我们要感谢陆军、海军、美国国立卫生研究院、空军、退伍军人事务部和卫生事务部对 CTA05：W81XWH-13-2-0052 和 CTA06：W81XWH-13-2-0053 项下 AFIRM II 工作的支持。美国陆军医学研究采购活动，820 Chandler Street，Fort Detrick MD 21702-5014，是授予和管理采购办公室。意见、解释、结论和建议是作者的观点、解释、结论和建议，不一定得到国防部的认可。此外，我们还要感谢国防部国会指导的医学研究计划 （CDMRP）、重建移植研究计划 （RTRP） 通过授予 W81XWH-17-1-0280、W81XWH-17-1-0624、W81XWH-17-1-0287 和 W81XWH18-1-0795 的支持。我们还要感谢整形与重建外科系和约翰霍普金斯大学医学院。此外，我们还要感谢全体兽医人员，包括 Melanie Adams、Karen Goss、Haley Smoot、Kayla Schonvisky 和 Victoria Manahan。

所有动物程序均按照约翰霍普金斯大学机构动物护理和使用委员会 （IACUC） 批准的动物协议进行。接受HC安置的雄性和雌性猪品系包括来自马萨诸塞州总医院（MGH）猪群的微型猪、尤卡坦猪和来自农业供应商的约克郡杂交猪（20-40公斤）。放置 HC 时，猪的年龄范围为 3-10 个月。HC可以相对于动物的实验程序随时放置。但是，建议事先放置它，以便收集基线血液值。还建议在进行任何实验操作之前给猪至少 1 周的适应期。
1. 术前规划
<ol><li>手术前，请兽医对所有动物进行彻底的临床评估。</li>
	<li>在手术前至少 12 小时禁食动物（无固体食物）。随时 随意 提供水。称量动物进行受控药物给药。</li>
	<li>在手术当天，用氯胺酮（20-30mg / kg）和甲苯噻嗪（2-3mg / kg肌内注射[IM]）混合到单个注射器中镇静动物。必要时，静脉缓慢给予镇静剂（氯胺酮和甲苯噻嗪）[IV]。在眼睛上使用无菌眼药膏，以防止麻醉时干燥。</li>
	<li>在整个手术过程中，将静脉导管放置在边缘耳静脉中，并以 5-10 mL/（kg∙h） 的 0.9% 生理盐水或乳酸林格溶液 （LRS） 给予维持液。</li>
	<li>当动物处于背卧位时，放置适当大小的气管插管，将其连接到麻醉机，并进行手部通气（以1-2L O2 / min保持0.5-3%的异氟醚）。</li>
	<li>给予先发制人的镇痛（0.02 mg/kg 丁丙诺啡静脉注射）;根据需要在术中给予额外剂量的丁丙诺啡。在手术开始前 10 分钟给予预防性抗生素（20-22 mg/kg 头孢唑林静脉注射），术中每 90 分钟一次。在手术开始前给予质子（0.5-1.0 mg/kg IV）和枸橼酸盐（1 mg/kg IV）一次。</li>
	<li>剃掉腹颈和背颈，这将作为放置中心静脉导管的部位。使用洗必泰磨砂膏对手术区域进行初步准备。</li>
	<li>确认猪在适当的手术麻醉平面内。通过测试睑和下颌张力来评估麻醉深度。如有必要，增加吸入麻醉剂或缓慢静脉注射额外的镇静剂（如氯胺酮）以起效。</li>
	<li>将猪转移到手术台上。</li>
</ol>2.术中监测
<ol><li>在维持麻醉下，持续监测心率和心电图、无创血压、脉搏血氧饱和度、二氧化碳图以及食管或直肠温度，至少每 15 分钟记录一次。<ol><li>通过四肢或尾部的血压袖带无创监测血压。</li>
		<li>使用呼吸机可以更准确地调节呼吸和吸入麻醉给药。对于呼吸机参数，确保潮气量在 5-10 mL/kg 范围内。在整个手术过程中根据动物的麻醉深度调整呼吸频率;将最大压力限制设置为 20 mmHg。</li>
	</ol></li>
	<li>在整个操作过程中使用温度调节的暖风毯或垫子，以防止体温过低。</li>
</ol>3. 手术准备
<ol><li>指定至少两个人是无菌的（外科医生和助手），至少两个人是非无菌的（循环员和麻醉师）。</li>
	<li>在全身麻醉下，将腹侧卧位的猪放在手术台上，其腿固定以稳定（图1）。</li>
	<li>用氯己定和70%乙醇的三次交替擦洗无菌制备手术区域，然后在皮肤表面使用离子载体，最短接触时间为10分钟。对以下两个区域进行无菌制备：<ol><li>在腹侧，从下颌骨的角度延伸到胸骨中部，并向双侧延伸至胸锁乳突骨的外侧缘。将无菌毛巾放在无菌准备区域的边界上。</li>
		<li>在背侧，准备与目标 IJV 同侧的背外侧颈部。将无菌毛巾放在背颈下方和背野上方，以便在腹侧野工作时保持无菌。</li>
	</ol></li>
	<li>在猪身上放上无菌的窗帘。在窗帘上切一个矩形区域，露出腹面。</li>
	<li>在单独的无菌工作台上，将双腔 HC 连接到一个长导引器上。<ol><li>将卡絮拧到每条管腔线末端的鲁尔锁适配器上（宽：红色;窄：白色）。用 10 mL 0.9% 生理盐水冲洗红线和白线。然后，夹住两条线。</li>
	</ol></li>
</ol>4. 颈内静脉识别与准备
<ol><li>在腹侧野，在气管和胸锁乳突肌的内侧边缘之间做一个4厘米的切口（图2）。分开颈阔肌并解剖结缔组织，以显示胸锁乳突肌外侧缘的 IJV。</li>
