Transhepatic Transcatheter Pulmonary Valve Replacement

Transcatheter pulmonary valve replacement (TPVR) is complicated in patients without adequate femoral or internal jugular vascular access. Transhepatic vascular access has been shown to be safe and effective across a spectrum of diagnostic and interventional procedures. Closure of the hepatic venous tract can be accomplished with a multitude of readily available vascular occlusion devices. The rates of major adverse events are low: 5% to 8% with hemoperitoneum and complete heart block are most significant. To our knowledge, this is the first report of using transhepatic access for TPVR; closure of the hepatic venous tract was achieved with an Amplatzer vascular plug type II.

Interventions for Pulmonary Vein Stenosis

Pulmonary vein stenosis (PVS) is a rare and unique disease of infants and young children. PVS is attended by high morbidity and mortality, and for many decades, effective therapy eluded the practitioner. However, in the most recent era, interventional techniques when employed in combination with systemic (primary) therapy have had a remarkable impact on outcomes in these at-risk children. Despite apparent complete relief of PVS in a discrete region of a pulmonary vein, stenosis reliably recurs and progresses. In this review, we discuss the current state-of-the-art interventional techniques, through the lens of our collective experiences and practices.

An Alternative Central Venous Access Route for Pediatric Patients with Chronic Critical Illness: The Transhepatic Approach

OBJECTIVE

To evaluate the safety and functionality of the transhepatic approach as an alternative route for central venous catheterization in pediatric patients with chronic critical illness.

METHODS

The study included data of 12 chronic critically ill pediatric patients who underwent central venous catheterization with transhepatic approach. The indications, procedure details, mean patency time, and catheter-related complications were retrospectively analyzed.

RESULTS

A total of 16 central venous catheters were placed through the transhepatic approach. A 5F port catheter was used in eight attempts, a 5F PICC in two attempts, and an 8-14F Hickman-Broviac catheter in six attempts. All procedures were performed with technical success. The mean patency time of the catheters was 132.1 d (range: 12-540 d). In the long-term follow-up, catheter-related sepsis was detected in a patient, and six catheters lost functionality due to malposition.

CONCLUSION

The transhepatic approach is a safe and functional alternative route for central venous access in chronic critically ill pediatric patients requiring long-term vascular access. The procedure using ultrasonography and fluoroscopy can be performed with high technical success. In the long-term follow-up, Dacron felt cuff tunneled catheters placed in the subcostal space with a transhepatic approach remained functional for a long time.

Safety and Efficacy of Percutaneous Translumbar Inferior Vena Cava Catheters: A Systematic Review and Meta-Analysis

PURPOSE

To examine the reported adverse events associated with inferior vena cava (IVC) catheterization and investigate the reasons for discrepancies between reports.

MATERIALS AND METHODS

Cochrane Library trials register, PubMed, Embase, and Scopus databases were systematically searched for studies that included any terms of IVC and phrases related to catheters or central access. Of the 5,075 searched studies, 137 were included in the full-text evaluation. Of these, 37 studies were included in the systematic review, and the adverse events reported in 16 of these 37 identified studies were analyzed. An inverse-variance random-effects model was used to conduct the meta-analysis. Outcomes were summarized by the incidence rate (IR) and 95% CI.

RESULTS

Compared with that of catheters <10 F in size (IR, 0.08; 95% CI, 0.03-0.12), the incidence of catheter-related infections per 100 catheter days was 0.2 more for catheters ≥10 F in size (IR, 0.28; 95% CI, 0.25-0.31). In addition, dual-lumen catheters showed 0.13 more malfunction per 100 catheter days (IR, 0.27; 95% CI, 0.16-0.37) than that shown by single-lumen catheters (IR, 0.14; 95% CI, 0.09-0.19). Both differences were statistically significant. Other adverse events were malposition (IR, 0.04; 95% CI, 0.04-0.05), fracture (IR, 0.01; 95% CI, 0.00-0.02), kinking (IR, 0.01; 95% CI, 0.00-0.01), replaced catheter (IR, 0.2; 95% CI, 0.1-0.31), removal (IR, 0.13; 95% CI, 0.1-0.16), IVC thrombosis (IR, 0.01; 95% CI, 0.00-0.03), and retroperitoneal hematoma (IR, 0.01; 95% CI, 0.00-0.01), all per 100 catheter days.

CONCLUSIONS

Translumbar IVC access is an option for patients with exhausted central veins. Small-caliber catheters cause fewer catheter-related infections, and single-lumen catheters function longer.

Palliative stenting of the venous duct in a premature neonate with obstructed infradiaphragmatic total anomalous pulmonary venous connection

In infracardiac, infradiaphragmatic total anomalous pulmonary venous connection, all four pulmonary veins connect to a descending vertical vein that usually drains to the portal vein or one of its tributaries. Obstruction is common, and definitive treatment is surgical repair. We present a case of late-diagnosed infradiaphragmatic total anomalous pulmonary venous connection in a premature neonate who was too high risk for surgery and underwent palliative stenting of the venous duct. We demonstrate the feasibility of a transhepatic approach when umbilical access is no longer available.

