Introduction

Abstract

The rapidly aging population and increased lifespan of individuals with chronic disease have resulted in an explosion in the demand for central venous access. Procedures once rare outside of the intensive care unit and operating room are now commonplace. For some, this responsibility represents a challenging burden in terms of coverage demands. For many, it represents a new service line with attractive economic potential. For patients, however, it more and more frequently represents an essential ingredient to the successful management of their care. The interventional radiologist is uniquely equipped to meet the increasing demands of an increasingly complex patient population. The introduction of imaging guidance in the late 1980s and early 1990s has disrupted traditional referral patterns for patients requiring central venous access. The radiologist's expertise with ultrasound and fluoroscopy ensures that almost every patient can have central venous access accomplished—usually more quickly, more safely, and more conveniently than without. In most circumstances there are cost-efficiency advantages to obtaining access in the interventional radiology suite as opposed to the operating room. Improvements in the portability of imaging equipment have also played an important role in bringing venous access with imaging guidance directly to the bedside of patients too ill to be transported to the IR suite. The expanding role of the interventional radiologist in central venous access has not gone unnoticed by our clinical colleagues, particularly those in surgery. There is a palpable movement in many specialties to gain competence with image techniques and perform image-guided access. Because imaging is one of our core competencies, we have an advantage in leveraging imaging tools for patient benefit. It is essential that interventional radiologists demonstrate mastery of standard techniques to obtain safe and reliable venous access when called upon. In this issue of Techniques in Vascular and Interventional Radiology we review principles related to the various forms of central venous access that interventional radiologists are commonly asked to perform. This edition will outline principles of patient assessment and common techniques in placing both tunneled and nontunneled central venous access, as well as techniques for port placement. We review complications associated with venous access and discuss in detail techniques for obtaining safe access in the patient who suffers from complex central occlusive disease. A specific article is devoted to the management of catheter infections. Annually in the USA, close to 15 million central venous access procedures are performed. Almost 70% of all hospital-acquired infections relate to contamination of central venous access devices. This translates to an estimated annual mortality as high as 90,000 deaths. Catheter-related infections are now considered a distinct public heath problem. Throughout this edition we emphasis principles that should minimize the rate of catheter-related infection. Further, we hope to emphasis the important role of standardization and process in the development of an imaging guided line service. While answers to important questions regarding comparative outcomes, cost-effectiveness, and efficacy cannot be answered in this edition of Techniques in Vascular and Interventional Radiology, mastery of the skills and comprehension of the principles outlined will help arm the interventional community with the tools to successfully manage both simple and complex cases and to contribute positively to the care of millions of patients. I am grateful to the energetic faculty at the University of Arkansas for their outstanding contributions to this volume. I am particularly grateful to Dr. Donald Denny for his excellent overview of salvage techniques, but more so for his role as my mentor many years ago. Lastly, I would like to express appreciation to Janath McKee for her expert editorial assistance and to Donna Ashlock, for her assistance with many of the images in this volume.