Percutaneous translumbar and transhepatic inferior vena caval catheters for prolonged vascular access in children

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.

Difficult Vascular Access in Children with Short Bowel Syndrome: What to Do Next?

Short Bowel Syndrome and intestinal failure are chronic and severe conditions that may require life-long parenteral nutrition in children. Survival of these children rely on the correct functioning of central venous catheters; therefore, careful management, prevention, and treatment of complications is of paramount importance. Despite a growing awareness of preserving the vascular real estate, a certain number of patients still experience a progressive and life-threatening exhaustion of vascular access. We searched the literature to highlight the current management of children with vascular exhaustion, specifically focusing on vascular access salvage strategies and last-resource alternative routes to central veins. Given the paucity of data, results are reported in the form of a narrative review.

Open Retroperitoneal Inferior Vena Cava Cannulation for Distal Ventriculoatrial Shunt Catheter Placement

Multiple alternative sites for distal ventriculoperitoneal shunts have been described including pleural, atrial, ureteral, fallopian, and gallbladder placement. In medically complex patients the sites for cerebrospinal fluid (CSF) diversion can be exhausted. We present a case where open retroperitoneal inferior vena cava cannulation was used for successful atrial catheter placement in a 17-month-old female. The patient had a complex abdominal, pulmonary, and vascular history precluding placement of the distal catheter in other sites or atrial placement through more peripheral venous cannulation. The patient underwent uncomplicated open retroperitoneal exposure of her inferior vena cava (IVC) with cannulation and placement of atrial catheter under fluoroscopic guidance. At the follow-up one year after surgery, the patient did not require revision with appropriate placement of the distal atrial catheter.

Right- Versus Left-Sided Approach for Transhepatic Tunneled Catheter Placement: Is There a Difference?

OBJECTIVE

We aimed to compare the technical difficulties, complications, long-term efficacy, and risks between right- and left-sided approach transhepatic tunneled catheterization.

METHODS

We retrospectively evaluated transhepatic tunneled catheter placement cases in our institution between May 2012 and November 2019. Demographic and procedural parameters were recorded. Statistical tests were used to compare the complication rates of right- and left-sided approach. Furthermore, Cox regression analyses were used to investigate the relationship between functional catheter days and included parameters.

RESULTS

A total of 83 procedures were performed in 46 patients, with a female to male ratio of 1.88 and a mean age of 55.5 ± 18.2 years. Indication for catheter placement was chronic renal insufficiency and loss of central venous access through traditional routes in all cases. Median functional catheter durations were 28 days (1-382) and 55.5 days (1-780) for right-sided and left-sided access, respectively. Complication rates were similar for both sides. There was no difference between primary and revision procedures in terms of safety and efficacy outcomes. In univariate Cox regression analysis, gender was the only variable which was found to be statistically significant (HR = 2.014 (1.004-4.038)) for functional catheter days. In multivariate Cox regression model, gender and access side were included which failed to reach statistical significance.

CONCLUSIONS

In our study, both right- and left-sided approaches provided similar safety and efficacy outcomes, suggesting that both techniques can be employed based on physician's preference.

Percutaneous transhepatic vein permcath: A case report

In patients with end-stage renal disease (ESRD), functional vascular access is like a lifeline. Among the patients undergoing hemodialysis, arteriovenous fistulas are done in most of them. However, in approximately 15% of these patients with multiple access failures, the use of tunneled dialysis catheters (TDC) for hemodialysis has become an integral component of treatment plans. Unfortunately, in many cases of multiple access failure, it is difficult to get proper access especially if problems with peritoneal dialysis also exist. The problems related to tunneled dialysis catheters are infections, thrombosis, hemorrhage, migration, dislodgement, leakage, kinking, and chronic venous stenosis. The progressive loss of venous access sites requires a systematic approach to alternative sites as it is important for patient survival. Herein, we present a case of ESRD with multiple access failures who was effectively managed with the placement of a percutaneous transhepatic vein permcath. Till date, there is very little data onsuch interventions from India.

Central venous access port placement by translumbar approach using angio-CT unit in patients with superior vena cava syndrome

PURPOSE

To evaluate the clinical results of central venous access port (CV port) placement by translumbar inferior vena cava cannulation using angio-CT unit for cancer patients with superior vena cava syndrome.