	<li>通过用 4-0 涂层和编织的不可吸收缝合扎带分隔其分支来隔离 3-4 厘米的 IJV。从周围的结缔组织进行圆周解剖。创建两个涂层和编织的不可吸收缝合带，以在导管插入过程中悬挂和稳定 IJV（图 3）。<ol><li>在 IJV 的颅端，将涂层和编织的不可吸收缝合带穿过血管下方两次，以在其周围形成一个环。</li>
		<li>在 IJV 的尾端，将涂层和编织的不可吸收缝合带穿过血管下方一次，以形成吊索。</li>
	</ol></li>
	<li>释放缝合系带的牵引力。将无菌盐水浸泡的纱布放在手术部位，以保护血管并保持系带位置。</li>
</ol>5.导管出口现场准备
<ol><li>通过向非手术侧侧倾斜重新定位猪，以暴露同侧背手术区域。重新固定四肢（图 4）。</li>
	<li>用#10刀片手术刀，在所需的导管出口部位（脊柱外侧3cm和头部尾部5cm）的皮肤上穿刺0.5cm（图5）。</li>
</ol>6. 导管的引入和隧道
<ol><li>在腹侧野，取下湿纱布并重新识别孤立的IJV段。选择目标进入部位，将导管皮下插入。确保其与 IJV 的深度相同，比胸锁乳突肌深，并且在两个涂层和编织的不可吸收缝合系带之间（图 6）。 注意：皮下图案应将缝合结埋在皮肤下方。由于深层真皮缝合线经过多次打结以确保稳定性和维护，因此它们偶尔会占用比预期更大的空间，并且可能会通过皮肤暴露。这个小面积的暴露区域并不是什么大问题，尽管暴露面积很小，但皮肤应该会适当愈合。</li>
	<li>将优势手置于背侧手术区域，将非优势手置于腹侧手术区域。将 HC 导引器放在背侧手术区域。将导管的剩余长度悬浮在无菌区域上方的空气中。</li>
	<li>用惯用手将导引器插入出口穿刺部位，将装置的尖端指向腹野中的非惯用手。</li>
	<li>向外表面和内侧推动导引器的尖端，使导管穿过脂肪组织，用非惯用手感觉尖端的出现。一旦尖端出现在目标入口部位，将导引器和导管拉过皮下隧道，直到主线的袖带刚好位于背野皮肤表面下方。</li>
	<li>从线路上剪下导引器。更换腹侧手术部位的湿纱布。</li>
</ol>7. 插入导管
<ol><li>将猪重新定位在仰卧位。重新固定四肢，更换无菌手套，并从腹侧手术部位取下纱布。</li>
	<li>夹住颅骨和尾部涂层和编织的不可吸收缝合系带的末端。将夹子放在窗帘上，使 IJV 段略微抬高。</li>
	<li>将导管的末端切成大约达到猪胸骨长度的 1/3 的长度。 注意： 通过垂直于管线的单切口横切尖端来最大限度地减少对导管尖端的操作，以避免管线碎裂或堵塞。一旦插入，HC应位于上腔静脉内，紧邻右心房的颅骨（图7）。</li>
	<li>使用 Adson-Brown 镊子，抓住离体 IJV 节段的中间。在同一点上，用弯曲的 Metzenbaum 剪刀在容器的中途切开。</li>
	<li>在用Adson-Brown镊子握住IJV段的同时，将静脉镐插入血管的尾段（图6）。在保持颅缝系带张力的同时，将导管末端插入血管尾部并穿入血管。导管完全插入后，将尾部缝合带打结一次以暂时固定 HC。</li>
	<li>使用 3-5 mL 0.9% 生理盐水，然后使用 5 mL 100 USP 单位/mL 肝素盐水抽血和冲洗，测试无菌野外两条管路的通畅性。</li>
	<li>确认通畅后，将尾部缝合线打结一到两次，以固定静脉导管周围的远端 IJV 段。将颅缝线打结一次，以阻塞 IJV 段的血流。</li>
	<li>分层闭合腹侧手术部位：颈阔肌简单间断缝合线，3-0编织可吸收缝合线，皮下线缝合线3-0单丝可吸收缝合线。</li>
</ol>8. 固定导管
<ol><li>解开猪的羽囊，重新定位在背卧位。重新固定四肢。</li>
	<li>将HC固定在动物皮肤上超过三个点，以避免导管脱落（图8）。<ol><li>调整 HC 的方向，使其形成“U”形。</li>
		<li>识别点：确保第一个点在出口部位 2 厘米以内，第二个点在导管的分叉部分上方，红线和白线发散，第三个点在前两点之间的“U”顶部。</li>
		<li>在每个点上，在导管上放置一条 ~3 厘米的 1 英寸（英寸）医用胶带，以在每侧形成一个翼。使用 0 合成、单丝、不可吸收的聚丙烯缝合线， 通过 简单的中断缝合线将每个翅膀固定在皮肤上。在分叉部分的第二个点，通过两条线之间的缝隙添加一条中断缝合线，并确保结位于胶带顶部以防止刺激。 注意：根据颈背穿刺部位的大小，可以放置简单的间断缝合线以减小尺寸并最大限度地降低导管意外移出皮肤的风险。确保导管周围的袖带保持皮下。</li>
		<li>使用 10 mL 0.9% 生理盐水和 10 mL 肝素盐水 通过 抽血和冲洗来测试无菌野外白线和红线的通畅性。</li>
	</ol></li>
	<li>创建一个保护项圈。<ol><li>用棉垫将 4 按以下方式缠绕在脖子上三到四次：<ol><li>从左颅角的背颈开始，沿对角线向右尾角缠绕，在红线和白线的上方或下方。将脖子下方缠绕到左尾角。沿对角线向右颅角缠绕，在红线和白线的上方或下方，然后缠绕到左颅角的起点。在随后的每次换行中交替在红线和白线的上方和下方。 注意： 项圈应完全覆盖皮肤附着部位和 HC 的主线。只有红线和白线应该被省略和访问。</li>
		</ol></li>
		<li>用弹性胶带将 3 或 4 用弹性胶带缠绕在脖子上三到四次，方法与棉垫相同（步骤 8.4.1）。如果绷带覆盖了线条，请在绷带上开一个缝隙以容纳它们。 注意： 注意不要将这一层包裹得太紧——手指应该能够轻松地在保护环下圆周滑动。</li>
