Sites of insertion

Central venous catheters can be inserted via several routes dictated by the presence of local pathology, anatomical abnormality, or venous occlusion due to thrombosis. The principal sites may be subdivided as to whether the procedure involves a percutaneous cannulation technique or direct surgical exposure (cut-down) on a venous tributary. Doubts concerning major central venous occlusion secondary to thrombosis should be resolved with angiography or ultrasound techniques. Occlusive superior central venous thrombosis presents a difficult problem and considerable technical expertise is required to gain venous access in these exacting circumstances. Direct percutaneous catheterization via the inferior vena cava has been performed with ultrasound or CT radiographic guidance. Alternatively, a combined angiographic and operative technique whereby catheters are placed through previously occluded veins using retrograde guidewire and Dormia basket techniques may be used. Fortunately, the need for such techniques is rare.

The preferred sites for central venous access in the absence of complicating factors are listed in Table.3.

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Table 3 Preferred sites for central venous access

The authors prefer to use the infraclavicular subclavian percutaneous route since Another minor but important point to remember is that the cephalic vein is absent prolonged peripheral venous therapy.

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