MATERIALS AND METHODS

A CV port was placed by translumbar inferior vena cava cannulation using an angio-CT unit, in 14 consecutive patients. All patients had occlusion or advanced stenosis of the superior vena cava due to cancer progression.

RESULTS

The technical success rate of the percutaneous translumbar CV port placement was 100%. The only complication related to port placement was bleeding in the right iliopsoas muscle seen on CT in one patient, but it stopped with conservative treatment. The mean initial device service interval was 125 days (range 6-448 days). Complications in the chronic phase occurred in two patients, one with catheter-related infection and the other with catheter breakage, for a rate of 0.44/1000 catheter days. In the patient with the broken catheter, the port chamber placement site was cut and replaced with a new catheter by guidewire exchange.

CONCLUSIONS

CV port placement with translumbar inferior vena cava cannulation using an angio-CT unit for cancer patients with superior vena cava syndrome was safe and effective.

Long-Term Infusion in Cancer Chemotherapy with the Groshong Catheter via the Inferior Vena Cava

Aims and background

Vascular access through a vein draining into the superior vena cava is commonly used for long-term infusion of drugs inr cancer chemotherapy; prolonged cannulation of the inferior vena cava is generally considered as having an excessively high complication rate.

Methods

Prolonged cisplatin infusion via the inferior vena cava by means of a Groshong catheter was evaluated in 20 consecutive patients with thoracic malignancies showing evidence of superior vena cava infiltration or obstruction.

Results

We achieved 1,291 catheter days for our survey with a mean duration of vascular access of 64.5 days per patient and a mean duration of infusion time of 40 days. There were 2 complications, a catheter obstruction after a 7-day rest period and an ileo-femoral thrombosis 6 days after catheter placement.

Conclusions

Our experience compared favourably with the results obtained by long-term central venous access via the supraumbilical route, and demonstrated the reliability and safety of this approach in cases where the superior vena cava cannulation is technically difficult or impossible.

CT-Guided Translumbar Placement of Permanent Catheters in the Inferior Vena Cava: Description of the Technique with Technical Success and Complications Data

PURPOSE

To evaluate indications, technical success rate and complications of CT-guided translumbar catheter placement in the inferior vena cava for long-term central venous access (Port and Hickman catheters) as a bail-out approach in patients with no alternative options for permanent central venous access.

MATERIALS AND METHODS

This retrospective study included 12 patients with a total of 17 interventions. All patients suffered from bilaterally chronically occluded venous vessels of their upper extremities, without patent internal jugular and/or subclavian veins. Catheter implantation was performed as a hybrid procedure with CT-guided translumbar access into the inferior vena cava with subsequent angiography-guided catheter placement of a Hickman-type catheter (7×) or a Port catheter (10×).

RESULTS

All interventions were technically successful. The total 30-day complication rate was 11.8% (n = 2). The two detected complications were bleeding at the subcutaneous port hub and subcutaneous kinking of the venous tube. Mean follow-up time was 68.4 ± 41.4 months (range 3.4-160 months). Six patients (50%) died during follow-up from non-procedure-related complications associated with the underlying disease. Late complications occurred in 8/17 (47.1%) cases and were infections of the catheter system in 35.3% (n = 6), mechanical defect of the catheter system in 5.8% (n = 1) and dislocation of the catheter system in 5.8% (n = 1). The overall infection rate was 0.77 per 1000 catheter days.

CONCLUSIONS

CT-guided translumbar placement of permanent catheters is a technically feasible and safe method for permanent central venous access as last resort in chronically occluded veins of the upper extremities.

Central Venous Access in Pediatric Patients

Occlusion of traditional sites for central venous cannulation is a challenging problem in patients that require a permanent central venous line for chronic administration of nutrients or drugs.

In rare cases, extensive central venous thrombosis of the superior and inferior vena cava may preclude catheterization, and uncommon routes should be used.

We describe our approach for placement of chronic central venous lines in two pediatric patients with short bowel syndrome and extensive caval occlusion.

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.