		<li>使用 0 合成、单丝、不可吸收的聚丙烯缝合线，将绷带末端的每个角缝合到下层以保持其位置。</li>
		<li>使用 0 合成、单丝、不可吸收的聚丙烯缝合线，通过在颅端和尾端的脊柱外侧系上水平床垫缝合线，将衣领固定在皮肤上。确保结位于绷带的顶部。</li>
		<li>创建一个导管袋来保护和储存红线和白线（图9）。<ol><li>剪一块长 ~100 厘米、宽 ~7.5 厘米的弹性胶带。</li>
			<li>测量 ~16 厘米的卷尺段。将胶带自行折叠，使粘合面彼此相对，以用两层胶带形成一个 16 厘米的翻盖。使用剩余的胶带，再重复此过程两次，以创建三个长度相等的“W”形襟翼（图10）。</li>
			<li>将胶带的剩余尾部折叠在三个襟翼的边缘上。尾巴朝向顶部，从上到下对襟翼编号 1-3。将边编号为 1-4，从尾边缘开始并顺时针移动。</li>
			<li>在第 4 侧，从翻盖 2 上取下一条纵向条，两端不包括 1 厘米。确保条子的宽度为 ~1 厘米。</li>
			<li>使用 0 涂层和编织的不可吸收缝合线进行连续缝合：将第 1 侧的襟翼 3 和第 4 侧缝合在一起，将第 1 侧的襟翼 3、2 和 3 缝合在一起，将第 1 侧的襟翼 2 和第 2 侧缝合在一起。在襟翼 2 的中心切一个 1 厘米的孔。</li>
		</ol></li>
		<li>将翻盖 1 朝下，将孔与线条离开衣领的点对齐，并调整袋子的方向，使开口呈尾部。确保袋子位于中线或略微偏侧到颈背侧。</li>
		<li>将红线和白线穿过翻盖 1 中的孔。确保襟翼 1 和 2 之间的线平放，襟翼 3 朝上（图 8）。</li>
		<li>使用 0 合成、单丝、不可吸收的聚丙烯缝合线，在每个角和每个边缘的中间用简单的中断缝合线将袋子固定到衣领上。不要通过皮肤缝合。</li>
	</ol></li>
</ol>9. 术后护理
<ol><li>从麻醉中恢复后，将猪放回笼子。由于猪的咀嚼性质，请确保猪是单独饲养的，以防止同种猪拔除导管。如果饲养在其他猪旁边，请放置屏障以防止笼子之间的导管咀嚼。</li>
	<li>在术后即刻，至少每天监测动物是否有疼痛、感染和愈合的迹象。呼吸频率、心率、体温、能量、食欲和饮水量是这段时间的良好健康指标。如果出现疼痛迹象，给予额外剂量的镇痛药（例如，每 48 小时 0.12 mg/kg 丁丙诺啡缓释 [SR] LAB）。从术后第 1 天 （POD） 开始，每天对手术部位进行导管维护（第 10 步）和目视检查。 注意：选择采用这种 Hickman 导管插入技术的研究人员可以通过多模式镇痛来修改此程序;然而，非甾体抗炎药可能会根据实验设计的其他要素改变研究结果。在计划镇痛方案之前，应考虑这一点。</li>
	<li>导管手术部位愈合后，对动物进行维护监测检查：每周进行体重测量，并在日常导管维护期间进行目视检查。如果出现食欲下降或精力下降等感染迹象，请咨询兽医。如果需要全血细胞计数，请从红线采集血液。 注：在感染动物中经常观察到以中性粒细胞增多为特征的白细胞增多症。</li>
</ol>10.导管保养
<ol><li>指定较宽的红线专门用于抽血，较窄的白线专门用于药物给药。始终用戴手套的手处理导管。 注：这些作用可能因研究设计而异。</li>
	<li>每天冲洗红色（指定抽血）线，以评估通畅情况并防止凝血，如下所示：<ol><li>使用无菌技术：在每个步骤之间用酒精垫擦拭灭菌剂和注射器尖端。如果灭菌剂或注射器变得无菌，请在继续之前更换受污染的材料。</li>
		<li>将 1 mL 0.9% 生理盐水冲入管路中。确认液体能够在不用力的情况下冲洗，以防止将凝块从管路推入动物体内。</li>
		<li>抽回 2 mL 液体。通过观察拉回的液体是暗红色血液来确认线通畅。</li>
		<li>如果需要抽血，连接一个空注射器以抽回适量的血液。 注意：如果抽取了多余的血液，可以通过将血液推回管线来将血液回流给动物，以减少失血。只有当装有血液的注射器继续使用无菌技术处理时，才应这样做。不要将受污染的血液放回中心导管。</li>
		<li>用 5 mL 100 USP/mL 肝素盐水冲洗管路，或冲洗整个管路所需的量。夹紧线。将线放回保护袋中，注意不要扭结或打结线。</li>
	</ol></li>
	<li>每天冲洗白色（设计给药）管线，以评估通畅性并防止凝血，如下所示：<ol><li>使用无菌技术：在每个步骤之间用酒精垫擦拭腌盘和注射器尖端。如果灭菌剂或注射器变得无菌，请在继续之前更换受污染的材料。</li>
		<li>将 1 mL 0.9% 生理盐水冲入管路中。确认液体能够在不用力的情况下冲洗，以防止将凝块从管路推入动物体内。</li>
		<li>使用此管线以特定于药物的速度和稀释度给药。在两次用药之间用 1-3 mL 0.9% 生理盐水冲洗管路。</li>
		<li>用 5 mL 100 USP/mL 肝素盐水冲洗管路，或冲洗整个管路所需的量。夹紧线。将线放回保护袋中，注意不要扭结或打结线。</li>
	</ol></li>
	<li>每天检查蒲团是否有功能障碍、破损或明显被血液、食物或粪便污染的迹象。如果是这样，请立即更换拨片。每天目视检查 Hickman 袋和保护项圈，以确保在步骤 8.2 和 8.3 中放置的缝合线保持完整。</li>
</ol>

