Fluoroscopically guided tunneled transhepatic venous central line placement; hepatic venography; left and right jugular
ultrasound; right subclavian catheter injection:
Procedure: Chronically debilitated patient on long-term care. Request for central line access for dopamine and antibiotics.
Unsuccessful attempt by anesthesia at left and right jugular central line placement. A right upper chest wall vein was
catheterized.. No central venous access
Procedure: Informed consent obtained the family. Initial ultrasound of both the left and right neck demonstrate no
visualization of either the external or internal jugular veins which are seen to be chronically occluded. The right upper
chest/subclavian catheter was injected and demonstrates tip is within a cast of collateral veins in the right paraspinal
region. Findings indicate long-standing chronic Central venous obstruction. Patient is markedly contracted so access to
the femoral veins is unobtainable there Therefore it was elected to perform transhepatic venous central line placement.
Using sterile technique, local anesthesia and fluoroscopic guidance as well as conscious sedation a 22-gauge Chiba
needle was inserted into the middle hepatic vein. Guidewire is advanced in the right atrium. Fascial dilatation was
performed and a 7-French peel-away sheath was advanced to level the right atrium.
A subcutaneous tunnel was created several centimeters from the entrance site. Through the tunnel a 33-cm/6-French
POWER -- LINE central line was pulled and advanced through the peel-away sheath with the tip placed entering the right
atrium and coursing up the lower SVC. All ports function well and the catheter sutured in place.
Impression: Jugular and femoral dialysis catheter access could not be achieved as discussed above. Successful
transhepatic venous tunneled central line placement as discussed above.
would it be 36571 or 36561
ultrasound; right subclavian catheter injection:
Procedure: Chronically debilitated patient on long-term care. Request for central line access for dopamine and antibiotics.
Unsuccessful attempt by anesthesia at left and right jugular central line placement. A right upper chest wall vein was
catheterized.. No central venous access
Procedure: Informed consent obtained the family. Initial ultrasound of both the left and right neck demonstrate no
visualization of either the external or internal jugular veins which are seen to be chronically occluded. The right upper
chest/subclavian catheter was injected and demonstrates tip is within a cast of collateral veins in the right paraspinal
region. Findings indicate long-standing chronic Central venous obstruction. Patient is markedly contracted so access to
the femoral veins is unobtainable there Therefore it was elected to perform transhepatic venous central line placement.
Using sterile technique, local anesthesia and fluoroscopic guidance as well as conscious sedation a 22-gauge Chiba
needle was inserted into the middle hepatic vein. Guidewire is advanced in the right atrium. Fascial dilatation was
performed and a 7-French peel-away sheath was advanced to level the right atrium.
A subcutaneous tunnel was created several centimeters from the entrance site. Through the tunnel a 33-cm/6-French
POWER -- LINE central line was pulled and advanced through the peel-away sheath with the tip placed entering the right
atrium and coursing up the lower SVC. All ports function well and the catheter sutured in place.
Impression: Jugular and femoral dialysis catheter access could not be achieved as discussed above. Successful
transhepatic venous tunneled central line placement as discussed above.
would it be 36571 or 36561