A technique for re-utilizing catheter insertion sites in children with difficult central venous access

Maintenance of central venous access in patients with chronic medical conditions such as short bowel syndrome demands forethought and ingenuity. We describe an innovative technique for re-utilizing central venous access sites in patients who have chronic central venous access needs. Records of patients undergoing this technique were reviewed between August 2012 and December 2015. The technique involves "cutting-down" to the sterile fibrous tunnel that naturally forms around tunneled catheters. The fibrous sheath is then isolated and controlled much as would be done for a venous "cut-down." A separate exit site is then created for the new catheter and it is tunneled to the "cut-down" site per routine. The non-functioning catheter is then removed from the surgical field. The proximal fibrous sheath is finally cannulated either directly with the new catheter or with a wire/dilator system. This technique effectively re-uses the same venous access point while allowing for a complete change of the physical line and external site. Twenty attempts at this technique were made in twelve patients; six patients underwent the site re-utilization procedure multiple times. Re-using the fibrous tunnel to re-cycle the internal catheter site was successful in seventeen of twenty attempts. All patients had chronic conditions leading to difficult long-term central venous access [short bowel syndrome (6), hemophilia (2), cystic fibrosis (1), chronic need for central IV access (3)]. Indications for catheter replacement included catheter occlusion/mechanical failure/breakage (9), dislodgement (6), infection (1), and inadequate catheter length due to patient growth (4). Broviac/Hickman catheter sites were most commonly re-used (13; one failure); re-using a portcath site was successful in 5 of 7 attempts. There were no short term infections or mechanical complications. We describe a novel technique for salvaging tunneled central venous catheter access sites. This technique is well suited for patients with difficult and long-term central venous access needs, particularly those with chronic conditions such as intestinal failure. It is specifically useful when tunneled lines are broken, precipitated or clotted and unamenable to wiring.

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.

Patency and Complications of Translumbar Dialysis Catheters

Translumbar tunneled dialysis catheter (TLDC) is a temporary dialysis access for patients exhausted traditional access for dialysis. While few small studies reported successes with TLDC, additional studies are warranted to understand the short- and long-term patency and safety of TLDC. We conducted a retrospective analysis of adult patients who received TLDC for hemodialysis access from June 2006 to June 2013. Patient demographics, comorbid conditions, dialysis details, catheter insertion procedures and associated complications, catheter patency, and patient survival data were collected. Catheter patency was studied using Kaplan-Meier curve; catheter functionality was assessed with catheter intervals and catheter-related complications were used to estimate catheter safety. There were 84 TLDCs inserted in 28 patients with 28 primary insertions and 56 exchanges. All TLDC insertions were technically successful with good blood flow during dialysis (>300 ml/minute) and no immediate complications (major bleeding or clotting) were noted. The median number of days in place for initial catheter, secondary catheter, and total catheter were 65, 84, and 244 respectively. The catheter patency rate at 3, 6, and 12 months were 43%, 25%, and 7% respectively. The main complications were poor blood flow (40%) and catheter-related infection (36%), which led to 30.8% and 35.9% catheter removal, respectively. After translumbar catheter, 42.8% of the patients were successfully converted to another vascular access or peritoneal dialysis. This study data suggest that TLDC might serve as a safe, alternate access for dialysis patients in short-term who have exhausted conventional vascular access.

Vascular Access for Placement of Tunneled Dialysis Catheters for Hemodialysis: A Systematic Approach and Clinical Practice Algorithm

The role of interventional radiology in the overall management of patients on dialysis continues to expand. In patients with end-stage renal disease (ESRD), the use of tunneled dialysis catheters (TDCs) for hemodialysis has become an integral component of treatment plans. Unfortunately, long-term use of TDCs often leads to infections, acute occlusions, and chronic venous stenosis, depletion of the patient's conventional access routes, and prevention of their recanalization. In such situations, the progressive loss of venous access sites prompts a systematic approach to alternative sites to maximize patient survival and minimize complications. In this review, we discuss the advantages and disadvantages of each vascular access option. We illustrate the procedures with case histories and images from our own experience at a highly active dialysis and transplant center. We rank each vascular access option and classify them into tiers based on their relative degrees of effectiveness. The conventional approaches are the most preferred, followed by alternative approaches and finally the salvage approaches. It is our intent to have this review serve as a concise and informative reference for physicians managing patients who need vascular access for hemodialysis.

Direct translumbar inferior vena cava ports for long-term central venous access in patients with cancer

PURPOSE

To evaluate the indications, complications, and long-term results of translumbar port placements to the inferior vena cava for long-term central venous access in a single tertiary center.