用于猪长期血管通路的 Hickman 导管

<ol>
	<li>Pontes, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incidents+related+to+the+Hickman&#174;+catheter:+identification+of+damages.">Incidents related to the Hickman&#174; catheter: identification of damages.</a> Revista Brasileira de Enfermagem. 71 (4), 1915-1920 (2018).</li><li>Kolikof, J., Peterson, K., Baker, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Central+Venous+Catheter.">Central Venous Catheter.</a> StatPearls. , (2022).</li><li>Central venous catheters: how, when, why? (Proceedings). DVM 360 Available from: <a target="_blank" href="https://www.dvm360.com/view/central-venous-catheters-how-when-why-proceedings">https://www.dvm360.com/view/central-venous-catheters-how-when-why-proceedings</a> (2011)</li><li>Abrams-Ogg, A. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+an+implantable+central+venous+(Hickman)+catheter+for+long-term+venous+access+in+dogs+undergoing+bone+marrow+transplantation.">The use of an implantable central venous (Hickman) catheter for long-term venous access in dogs undergoing bone marrow transplantation.</a> Canadian Journal of Veterinary Research. 56 (4), 382-386 (1992).</li><li>Florescu, M. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+technique+of+placement+of+an+external+jugular+tunneled+hemodialysis+catheter+in+a+large+pig+model.">Surgical technique of placement of an external jugular tunneled hemodialysis catheter in a large pig model.</a> The Journal of Vascular Access. 19 (5), 473-476 (2018).</li><li>. Central Venous Catheter Placement: Modified Seldinger Technique Available from: <a target="_blank" href="https://www.cliniciansbrief.com/article/central-venous-catheter-placement-modified-seldinger-technique">https://www.cliniciansbrief.com/article/central-venous-catheter-placement-modified-seldinger-technique</a> (2015)</li><li>Perondi, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bacterial+colonization+of+non-permanent+central+venous+catheters+in+hemodialysis+dogs.">Bacterial colonization of non-permanent central venous catheters in hemodialysis dogs.</a> Heliyon. 6 (1), e03224 (2020).</li><li>Faulkner, R. T., Czajkowski, W. P., Rayfield, E. J., Hickman, R. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technique+for+portal+catheterization+in+rhesus+monkeys+(Macaca+mulatta).">Technique for portal catheterization in rhesus monkeys (Macaca mulatta).</a> American Journal of Veterinary Research. 37 (4), 473-475 (1976).</li><li>Moss, J. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Central+venous+access+devices+for+the+delivery+of+systemic+anticancer+therapy+(CAVA):+a+randomised+controlled+trial.">Central venous access devices for the delivery of systemic anticancer therapy (CAVA): a randomised controlled trial.</a> Lancet. 398 (10298), 403-415 (2021).</li><li>Dai, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+tunneled+and+nontunneled+peripherally+inserted+central+catheter+placement:+A+randomized+controlled+trial.">Effect of tunneled and nontunneled peripherally inserted central catheter placement: A randomized controlled trial.</a> The Journal of Vascular Access. 21 (4), 511-519 (2020).</li><li>Wu, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Tunneled+peritoneal+catheter+vs+repeated+paracenteses+for+recurrent+ascites:+a+cost-effectiveness+analysis.">Tunneled peritoneal catheter vs repeated paracenteses for recurrent ascites: a cost-effectiveness analysis.</a> Cardiovascular and Interventional Radiology. 45 (7), 972-982 (2022).</li><li>Onwubiko, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Small+tunneled+central+venous+catheters+as+an+alternative+to+a+standard+hemodialysis+catheter+in+neonatal+patients.">Small tunneled central venous catheters as an alternative to a standard hemodialysis catheter in neonatal patients.</a> Journal of Pediatric Surgery. 56 (12), 2219-2223 (2021).</li><li>da Silva, S. R., Reichembach, M. T., Pontes, L., de Souza, G. d. e. P. E. S. C. M., Kusma, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Heparin+solution+in+the+prevention+of+occlusions+in+Hickman&#174;+catheters+a+randomized+clinical+trial.">Heparin solution in the prevention of occlusions in Hickman&#174; catheters a randomized clinical trial.</a> Revista Latino-Americana de Enfermagem. 29, e3385 (2021).</li><li>Landoy, Z., Rotstein, C., Lucey, J., Fitzpatrick, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hickman-Broviac+catheter+use+in+cancer+patients.">Hickman-Broviac catheter use in cancer patients.</a> Journal of Surgical Oncology. 26 (4), 215-218 (1984).</li><li>Bawazir, O. A., Altokhais, T. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hickman+central+venous+catheters+in+children:+open+versus+percutaneous+technique.">Hickman central venous catheters in children: open versus percutaneous technique.</a> Annals of Vascular Surgery. 68, 209-216 (2020).</li><li>Cappello, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Central+venous+access+for+haemodialysis+using+the+Hickman+catheter.">Central venous access for haemodialysis using the Hickman catheter.</a> Nephrology Dialysis Transplantation. 4 (11), 988-992 (1989).</li><li>Shastri, L., Kj&#230;rgaard, B., Rees, S. E., Thomsen, L. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Changes+in+central+venous+to+arterial+carbon+dioxide+gap+(PCO2+gap)+in+response+to+acute+changes+in+ventilation.">Changes in central venous to arterial carbon dioxide gap (PCO2 gap) in response to acute changes in ventilation.</a> BMJ Open Respiratory Research. 8 (1), e000886 (2021).</li><li>Smith, A. C., Swindle, M. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preparation+of+swine+for+the+laboratory.">Preparation of swine for the laboratory.</a> ILAR Journal. 47 (4), 358-363 (2006).</li><li>Swindle, M. M., Makin, A., Herron, A. J., Clubb, F. J., Frazier, K. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Swine+as+models+in+biomedical+research+and+toxicology+testing.">Swine as models in biomedical research and toxicology testing.</a> Veterinary Pathology. 49 (2), 344-356 (2012).</li><li>Hughes, H. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Swine+in+cardiovascular+research.">Swine in cardiovascular research.</a> Laboratory Animal Science. 36 (4), 348-350 (1986).</li><li>Svendsen, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+minipig+in+toxicology.">The minipig in toxicology.</a> Experimental and Toxicologic Pathology. 57 (5-6), 335-339 (2006).</li><li>Tumbleson, M. E., Schook, L. 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(80), e50475 (2013).</li><li>Nordstr&#246;m, C. -. H., Jakobsen, R., M&#248;lstr&#248;m, S., Nielsen, T. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cerebral+venous+blood+is+not+drained+via+the+internal+jugular+vein+in+the+pig.">Cerebral venous blood is not drained via the internal jugular vein in the pig.</a> Resuscitation. 162, 437-438 (2021).</li><li>Habib, C. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=MR+imaging+of+the+yucatan+pig+head+and+neck+vasculature.">MR imaging of the yucatan pig head and neck vasculature.</a> Journal of Magnetic Resonance Imaging. 38 (3), 641-649 (2013).</li><li>Flournoy, W. 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(126), e55238 (2017).</li><li>Chuang, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+external+catheters+with+subcutaneous+vascular+access+ports+for+chronic+vascular+access+in+a+porcine+model.">Comparison of external catheters with subcutaneous vascular access ports for chronic vascular access in a porcine model.</a> Contemporary Topics in Laboratory Animal Science. 44 (2), 24-27 (2005).</li></ol>

