryological variations such as a persistent left-sided superior vena cava are often diagnosed incidentally only after placement of a CVC, which is seen to take an abnormal course on X-ray. Acquired abnormalities such as stenosis or thrombosis of seeparation central veins can be problematic and can present as a failure to pass a guidewire or catheter or complications after such attempts.

Catheters can also be misplaced outside veins in a patient with otherwise normal anatomy with potentially disastrous consequences.

We discuss the possible management options for these patients including the various imaging techniques used to verify correct or incorrect catheter placement and the limitations of each. If the course of cattheter misplaced catheter can be bickman identified as not lying within a vulnerable structure then it can be sepadation removed.

If the misplaced catheter is lying within or traversing large and incompressible arteries separration veins, it should not be removed before consideration of what is likely to happen when it is removed. Advice and further imaging should be sought, typically in conjunction with interventional radiology or vascular surgery. With regard to misplaced CVCs, in the short term, a useful aide memoir is: The central veins are the target for placement of the internal section of central venous catheters CVCs and their tips.

Large numbers are performed yearly, estimated at in the UK inthe sepsration via the upper body. Ultrasound, ECG guidance, real-time X-ray imaging, and other aids dramatically increase the successful placement cwtheter needles, guidewires, and catheters, but significant numbers of catheter misplacements can still occur, particularly if operators are not fully proficient in such techniques.

In addition, there are a large number of congenital and acquired abnormalities of the venous system, which will be encountered on an intermittent basis by anyone regularly performing separxtion procedures. We present an illustrated narrative review of this complicated area of practice and discuss practical management issues.

It is generally easy to recognize and manage such abnormalities if you have seen or read about it before, but not if faced with them for the first time in a stressful clinical situation.

Much of the literature is in the form of isolated case reports or small series, which are cumbersome and time-consuming to access, and do not always provide pragmatic guidance or solutions to the problem. This information to our knowledge has not been drawn together previously in the anaesthetic or critical care literature. CVCs are inserted for a large number of different indications. Many different types of catheters exist, for example, tunnelled or non-tunnelled, mono-lumen or multi-lumen, dialysis catheters, and peripherally inserted central catheters PICCS.

CVCs uickman inserted in a number of hospital locations intensive care units, theatres, wards, radiology department and by a number of different healthcare professionals with separatoin techniques for insertion and for ensuring correct catheter placement.

Whatever the indication or type of the central catheter inserted, the usual aim is to place the catheter tip in as optimal central vein location as is possible, avoiding misplacement and other complications of insertion. The ideal cathteer tip position has been the subject of much debate. There are potential complications associated with all tip positions. The most proximal venous valves lie 2. Incorrect catheter placement proximal to these valves will lead to inaccurate CVP monitoring or potential irritation of the valve area by the catheter or infused fluids.


In order to prevent the rare but lethal complication of cardiac tamponade, the tip should ideally lie proximal cagheter the boundaries of the pericardial sac; however, too proximal placement of the tip increases the risk of thrombosis. A simplified schematic illustration of the major central veins.

There can be considerable variability. Some of the more common congenital venous abnormalities are shown, such as an anomalous pulmonary venous drainage see text. A persistent left vena hickmab would occur if the ligament of the left vena cava remained patent after failure of the degeneration of the embryological anterior cardinal vein.

This can be seen to connect to the coronary sinus. The importance of achieving the separatino catheter tip position depends to some extent on cahteter indication for the CVC. A misplaced catheter lying in a longitudinal plane of a large central vein may be suitable for some applications, for example, infusion of non-hypertonic fluids and monitoring CVP.

Hickman line

However, other infusions such as parenteral nutrition, cancer chemotherapy, sclerosant drugs, and vasopressors require greater dilution and mixing of drugs for successful longer-term use. Similarly, extracorporeal circuits for dialysis, haemofiltration, apheresis, or cardiopulmonary bypass need very high blood flows past the catheters, plus separation of inflow and outflow catheters to avoid blood recirculation. Measuring central venous oxygen saturations as a surrogate for mixed venous oxygen saturations requires the catheter tip to lie either in or close to the right atrium RA to minimize measurement error.

In all these situations the catheter tip needs to be either in, or very close to, the RA. Poor catheter positioning is a common reason for premature failure of CVCs due to vein or catheter thrombosis or other reasons. Relatively detailed anatomical knowledge of the central veins is a prerequisite for safe placement of CVCs, and to enable identification of abnormalities when they occur.

A description of the normal anatomy of the central veins follows. The anatomy of the IJ, subclavian, axillary, femoral, and other routes of access to the central veins are well described elsewhere, and this article will mainly focus on the central veins within the thorax and, to a lesser extent, the abdomen. This shows the major vessels and branches, and some more common variants.

Such simplified images may be helpful when performing procedures or reviewing images. We also show volume rendered reformatted computed tomography CT anatomy images later in the text showing normal and variant anatomy.

Venous walls are relatively thin and fragile in comparison with arterial walls, rendering them at greater risk from iatrogenic injury.