MATERIALS AND METHODS

This retrospective study included all patients with cancer who underwent translumbar port placement from January 2000 to July 2012; 31 patients (all women) with an average age of 53.1 years ± 11.1 (range, 30-77 y) were included in the study. Of these patients, 26 (81%) had breast cancer, 3 had lung cancer, 1 had ovarian cancer, and 1 had rectal cancer. Indications included central venous occlusion in 9 patients (29%) and bilateral mastectomy and lymph node dissection in 22 patients (71%).

RESULTS

All procedures were technically successful. The overall 30-day complication rate was 9.7% (n = 3). Average catheter use was 14.1 months ± 21 (range, 0.75-108 mo). Thirteen (41.9%) ports were removed because they were no longer needed; 4 (12.9%) ports required removal for port malfunction; 12 (38.7%) patients died with their ports still in place; 2 (6.5%) ports remain in use. Three (9.7%) ports required delayed secondary intervention to remain functional. One patient had a systemic infection attributed to the port, resulting in an overall infection rate of 0.08 per 1,000 catheter days.

CONCLUSIONS

Translumbar inferior vena cava port placement is a technically feasible and safe alternative method for long-term central venous access.

Review article: the management of long-term parenteral nutrition

BACKGROUND

Home parenteral nutrition (HPN) is currently the management of choice for patients with chronic intestinal failure.

AIM

To summarise the major issues in delivering long-term parenteral nutrition (>3 months) and assess outcome as per complications, mortality and quality of life. To assess the evidence for the therapeutic use of trophic factors such as teduglutide and to review evolving therapeutic options in the treatment of chronic intestinal failure.

METHODS

A literature search using PubMed and MEDLINE databases was performed.

RESULTS

Safe delivery of HPN relies upon individualised formulations of parenteral nutrition administered via carefully maintained central venous catheters by trained patients or carers, supported by a skilled multidisciplinary team. Early diagnosis and treatment of complications including catheter-associated blood stream infection (reported incidence 0.14-0.83 episodes/patient-year on HPN) and central venous thrombosis (reported incidence 0.03 episodes/patient-year) is important to minimise mortality and morbidity. There is a significant variation in the reported incidence of both hepatobiliary complications (19-75%) and advanced liver disease (0-50%). Five-year survival rates in large centres are reported between 60% and 78% with survival primarily related to underlying diagnosis. Long-term survival remains higher on HPN than with intestinal transplantation. The role of intestinal lengthening procedures is yet to be validated in adults.

CONCLUSIONS

Home parenteral nutrition delivered by skilled nutrition teams has low incidences of catheter-related complications. Most deaths relate to the underlying disease. Therapies such as teduglutide and small bowel transplantation appear promising, but home parenteral nutrition appears likely to remain the bedrock of management in the near term.

Increased complexity and complications associated with multiple peripherally inserted central catheter insertions in children: the tip of the iceberg

PURPOSE

To assess the effects of repeated placements of peripherally inserted central catheters (PICCs) on the venous system in children.

MATERIALS AND METHODS

Children who underwent successful first-time PICC placements between 2005 and 2007 were retrospectively evaluated. Patient demographics, procedural data, and complications were obtained from hospital databases. Data from subsequent PICC insertions were compared with those from previous PICC insertions. A generalized estimating equation was used with appropriate statistical tests for data analysis.

RESULTS

PICCs were grouped into four groups: first PICCs (n = 1,274), second PICCs (n = 167), third PICCs (n = 52), and fourth to seventh PICCs (n = 32). Successive PICCs were associated with progressively increased difficulty of access compared with earlier PICCs, as demonstrated by significant increases in procedural duration (P = .01) and fluoroscopy time (P = .005). Increased complexity was also evident through significant increases in the percentages of cases that required venography/digital subtraction angiography (P <.0001), multiple attempts to gain venous access (P <.0001), and a switch to another limb for venous access (P <.0001) between subsequent and first PICCs. In addition, rates of procedural complications also increased for subsequent PICCs compared with first PICCs (P <.0001). Furthermore use of the most preferred vein for vascular access significantly decreased in subsequent versus first PICC insertions (P <.0001).

CONCLUSIONS

Increased procedural complexity and complications were found with successive PICC insertions. These results confirm the need for a prospective study to directly assess the long-term effects of PICCs on venous patency.