所有作者均未对本手稿中提到的任何产品、设备或药物有任何经济利益。

虽然CVC在大型动物研究中具有一系列功能，但目前的文献缺乏在30天以上的长期试验中安全和可持续使用的共识方法。该协议的 HC 插入、皮肤固定和储存在手工袋中的分步程序经过重大调整，以提高质量。因此，该协议提出了一种 HC 使用技术，该技术允许高效和有效的静脉通路，同时确保动物福利并最大限度地减少并发症。
该协议的临床和研究应用 猪被用于?...

中心静脉导管 （CVC） 在患者护理中不可或缺的作用归功于其便利性、良好的安全性和多功能性1。CVC 的功能包括可靠的全肠外营养、造血干细胞移植、血浆置换/单采术以及高效的液体、血液或联合给药2。在兽医学中，CVC 还 通过 快速稀释刺激性药物和无需重复静脉穿刺的血液采样来最大限度地减少动物不适3.尽管CVCs具有广泛的应用，但在大型动物研究中的使用仍然面临一些相当大的挑战4。
对于非兽医研究人员来说，通过导丝或导引导管经皮 CVC 放置可能很困难，尤其是在具有深静脉结构的动物中5.不正确的 CVC 安装技术可能会导致无意中放置在附近的结构中，因此需要超声引导放置或术后 X 线照相定位6.然而，与人类手术室相比，超声波在许多大型动物研究实验室中并不容易获得。此外，长期使用留置导尿管可导致动物扭结、穿刺、感染或解救，并可能破坏及时治疗、临床监测和研究结果 4,7。更换 CVC 需要额外的资源，包括材料采购、手术安排、禁食时间和影像学通路。因此，CVC相关的并发症会造成重大的技术和财务障碍，或对富有成效的转化研究造成干扰，特别是在猪中。食物或粪便污染、抓挠笼壁和踢刺激部位可能会损害 CVC，长期使用会放大 CVC 相关并发症的风险。因此，在猪中安全、简单地维护 CVC 需要仔细考虑 CVC 的选择、放置、固定、保护、卫生和监测。
本协议中使用的希克曼导管 （HC） 是一种带有聚酯袖带和一至三腔的隧道式 CVC，通常用于人类和动物的长期静脉通路 1,4,8,9。与非隧道式变异相比，隧道式导管入路的并发症发生率和维护成本较低10,11,12。袖带通过融入皮肤出口部位周围的皮下组织来减少 HC 解救。多腔设计还可以将给药和抽血分开，从而最大限度地减少血液样本污染和不准确。尽管如此，HC 的使用并非没有挑战，其中最常见的包括骨折、迁移、闭塞和感染13,14,15,16。因此，在转化研究中使用时，正确安装和维护 HC 是必不可少的技能。然而，目前的文献几乎没有为长期试验期间在猪中使用HC的最佳实践提供指导5,6,17。
本研究的目的是概述一种优化的方法，用于将 HC 插入颈内静脉 （IJV）、皮肤固定和持久保护，以最大限度地减少猪的长期导管相关并发症和不适。本文讨论了 HC 使用的重要考虑因素、可能遇到的潜在挑战以及可能提高该方法质量的修改。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>#10 blade</td>
			<td>Medline</td>
			<td>MDS15110</td>
			<td></td>
		</tr>
		<tr>
			<td>0.9% Sterile Sodium Chloride</td>
			<td>Baxter&#160;</td>
			<td>2F7123</td>
			<td></td>
		</tr>
		<tr>
			<td>0-0 Coated and Braided Nonabsorbable Suture</td>
			<td>Covidien</td>
			<td>S-196</td>
			<td></td>
		</tr>
		<tr>
			<td>0-0 Synthetic, Monofilament, Nonabsorbable Polypropylene Suture</td>
			<td>Ethicon</td>
			<td>8690H</td>
			<td></td>
		</tr>
		<tr>
			<td>1 inch Medical Tape</td>
			<td>3M</td>
			<td>1548S-1</td>
			<td></td>
		</tr>
		<tr>
			<td>10 USP units/mL Heparin flush</td>
			<td>Becton, Dickinson and Company</td>
			<td>306424</td>
			<td></td>
		</tr>
		<tr>
			<td>3-0 Braided Absorbable Suture</td>
			<td>Covidien</td>
			<td>SL-636 (cutting needle), GL-122 (taper needle)</td>
			<td></td>
		</tr>
		<tr>
			<td>3-0 Monofilament Absorbable Suture</td>
			<td>Covidien</td>
			<td>SM-922 (cutting needle), CM-882 (taper needle)</td>
			<td></td>
		</tr>
		<tr>
			<td>4-0 Coated and Braided Non-absorbable Suture Ties</td>
			<td>Ethicon</td>
			<td>A303H</td>
			<td></td>
		</tr>
		<tr>
			<td>70% Ethanol</td>
			<td>Vedco</td>
			<td>VINV-IPA7</td>
			<td></td>
		</tr>
		<tr>
			<td>Adson tissue forceps</td>
			<td>MPM Medical Supply</td>
			<td>132-508</td>
			<td></td>
		</tr>
		<tr>
			<td>Adson-Brown forceps</td>
			<td>MPM Medical Supply</td>
			<td>106-2572</td>
			<td></td>
		</tr>
		<tr>
			<td>Air warming blanket and pad</td>
			<td>3M Bair Hugger</td>
			<td>UPC 00608223595770</td>
			<td></td>
		</tr>
		<tr>
			<td>Backhaus towel clamp</td>
			<td>MPM Medical Supply</td>
