Chest to back tunneling for medium/long term venous access in patients with cognitive impairment at risk for accidental venous catheter removal.

Accidental vascular catheter removal (AVCR) by patients with cognitive impairment can result in loss of access for infusion therapy, significant blood loss, air embolism with large bore catheters, and withholding life-sustaining dialysis treatment. Chest-to-back (CTB) tunneling of central venous catheters is a technique described in the Rapid Assessment of Vascular Access Exit Site and Tunneling Options (RAVESTO) for patients at risk for AVCR. In this retrospective review, data was collected for all venous access devices inserted using CTB tunneling in patients requiring medium to long term intravenous access for infusion or hemodialysis, who had a history of self-removing medical devices due to an alteration in mental status, or patients with severely impaired skin integrity. Vascular access devices were placed using real-time ultrasound and intracavitary electrocardiography (ECG) guidance. In this case series, from January 2020 to October 2024, a total of 46 out of 47 patients successfully received CTB-tunneled venous access devices. There was no reported symptomatic deep vein thrombosis. CTB tunneling was unable to be completed in one case due to severe patient agitation. The mean dwell was 23 days (ranging from 1 to 130 days). Nineteen patients completed their prescribed therapy, 18 patients were discharged with the catheter but were lost to follow up, four patients self-removed their catheter, three patients developed fungal infections receiving TPN, one patient experienced a primary catheter malposition which was removed after unsuccessful attempts at repositioning, and one patient receiving dialysis had a catheter exchange on day 32 due to poor flow. CTB tunneling is useful in patients with cognitive impairment who are at risk for AVCR and require medium to long term intravenous access. This retrospective review suggests that the use of ultrasound and intracavitary ECG makes the bedside CTB tunneling a safe and minimally invasive procedure.