Venous access salvage techniques

For patients who need long-term central venous access but who have developed obstruction of the usual central veins, "salvage" access techniques offer successful alternatives. These techniques include translumbar inferior vena cava access, transhepatic inferior vena cava access, catheterization of small venous collaterals, and recanalization of occluded veins. Inferior vena cava access techniques allow a range of devices to be placed, including ports, infusion catheters, and hemodialysis catheters. Collateral vessels may be too small to allow for large-caliber devices, such as hemodialysis catheters. Success rates for these access techniques are high and complications are infrequent. These access routes are in general quite durable. Adults and children can be treated. Once placed, devices are managed and used as they would be for any routinely placed venous access device.

Transhepatic hemodialysis catheters: functional outcome and comparison between early and late failure

PURPOSE

To describe the authors' experience with transhepatic placement of catheters, highlighting early and late complications, and to determine if this procedure is a viable option in patients in whom central venous occlusions present a significant challenge.

MATERIALS AND METHODS

The records of all the patients who underwent placement of transhepatic hemodialysis from January 2003 to October 2008 were retrospectively reviewed. Selected patients were dialysis-dependent, having undergone multiple access procedures and revisions. Kaplan-Meier analysis was used to estimate primary and secondary patency.

RESULTS

Twenty-two patients (mean age 42 years, range 22-70 years, 59% women) underwent a total of 127 transhepatic catheter placements at 24 transhepatic access sites; technical success was achieved in all cases. There were no hepatic injuries (bleeding or fistula formation). There were 105 exchanges in 14 patients, with a mean of 7.5 exchanges, a median of 5 exchanges (range 1-18 exchanges), and a catheter migration rate of 0.39 per 100 catheter-days. The sepsis rate was 0.22 per 100 catheter-days, and the catheter thrombosis rate was 0.18 per 100 catheter-days. The mean cumulative catheter duration in situ was 506.2 days, and the mean time catheter in situ was 87.7 days. The mean total access site interval was 1,046 catheter-days (range of 423-1,413 catheter-days).

CONCLUSIONS

Transhepatic hemodialysis catheter placement is associated with low rates of morbidity. In this series, transhepatic catheters provided the possibility of long-term functionality, despite associated high rates of catheter-related maintenance, provides a potentially viable access for patients with exhausted access options.

Transhepatic venous approach for balloon-assisted cervical collateral venous access

Central venous catheter placement is indicated in many situations, and an increasing number of patients require temporary and long-term central catheters. Frequently, patients who have undergone multiple central veins catheterizations develop complete and diffuse venous occlusion, and this constitutes a difficult-to-manage clinical problem. We report a case of a 20-year-old patient who was referred to our department for central venous line placement who manifested bilateral femoral, jugular, and subclavian veins occlusion. A central venous catheter was implanted through a cervical collateral vein, targeting on and puncturing an angioplasty balloon, and advanced into the collateral vein through a transhepatic venous access.

Acesso venoso trans-hepático percutâneo para hemodiálise: uma alternativa para pacientes portadores de insuficiência renal crônica

CONTEXTO: Acesso venoso trans-hepático percutâneo para hemodiálise é uma opção para pacientes que já exauriram acessos venosos tradicionais. OBJETIVO: Apresentar uma série de casos que demonstram a factibilidade e a funcionalidade da implantação dos cateteres semi-implantáveis por meio de acesso venoso trans-hepático percutâneo em pacientes sem possibilidades de outros acessos. MÉTODOS: Análise observacional retrospectiva dos prontuários de seis pacientes que foram submetidos à implantação de nove cateteres trans-hepáticos percutâneos para hemodiálise. Os cateteres foram implantados na ausência de acessos venosos periféricos disponíveis. No seguimento dos pacientes, procurou-se avaliar: sucesso técnico do procedimento, taxa de complicação, taxa de infecção e patência do acesso. RESULTADOS: Quatro homens e duas mulheres com idades entre 31 e 85 anos (média: 55 anos). Sucesso técnico obtido em 100%. A média de duração dos cateteres foi de 300,5 dias (2 a 814 dias). Médias de patência primária e secundária foram de 179,60 e 328,33 dias, respectivamente. Taxa de trombose dos cateteres foi de 0,05 por 100 cateteres-dias, assim como a taxa de infecção. Houve três complicações precoces (30 primeiros dias de implantação dos cateteres): dois deslocamentos dos cateteres e uma infecção. Duas complicações tardias foram observadas: uma trombose e uma migração. Três pacientes (50%) tiveram que trocar seus cateteres. Taxa de mortalidade em 30 dias foi de 33%, porém não relacionada ao procedimento. CONCLUSÃO: Implantação do cateter para hemodiálise por meio do acesso venoso trans-hepático percutâneo parece ser uma técnica segura, porém a utilização desse acesso deve ser aplicada somente em casos de esgotamento de outros acessos vasculares profundos.

