Long-term central venous access is frequently required to facilitate the management of patients with malignant disease. The silastic Hickman catheter has the advantages of low thrombogenicity and dual lumens, allowing blood sampling or intravenous administration of fluid simultaneously with the chemotherapy. While Broviac catheters and those with subcutaneous reservoir ports are sometimes used in neonates or patients requiring long-term antibiotic administration, the Hickman catheter is now, almost exclusively, used in Oxford for cancer chemotherapy.

Access to the vena cava can be obtained via any superficial vein of adequate size, the most commonly used being the external jugular, internal jugular, cephalic, and long saphenous veins. Either a percutaneous or cut-down technique can be used, the latter being preferable in thrombocytopenic patients to avoid haematoma formation.

The catheter should be tunnelled from the chest or abdominal wall to the incision over the vein of access (Fig. 1) 2780. This has not been shown to reduce the incidence of catheter related infections, but it does facilitate catheter care and cosmesis. The catheters have a Dacron cuff which should be placed just under the skin near the exit site. This becomes fixed in the subcutaneous fat, preventing accidental catheter removal, and may also act as a physical barrier to pericatheter infections. The catheter must be trimmed to allow the tip to lie in the vena cava close to the right atrium or just within the atrium itself.

The cephalic vein is usually too small in children, and is also estimated to be absent or too small in 10 to 20 per cent of adults. In addition, catheters passed through it are prone to ‘wander’ into other veins besides the superior vena cava. For this reason use of the internal jugular vein or long saphenous vein is preferable: these are more constant in size and position and allow the catheter to take a more direct route to the atrium. Moreover the long saphenous vein is familiar to most surgeons and fears of increased infection and venous thrombosis associated with its use have proved unfounded. It is also most suitable for exposure under local anaesthetic. Unlike the smaller veins, the internal jugular vein should not be ligated around the catheter; instead the catheter should be tied into the wall of the vein with a fine monofilament purse-string suture. Radiographic screening is advisable.

This should be undertaken by specialized nursing staff following a departmental protocol, and patient involvement should be encouraged. An aseptic technique and intermittent heparin flushing are advisable. Complications are common but can usually be overcome without catheter removal. Catheter occlusion is usually gradual and is indicated by an increasing resistance to the pressure of infusion. It may be reversed by ‘locking’ the catheter with a solution containing 5000 U of urokinase on a few consecutive days. If this fails the catheter should be flushed with a 0.1 M solution of HCl in case the occluding material consists of insoluble calcium salts.

Venous thrombosis is often asymptomatic, but when diagnosed, the catheter should be left in situ (if it is patent) while anticoagulation therapy is commenced. Vena caval thrombosis is uncommon, but is associated with a mortality rate of up to 50 per cent. A patent catheter is ideally placed to administer local fibrinolytic therapy and should not be removed. Thrombosis is less common in patients with haematological malignancies, because of intermittent thrombocytoplenia or coagulopathies, compared to those with solid tumours or those whose catheters are used solely for nutrition or antibiotics.

The likelihood of sepsis varies with the underlying disease, but an incidence of over 50 per cent has been reported in bone marrow transplant patients. The catheter is frequently not the source of the infection and should not be removed until other causes have been excluded and the infection has failed to respond to prolonged high-dose antibiotics.

With meticulous care Hickman catheters will last the several months required for the completion of chemotherapy: a catheter lifespan of several years has been reported.

Ebbs SR, Cameron AE. A standardised approach to the insertion of Hickman catheters. Ann R Coll Surg Engl 1988; 70: 283 - 4.

Rich AJ. Five years experience with long saphenous catheterisation for chronic venous access. Clin Nutr 1990; 9: 127 - 30.