			<td>117-5508</td>
			<td></td>
		</tr>
		<tr>
			<td>Brown needle holder</td>
			<td>MPM Medical Supply</td>
			<td>110-1513</td>
			<td></td>
		</tr>
		<tr>
			<td>Buprenorphine</td>
			<td>PAR Pharmaceutical</td>
			<td>3003408B</td>
			<td></td>
		</tr>
		<tr>
			<td>Cefazolin</td>
			<td>Hikma Farmacuetica (Portugal)</td>
			<td>PLB 133-WES/1</td>
			<td></td>
		</tr>
		<tr>
			<td>Chlorhexidine</td>
			<td>Vet One</td>
			<td>501027</td>
			<td></td>
		</tr>
		<tr>
			<td>Clave</td>
			<td>Baxter</td>
			<td>7N8399</td>
			<td></td>
		</tr>
		<tr>
			<td>Cotton Padding</td>
			<td>Medline</td>
			<td>NON6027</td>
			<td></td>
		</tr>
		<tr>
			<td>Debakey forceps</td>
			<td>MPM Medical Supply</td>
			<td>106-5015</td>
			<td></td>
		</tr>
		<tr>
			<td>Elastic Adhesive Bandage Tape</td>
			<td>3M</td>
			<td>XH002016489</td>
			<td></td>
		</tr>
		<tr>
			<td>Halstead mosquito forceps</td>
			<td>MPM Medical Supply</td>
			<td>115-4612</td>
			<td></td>
		</tr>
		<tr>
			<td>Hickman Catheter</td>
			<td>Bard Access Systems</td>
			<td>603710</td>
			<td></td>
		</tr>
		<tr>
			<td>Hickman Catheter Repair Kit, 7Fr, Red and White Connectors</td>
			<td>Bard Access Systems</td>
			<td>0601690 (red), 0601680 (white), 502017</td>
			<td></td>
		</tr>
		<tr>
			<td>Kelly hemostatic forceps</td>
			<td>MPM Medical Supply</td>
			<td>115-7014</td>
			<td></td>
		</tr>
		<tr>
			<td>Ketamine</td>
			<td>Vet One</td>
			<td>383010-03</td>
			<td></td>
		</tr>
		<tr>
			<td>Lactated Ringers</td>
			<td>Baxter</td>
			<td>2B2324X</td>
			<td></td>
		</tr>
		<tr>
			<td>Maropitant Citrate</td>
			<td>Zoetis</td>
			<td>106</td>
			<td></td>
		</tr>
		<tr>
			<td>Mayo scissors</td>
			<td>MPM Medical Supply</td>
			<td>103-5014</td>
			<td></td>
		</tr>
		<tr>
			<td>Metzenbaum scissors</td>
			<td>MPM Medical Supply</td>
			<td>132-711</td>
			<td></td>
		</tr>
		<tr>
			<td>Pantoprazole</td>
			<td>JH Pharmacy</td>
			<td>NDC 0143-9284-10</td>
			<td></td>
		</tr>
		<tr>
			<td>Scalpel blade handle</td>
			<td>Medline</td>
			<td>MDS10801</td>
			<td></td>
		</tr>
		<tr>
			<td>Vein Pick</td>
			<td>SAI infusion technologies</td>
			<td>VP-10</td>
			<td></td>
		</tr>
		<tr>
			<td>Veterinary Ophthalmic Ointment</td>
			<td>Dechra</td>
			<td>IS4398</td>
			<td></td>
		</tr>
		<tr>
			<td>Xylazine</td>
			<td>Vet One</td>
			<td>510004</td>
			<td></td>
		</tr>
	</tbody>
</table>

hickman catheter use for long-term vascular access in a preclinical swine model

中心静脉导管 （CVC） 是大型动物研究中的宝贵设备，因为它们促进了广泛的医疗应用，包括血液监测和可靠的静脉输液和药物管理。具体来说，隧道式多腔希克曼导管 （HC） 因其较低的解救率和并发症发生率而常用于猪模型。尽管与其他CVC相比，并发症较少，但HC相关发病率仍然是一个重大挑战，因为它会显着延迟或以其他方式对正在进行的研究产生负面影响。正确插入和维护 HC 对于预防这些并发症至关重要，但尚未就最佳实践达成共识。该协议的目的是全面描述在猪中插入和维持隧道式 HC 的方法，以减轻 HC 相关并发症和发病率。在 >100 头猪中使用这些技术可使专利线长达 8 个月无并发症，并且没有与导管相关的死亡或腹侧手术部位感染。该协议提供了一种优化 HC 寿命的方法，并为在使用过程中处理问题提供了指导。