Percutaneous transhepatic and transseptal dilatation of a surgically implanted Melody® Valve in the mitral position in a 2-year-old child

The use of the Melody^® (Medtronic, Minneapolis, MN, USA) biological prosthesis in mitral position has shown acceptable short-term results. Furthermore, it allows its expansion with a balloon when the patient grows up, and this procedure can be performed by a venous catheterization through transseptal approach through an interatrial communication or puncturing the septum. Patients with complex congenital heart disease undergoing multiple surgical and percutaneous interventions may present with vascular complications such as thrombosis of the femoral venous system that make percutaneous access impossible. In this situation, the transhepatic approach is a very useful alternative to access the heart.

Direct Percutaneous Transthoracic Cardiac Access for Recanalization of Longstanding Branch Pulmonary Artery Atresia

We describe the use of direct percutaneous cardiac access to recanalize an atretic right pulmonary artery in an adolescent with complex congenital heart disease and right heart failure. This case highlights the problems associated with loss of central venous access and potential advantages of a direct cardiac approach to catheterization. (Level of Difficulty: Intermediate.)

Traditional Long-Term Central Venous Catheters Versus Transhepatic Venous Catheters in Infants and Young Children

OBJECTIVES

Children with congenital heart disease may require long-term central venous access for intensive care management; however, central venous access must also be preserved for future surgical and catheterization procedures. Transhepatic venous catheters may be an useful alternative. The objective of this study was to compare transhepatic venous catheters with traditional central venous catheters regarding complication rate and duration of catheter service.

DESIGN

Retrospective review of 12 congenital heart disease patients from September 2013 to July 2015 who underwent placement of one or more transhepatic venous catheters.

SETTING

Single freestanding pediatric hospital located in the central United States.

PATIENTS

Pediatric patients with congenital heart disease who underwent placement of transhepatic venous catheter.

INTERVENTIONS

Cohort's central venous catheter complication rates and duration of catheter service were compared with transhepatic venous catheter data.

MEASUREMENTS AND MAIN RESULTS

Twelve patients had a total of 19 transhepatic venous lines. Transhepatic venous lines had a significantly longer duration of service than central venous lines (p = 0.001). No difference between the two groups was found in the number of documented thrombi, thrombolytic burden, or catheter sites requiring wound care consultation. A higher frequency of infection in transhepatic venous lines versus central venous lines was found, isolated to four transhepatic venous lines that had a total of nine infections. All but one was successfully managed without catheter removal. The difference in the proportion of infections to catheters in transhepatic venous lines versus central venous lines was significant (p = 0.0001), but no difference in the rate of infection-related catheter removal was found.

CONCLUSIONS

Without compromising future central venous access sites, transhepatic venous lines had superior duration of service without increased thrombosis, thrombolytic use, or insertion site complications relative to central venous lines. Transhepatic venous catheters had a higher infection rate, and further investigation into the etiology is warranted.

Transhepatic Cannulation for Venovenous Extracorporeal Membrane Oxygenation

Limited vascular access because of vessel injury or thrombosis may complicate care of children with congenital heart disease. Although transhepatic venous access for cardiac catheterization and central venous catheter placement has been used in children, its use for extracorporeal membrane oxygenation (ECMO) has not been described. We report successful use of transhepatic cannulation for venovenous ECMO to support a 15 month-old child with bidirectional Glenn anatomy and intractable hypoxemia.

Retrieval of an intra-cardiac embolised very long wire via transhepatic access from a war victim child

We present the case report of a war victim child with severe burn scars, orthopnoea, and dyspnoea due to diffuse pulmonary thromboembolism. During ICU stay, a central venous catheter's 45-mm wire embolised into the heart. The embolised wire was successfully removed via transhepatic access through the creation of an artificial simple snare.

Transhepatic Central Venous Catheters in Pediatric Patients With Congenital Heart Disease

OBJECTIVES

Patients with congenital heart disease may have limited venous access routes as a result of multiple central venous catheters, surgical interventions, and catheterization procedures. Unconventional venous access includes transhepatic central venous catheter. We evaluated transhepatic central venous catheter placed in patients with congenital heart disease and risk factors associated with complications and outcomes.

DESIGN

Demographic, procedural, and complication data were retrospectively collected on all patients who underwent transhepatic central venous catheter placement at our center over the past 10 years.

SETTING

This study was completed in a tertiary congenital heart center.

PATIENTS

A total of 92 transhepatic central venous catheters were placed in 54 patients (63% male patients). The median age and weight of the patient population was 5.7 months and 5.5 kg, respectively.

INTERVENTIONS

Placement of a transhepatic central venous catheter.

MEASUREMENTS AND MAIN RESULTS

Successful catheter placement occurred in 96% of cases with median procedure time of 54 minutes with a procedural complication rate of 14%. A total of 86 complications occurred in 54 catheters placed during 2,166 catheter-days (39.7 complications per 1,000 catheter-days). Individual complication rates per 1,000 catheter-days included catheter dysfunction (14.8), dislodgement (8.8), systemic infection (5.1), thrombosis (4.2), local infection (3.7), and bleeding (3.2). Two complications contributed to patient deaths. Factors associated with developing complications included polyurethane central venous catheters (p = 0.03) and catheter duration at least 21 days (p = 0.004). The overall mortality in this population was 50% with median length of hospitalization of 49 days (interquartile range, 33-97).

CONCLUSIONS

Transhepatic central venous catheters represent a viable option for patients with limited access. Polyurethane catheters and catheter duration at least 21 days are associated with increased transhepatic central venous catheter complications. Although complication rates are higher than more traditional forms of central venous catheters, the long duration of hospitalization and high mortality rates in this patient population attest to their risks for poor outcomes irrespective of venous access.