Dual-tract transhepatic U-shaped hemodialysis inferior vena cava catheter: a feasibility study in a swine model

PURPOSE

To evaluate the feasibility of establishing a U-shaped inferior vena cava (IVC) catheter entirely from a transhepatic approach and to determine the catheter caliber that would provide adequate flow for hemodialysis.

MATERIALS AND METHODS

Three pigs (weight, 45-50 kg) were used. A peripheral right hepatic vein was accessed transhepatically by using a 22-gauge needle, and a 0.018-inch wire was passed into the hepatic veins and IVC. An accessory right hepatic vein was accessed from the IVC. A snare was deployed in the accessory vein and used as a target for a second transhepatic 22-gauge needle pass. A wire was snared through the second transhepatic tract, around into the IVC, and through the first transhepatic tract. The 0.018-inch wire was upsized to a 0.035-inch platform. Measurements where made to tailor a U-shaped catheter from simple 10.2- and 12-F tubes by cutting them longitudinally (single long side hole) along the length of the IVC segment. The U-shaped hemodialysis catheter was placed over the wire and positioned so that the catheter opening lay in the IVC. With use of a dialysis machine, pressures and flow tolerance at set flow rates (100, 200, 300, 350, and 400 mL/min) were tested.

RESULTS

All pigs underwent and survived successful catheter placements. All 10.2- and 12-F catheters tolerated flow rates up to 350 and 400 mL/min, respectively.

CONCLUSIONS

Establishing a U-shaped hemodialysis catheter with an entirely transhepatic approach is technically feasible. The 10.2-F U-shaped dialysis catheters provided a flow rate (>350 mL/min) that is appropriate for hemodialysis in human clinical settings.

Percutaneous translumbar inferior vena cava cannulation under computed tomography guidance

Percutaneous translumbar inferior vena cava (IVC) cannulation is an alternative approach for central venous catheterization, but there have been sporadic reports of puncture-related complications. To avoid complications during IVC puncture, percutaneous translumbar IVC cannulation was performed under computed tomography (CT) guidance in addition to fluoroscopy in two patients. To perform chemotherapy for recurrent breast cancer, we planned subcutaneous port catheter placement for central venous access. Under CT guidance, the direction and insertion distance of a long elastor needle were adjusted, and the IVC was punctured at the level of the third lumbar vertebra while taking care to avoid the right urinary tract. A guidewire was inserted through the long elastor needle, and a catheter was placed over the guidewire. It was possible to perform central venous catheterization by percutaneous translumbar inferior vena cava cannulation under CT guidance.

Central venous access: techniques and indications in oncology

Long lines can be inserted centrally or peripherally through patent veins into the central venous system down to the atrial caval junction. Traditionally surgeons, anesthetists, cardiologists and more recently interventional radiologists have been placing them using vein cutdown or percutaneous needle puncture techniques. Typical candidates for implanted venous catheters are cancer patients undergoing long-term chemotherapy. The most important issues, in addition to the patency of central veins and the history of previous indwelling catheters, pacewires or venous thrombosis, are the patient's performance status, body mass index, medical history and respiratory status, and the relevant technique. The present article will give an overview of the radiological and surgical implantation techniques and will highlight the impact of imaging means on the technical feasibility, assessment and treatment of device-related complications.