The indispensable role of central venous catheters (CVCs) in patient care is owed to their convenience, favorable safety profile, and versatility1. Functions of a CVC include reliable access for total parenteral nutrition, hematopoietic stem cell transplantation, plasmapheresis/apheresis, and efficient fluid, blood, or co-drug administration2. In veterinary medicine, CVCs also minimize animal discomfort via the rapid dilution of irritant drugs and blood sampling without repeated venipuncture3. Despite their broad applications, the use of CVCs in large animal research still presents several considerable challenges4.
Percutaneous CVC placement via a guidewire or introducer catheter can be difficult for non-veterinary researchers, particularly in animals with deep venous structures5. An improper CVC installation technique may result in inadvertent placement into nearby structures, necessitating ultrasound-guided placement or a postprocedure radiography of the positioning6. However, compared to human operating rooms, ultrasounds are not readily available in many large animal research laboratories. Further, long-term use of indwelling catheters can result in line kinking, puncture, infection, or extrication by animals, with the possible disruption of timely treatment, clinical monitoring, and research outcomes4,7. Replacement of the CVC requires additional resources, including material procurement, surgical scheduling, fasting time, and radiographic access. CVC-related complications can therefore create significant technical and financial barriers or a disruption to productive translational research, particularly in swine. Contamination by food or feces, scratching against cage walls, and kicking sites of irritation may compromise a CVC, and the risk of CVC-related complications is amplified by long-term use. Thus, safe and uncomplicated maintenance of a CVC in swine requires careful consideration of CVC choice, placement, securement, protection, sanitation, and surveillance.
The Hickman catheter (HC) used in this protocol is a tunneled CVC with a polyester cuff and one to three lumens, that is commonly used for long-term intravenous access in humans and animals1,4,8,9. The tunneled catheter approach has been associated with lower complication rates and maintenance costs relative to non-tunneled variations10,11,12. The cuff reduces HC extrication by incorporating into the subcutaneous tissues surrounding the skin exit site. The multi-lumen design also enables the separation of medication administration and blood draws, thereby minimizing blood sample contamination and inaccuracy. Despite this, HC use is not without challenges, the most common of which include fracture, migration, occlusion, and infection13,14,15,16. Proper installation and maintenance of a HC are therefore indispensable skills when used in translational research. However, the current literature offers little guidance for best-practices for HC use in swine during long-term trials5,6,17.
The purpose of this study is to outline an optimized approach for HC insertion into the internal jugular vein (IJV), skin securement, and durable protection that minimizes long-term catheter-related complications and discomfort in swine. A discussion of the important considerations for HC use, potential challenges that may be encountered, and modifications that may improve the quality of this approach is included.

作者聚焦：Hickman 导管在临床前猪模型中用于长期血管通路  

Hickman 导管在临床前猪模型中用于长期血管通路

This protocol describes a reliable and reproducible technique for the insertion and maintenance of a tunnel Hickman catheter for long-term vascular access in a large animal model. The approach allows for convenient daily sampling of whole blood from awake animals and intravenous administration of medication and fluids. Some of the main challenges to the long-term central venous lines in large animals are infection and damages.As large animals are occasionally able to gain access to the lines and cause mechanical trauma. To mitigate these challenges, our group has invented our special pouches that protects the line while still allowing easy access to the same catheter. Central venous catheters are invaluable devices in large animal research as they facilitate a wide range of medical applications, but there is no consensus on the best practices for their insertion and maintenance.In response, we have proposed a protocol that comprehensively describes an approach for proper placement of a tunneled Hickman catheter in pigs that minimizes catheter-related complications and morbidity. The use of our approach in over 100 pigs has resulted in long-term patency and minimal complication rates. This protocol offers a method to optimize the lifespan of the Hickman catheter, and guidance for approaching issues during its use.

超过100头猪在我们的实验室中成功进行了HC插入。HC 可以在 1 小时内由外科医生、助手、循环器和麻醉师安全正确地放置和固定。导管袋大约需要 15-20 分钟才能制作。该技术简单明了且易于教授，并由兽医、外科住院医师和医学生按照监督指示进行。
HC 已在原位放置长达 8 个月，没有并发症或翻修。在最近一个包含32头猪的代表性队列中，终点范围为8至132天，78.13%的HC在实验...

Watch this Scientific Journal Video about Hickman Catheter Use for Long-Term Vascular Access in a Preclinical Swine Model at JoVE.com

描述了一种可靠且可重复的方法，用于插入和维护隧道式 Hickman 导管，用于猪的长期血管通路。放置中心静脉导管可以方便地每天从清醒的动物身上取样全血，并静脉注射药物和液体。

Central venous catheters (CVCs) are invaluable devices in large animal research as they facilitate a wide range of medical applications, including blood ...

该协议描述了一种可靠且可重复的技术，用于在大型动物模型中插入和维护用于长期血管通路的隧道Hickman导管。该方法允许方便地每天从清醒的动物身上取样全血，并静脉注射药物和液体。大型动物长期中心静脉管路面临的一些主要挑战是感染和损伤。由于大型动物偶尔能够接触到线路并造成机械创伤。为了缓解这些挑战，我们团队发明了我们的特殊袋子，可以保护管路，同时仍然可以轻松访问同一根导管。中心静脉导管是大型动物研究中的宝贵设备，因为它们促进了广泛的医疗应用，但对其插入和维护的最佳实践尚未达成共识。作为回应，我们提出了一种方案，该方案全面描述了一种在猪中正确放置隧道式希克曼导管的方法，该方法可最大限度地减少与导管相关的并发症和发病率。在100多头猪中使用我们的方法已经实现了长期通畅和最小的并发症发生率。该协议提供了一种优化希克曼导管寿命的方法，以及在其使用过程中处理问题的指南。

hickman-catheter-use-for-long-term-vascular-access-preclinical-swine

Research

JoVE Journal

Medicine

Hickman Catheter Use for Long-Term Vascular Access in a Preclinical Swine Model

2.5K 次观看.  Johns Hopkins University School of Medicine. 该协议描述了一种可靠且可重复的技术，用于在大型动物模型中插入和维护用于长期血管通路的隧道Hickman导管。该方法允许方便地每天从清醒的动物身上取样全血，并静脉注射药物和液体。大型动物长期中心静脉管路面临的一些主要挑战是感染和损伤。由于大型动物偶尔能够接触到线路并造成机械创伤。为了缓解这些挑战，我们团队发明了我们的特殊袋子，可以保护管...

