Name: Author Spotlight: Hickman Catheter Use for Long-Term Vascular Access in a Preclinical Swine Model
Uploaded: 2023-03-31T14:00:00
Description: Watch this Scientific Journal Video about Hickman Catheter Use for Long-Term Vascular Access in a Preclinical Swine Model at JoVE.com

We would like to acknowledge the support of the Army, Navy NIH, Air Force, VA, and Health Affairs regarding the AFIRM II effort under award CTA05: W81XWH-13-2-0052 and CTA06: W81XWH-13-2-0053. The U.S. Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick MD 21702-5014, is the awarding and administering acquisition office. Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the Department of Defense. In addition, we would like to acknowledge support from the Department of Defense Congressionally Directed Medical Research Programs (CDMRP), Reconstructive Transplantation Research Program (RTRP), through awards W81XWH-17-1-0280, W81XWH-17-1-0624, W81XWH-17-1-0287, and W81XWH18-1-0795. We would also like to acknowledge the Department of Plastic and Reconstructive Surgery and the Johns Hopkins University School of Medicine. Additionally, we would like to acknowledge the entire veterinary staff, including Melanie Adams, Karen Goss, Haley Smoot, Kayla Schonvisky, and Victoria Manahan.

All animal procedures were conducted in accordance with an animal protocol approved by the Johns Hopkins University Institutional Animal Care and Use Committee (IACUC). Strains of male and female swine undergoing HC placement include miniature swine from the Massachusetts General Hospital (MGH) swine colony, Yucatan swine, and Yorkshire-crossed swine from an agricultural vendor (20-40 kg). Swine ranged from 3-10 months of age when the HC was placed. The HC may be placed anytime relative to the animal&#39;s experimental p...

Hickman Catheter for Long-Term Vascular Access in Swine

<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. 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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. 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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. 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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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While CVCs serve a spectrum of functions in large animal research, current literature lacks a consensus approach for safe and sustainable use in long-term trials over 30 days. This protocol&#39;s stepwise procedure for HC insertion, skin securement, and storage in a handmade pouch has undergone significant adjustments for quality improvement. As such, this protocol presents a technique for HC use that permits efficient and effective intravenous access while ensuring animal welfare and minimizing complications.
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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.

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

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.

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

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

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.

Over 100 swine have undergone successful HC insertion in our lab. The HC can be safely and correctly placed and secured in under 1 h with a surgeon, assistant, circulator, and anesthetist. The catheter pouch takes roughly 15-20 min to make. The technique is straightforward and easy to teach and has been performed by veterinarians, surgical residents, and medical students following supervised instructions.
HCs have remained in place without complications or revision for up to 8 months. In a rec...

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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.

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

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Research

JoVE Journal

Medicine

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.

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.

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.