Placement and management of long-term central venous access catheters and ports

Recent developments in long-term central venous access devices, access techniques, and the management of complications are described. Factors used in selecting a device include the intensity and frequency of therapy and the preferences of the patient. Implantable ports and external catheters are available with valved (Groshong) and nonvalved catheters and with single or multiple lumens. Single- or dual-lumen, peripherally inserted central catheters and ports provide a smaller and less invasive alternative to central access. Sonographic guidance during central catheterization allows detection of venous abnormalities, increases the success rate, and decreases the number of complications. When occlusion of the jugular veins, subclavian veins, or superior vena cava prevents routine access, alternatives include translumbar or transhepatic cannulation of the inferior vena cava. Common complications of long-term access are catheter and venous thrombosis and catheter infection. Catheter thrombosis is treated by fibrinolysis. Daily administration of 1 mg of warfarin reduces the risk of thrombosis. An infected catheter can be diagnosed without catheter removal by comparison of quantitative blood cultures from the catheter and peripheral vein. Early recognition of catheter-related infection may save the catheter. Removal of an infected catheter depends on the nature of the offending agent, severity of infection, success of treatment, and degree of difficulty in obtaining alternative access.