Structurally, they are composed of three layers: These layers are not distinct in all veins, but relative to arteries, there is a larger proportion of the outer connective tissue layer and a smaller proportion of the middle muscular layer.

This allows the venous system to be distensible and compliant and act as a blood reservoir, but is the reason for their relative fragility. The longitudinal organization of the layers means that tears in the vein walls tend to extend along the long axis, causing larger defects with the potential for serious bleeding.

The brachiocephalic innominate veins are two large trunks, placed one on either side of the root of the neck and formed by the union of the IJ and SCVs of the corresponding side; they are devoid of valves. Here it forms the SVC.

It lies anteriorly and to the right of the brachiocephalic artery. The right brachiocephalic vein, at its commencement, receives the right vertebral vein and, lower down, the right internal thoracic mammary and right inferior thyroid veins. Sometimes the vein from the first intercostal space also joins here. Owing to its relatively straight course into the SVC, in terms of catheter placement, it could be functionally considered as a proximal limb of the SVC.

The left brachiocephalic vein, some 6 cm long, begins posterior to the sternal end of the left clavicle and runs obliquely downwards and to the right, behind the upper half of the manubrium sterni to the sternal end of the first right costal cartilage.

Here, it unites with the right brachiocephalic vein to form the SVC. Behind it are the three large arteries, the right brachiocephalic, left common carotid, and the left subclavian artery, arising from the aortic arch, together with the vagus and phrenic nerves.

The left brachiocephalic vein may occupy a higher level, crossing the jugular notch and lying directly in front of the trachea. Its tributaries are the left vertebral, left internal thoracic mammaryleft inferior thyroid, and the left highest intercostal veins, and occasionally, some thymic and pericardiac veins. Its angle of approach to the right brachiocephalic vein is very variable and this is an important determinant of the ease of central catheter positioning from the left IJ and SCV routes.


The more acute the angle is, the longer the distal section of catheter needed to be able to traverse the corner, and to lie in the longitudinal axis of the SVC or upper RA.

This is important to avoid acute angulation against the wall of the SVC or RA, with the attendant risks of thrombosis, catheter failure, or perforation. The right brachiocephalic vein receives lymph from the right lymphatic duct, and the left brachiocephalic vein receives lymph from the thoracic duct. Such anatomy is very variable. The SVC drains venous blood from the upper half of the body Fig.

It descends vertically behind the first and second intercostal spaces, ending in the upper part of the RA, opposite the upper border of the third right costal cartilage. In its course, it describes a slight curve, the convexity of which is posterior and to the right side. The SVC lies anterolateral to the trachea and posterolateral to the ascending aorta.

The right phrenic nerve lies between the SVC and the mediastinal pleura. The terminal half of the SVC is in the middle mediastinum, where it lies beside the ascending aorta.

The lower half of the vessel is within the pericardial sac. Just before it pierces the pericardium, it receives the azygous vein and several small veins from the pericardium and other structures from within the mediastinal cavity. The upper level of the pericardial sac, as it traverses the SVC, lies below the level of the carina. Hence, the use of the carina as an X-ray landmark to identify the placement of a CVC tip outside of the pericardium, therefore minimizing the small but serious risk of cardiac tamponade if the tip perforates the vessel wall.

The SVC lies in close anatomical proximity to the mediastinal pleura Fig. Perforation of the vein wall here, with a guidewire, dilator, or catheter, may cause uncontrolled bleeding into the low pressure pleural space. A catheter while left in situ may control such bleeding weparation then becomes evident on removal. With age or disease, the SVC may become increasingly tortuous, which can cause difficulty when attempting to advance separatio guidewire or catheter. The SVC has no valves.

The azygous and hemiazygous venous systems drain the back, thoracic, and sepaaration walls Fig. They exhibit much variation. It enters the thorax through the aortic hiatus in the diaphragm and ascends in the posterior mediastinum, passing close to the right sides of the bodies of the inferior eight thoracic vertebrae.

It arches over the superior aspect of the root of the lung to enter the posterior aspect of the SVC just before it pierces the pericardium. It bulges into the pleural space or may even lie free within the pleural space.

The azygous venous system offers an alternative means of venous drainage from the lower body thoracic, abdominal, and back regionswhen there is obstruction of the IVC, and can offer a route of access for the catheter to enter the SVC.

The smaller hemiazygous system provides venous drainage for hickmam left chest and upper abdomen and anastomoses with the azygous system. The IVC drains blood from the lower half of the body Fig. It is formed from the junction of the common iliac veins. It is about 2. It then perforates the diaphragm and continues cranially and medially for about 2. Here, it pierces the fibrous pericardium and opens into the lower part of the RA. There are no functional valves in the IVC.

Hickman catheter separation.

There is a range or severity varying from i. Misplaced catheters have been reported in almost every possible anatomical position, including the arterial system, mediastinum, pleura, pericardium, trachea, oesophagus, subarachnoid space, and other aberrant sites.

Certain patterns are well recognized as clinically important from audits, medicolegal analyses, and clinical experience.