视频: 作者聚焦：Hickman 导管在临床前猪模型中用于长期血管通路  

Central venous catheters (CVCs) are invaluable devices in large animal research as they facilitate a wide range of medical applications, including blood monitoring and reliable intravenous fluid and drug administration. Specifically, the tunneled multi-lumen Hickman catheter (HC) is commonly used in swine models due to its lower extrication and complication rates. Despite fewer complications relative to other CVCs, HC-related morbidity presents a significant challenge, as it can significantly delay or otherwise negatively impact ongoing studies. The proper insertion and maintenance of HCs is paramount in preventing these complications, but there is no consensus on best practices. The purpose of this protocol is to comprehensively describe an approach for the insertion and maintenance of a tunneled HC in swine that mitigates HC-related complications and morbidity. The use of these techniques in &gt;100 swine has resulted in complication-free patent lines up to 8 months and no catheter-related mortality or infection of the ventral surgical site. This protocol offers a method to optimize the lifespan of the HC and guidance for approaching issues during use.

A reliable and reproducible approach for the insertion and maintenance of a tunneled Hickman catheter for long-term vascular access in swine is described. Placement of a central venous catheter allows for convenient daily sampling of whole blood from awake animals and intravenous administration of medication and fluids.

科研

医学

Internal Jugular Vein Identification and Catheter Exit Site Preparation

To begin, place the anesthetized swine on the operating table. In the ventral field, make a four-centimeter incision between the trachea and the medial border of the sternocleidomastoid muscle. Divide the platysma and dissect the connective tissue to expose the internal jugular vein, or IJV, on the lateral border of the sternocleidomastoid muscle.Then isolate three to four centimeters of the IJV by dividing its branches with 4.0 coated and braided non-absorbable suture ties. Circumferentially dissect away from the surrounding connective tissue. At the cranial end of the IJV, pass a coated and braided non-absorbable suture tie twice underneath the vessel to create a loop around it.At the coddle end, pass a suture tie once underneath the vessel to create a sling. For catheter exit site preparation. Reposition the swine via lateral tilt toward the non-surgical side to expose the ipsilateral dorsal surgical field.Once the limbs are resecured, with a number 10 blade scalpel, make a 0.5 centimeter puncture in the skin at the desired catheter exit site, three centimeters lateral to the vertebral column, and five centimeter coddle to the head.

颈内静脉识别和导管出口部位准备

Introduction and Tunneling of Catheter

For tunneling of the catheter, remove the wet gauze and reidentify the isolated IJV segment, then choose a target entry site for catheter introduction subcutaneously at the same depth as the IJV, deeper than the sternocleidomastoid, and between the two coated and braided non-absorbable suture ties. Hold the Hickman catheter introducer in the dominant hand in the dorsal surgical field and suspend the remaining length of the catheter in the air above the sterile field. The non-dominant hand should be in the ventral surgical field.Insert the introducer into the exit puncture site with the dominant hand, pointing the tip of the device toward the non-dominant hand in the ventral field. Push the tip of the introducer superficially and medially to tunnel the catheter through the adipose tissue, feeling for the emergence of the tip with a non-dominant hand. Once the tip emerges at the target entry site, pull the introducer and catheter through the subcutaneous tunnel until the cuff of the main line is just underneath the surface of the skin of the dorsal field.

导管的引入和隧道

Insertion and Securing the Catheter

Cut the end of the catheter to approximately the length at which it would reach down to one third of the length of the swine's sternum. Using Adson-Brown forceps, grasp the middle of the isolated IJV segment and make a cut halfway through the vessel with curved Metzenbaum scissors. While holding the IJV segment, insert the vein pick into the caudal segment of the vessel.While maintaining tension on the cranial suture tie. Insert and thread the end of the catheter into the vessel caudally. Once the catheter is fully inserted, knot the caudal suture tie once to temporarily secure the Hickman catheter.Once patency is confirmed, knot the caudal suture tie twice to secure the distal IJV segment around the intravenous catheter. Then knot the cranial suture tie once to occlude blood flow in the IJV segment. Once done to close the ventral surgical site, first suture platysma simple interrupted sutures with a 3-0 braided absorbable suture.Then close subcuticular running sutures with a 3-0 monofilament absorbable suture. To secure the Hickman catheter to the animal's skin, orient the Hickman catheter so that it forms a U shape. Then identify three points.The first point is within two centimeters of the exit site. The second point is over the forked portion of the catheter where the red and white lines diverge. And the third point is at the top of the U between the first two points.At each point, place a three centimeter piece of one inch medical tape over the catheter to create a wing on each side. With a O synthetic monofilament, non-absorbable polypropylene suture, secure each wing to the skin via a single simple interrupted suture. At the second point over the forked portion, add a single interrupted suture through the gap between the two lines and ensure that the knot lies on top of the tape to prevent irritation.Test the patency of the white and red lines outside the sterile field via blood draws and flushes using 10 milliliters of 0.9%normal saline and 10 milliliters of heparinized saline. Once the catheter pouch with the desired number of flaps is created, align the hole and flap one with the point where the lines exit the collar, orienting it so that it's opening is caudal. Ensure the pouch is on the midline or slightly lateral to the dorsal neck.Then pull the red and white lines through the hole and flap one, ensuring the lines lay flat between flaps one and two with flap three facing up. Using a 0 synthetic monofilament, non-absorbable polypropylene suture, secure the pouch to the collar with a simple interrupted suture at each corner and midway along each end. Do not suture through the skin.In a representative cohort of 32 swine with endpoint ranging from eight to 132 days, 78.13 of Hickman catheters remained patent until the experimental endpoint. Small repairs were required in 9.38%of cases, while rates of removal or replacement before and after 30 days were 9.38%and 12.5%respectively. Reasons for line compromises included displacement, puncture, and internal blockage.However, timely repair and replacement demonstrated a 100%functional success rate without significant interference with data collection.