Thoracoscopic-assisted placement of azygos vein central venous catheter in a child

Loss of central venous access in intestinal failure patients is a potentially fatal complication, and an indication for intestinal transplantation. Thrombosis of the superior vena cava (SVC) has historically been considered a contraindication to small bowel transplantation; however, unconventional central venous access can facilitate survival and eventual transplant procedure in patients with end-stage central venous access. We describe a technique for azygos vein central catheter insertion utilizing thoracoscopic guidance in a 14-year-old girl with thrombosis of the SVC and chronic idiopathic pseudo-obstruction syndrome awaiting multivisceral transplantation. The technique is simplified by utilizing carbon dioxide (CO(2)) insufflation of the thoracic cavity to collapse the lung instead of double-lumen endotracheal tube placement, and no postoperative chest tube drainage of the pleural space is required. Thoracoscopic-assisted central access can also be used in children requiring chronic hemodialysis with limited venous sites due to thrombosis or small size of vessels.

Transhepatic central venous catheter for long-term access in paediatric patients

Vascular access in paediatric patients with chronic and/or life-threatening illness is crucial to survival. Access is frequently lost in this group because of thrombosis, infection, or displacement, and vascular options can quickly be exhausted. The last resort access procedure is generally a direct atrial catheter inserted via a thoracotomy. A viable alternative is the percutaneous transhepatic Broviac catheter (Bard Access Systems, Salt Lake City, UT). We retrospectively reviewed the charts of 5 patients who underwent percutaneous transhepatic Broviac insertion for long-term access over a 4-year period in a single institution. Four of the patients (80%) had a significant cardiac abnormality, with 1 patient requiring long-term parenteral nutrition after complicated necrotizing enterocolitis. All patients had significant caval thrombosis, which precluded them having placement of a standard percutaneous or openly placed central catheter. Of the 5 patients, 2 (40%) died of cardiac-related illnesses. Of the 3 surviving patients, 2 had functioning catheters electively removed because they were no longer required. One catheter was removed at thoracotomy for right atrial perforation because of catheter erosion. Vascular access in paediatric patients with chronic and/or life-threatening illness is crucial to survival. Transhepatic central venous catheters are a feasible, reliable, and relatively easily placed form of central access in patients with multiple venous thromboses requiring long-term access. This route should be considered in paediatric patients requiring central access in preference to a thoracotomy.

Transhepatic Broviac catheter placement for long-term central venous access in critically ill children with complex congenital heart disease

OBJECTIVE

Critically ill children with cardiac disease often require prolonged central venous access. Thrombosis of systemic veins or the need to preserve vessels for future cardiac procedures limits sites for placement of central venous catheters in these patients. This study evaluates the use of Broviac placement via the transhepatic approach for this patient population.

DESIGN

A retrospective review.

SETTING

A tertiary care center.

PATIENTS

All children with complex congenital heart disease who underwent transhepatic Broviac placement between May 2000 and April 2004.

INTERVENTIONS

Transhepatic Broviac placement.

MEASUREMENTS AND MAIN RESULTS

Thirty-two children with a median age of 5 months (20 days-5.3 yrs) and a median weight of 4.2 kg (2.2-24.9 kg) underwent 40 transhepatic Broviac placements. There were three (8.8%) procedural-related complications. One patient suffered an intra-abdominal bleed requiring an urgent laparotomy and removal of the Broviac, one patient required transfusion because of a mild self-contained intra-abdominal bleed, and one patient developed temporary complete heart block. There was one catheter infection. Thrombus was noted by echocardiography on the tip of two Broviacs; however, no intracardiac vegetations or embolic events occurred. There was no mortality related to the procedure. Broviacs remained in place for a median of 36 days (1 day-6 months). Five Broviacs were dislodged inadvertently (two during cardiac massage and three resulting from patient manipulation). The remaining Broviacs were electively removed safely without coil embolization. At a median follow-up of 3.5 months (10 days-3 yrs), there have been no long-term complications related to the Broviacs.

CONCLUSIONS

Transhepatic Broviac catheters can be used safely in critically ill children with cardiac disease and remain indwelling for adequate periods of time. This modality of prolonged vascular access should be considered for children whose veins are occluded or need to be preserved for future procedures.

Bilhemia: a fatal complication following percutaneous placement of a transhepatic inferior vena cava catheter in a child

A transhepatic central venous catheter was implanted in a 2-year-old child with a history of multiple venous access procedures and superior and inferior vena cava thrombosis. After 2 weeks, inadvertent dislodgement of the catheter was complicated by a biloma. The biloma was percutaneously drained, but a biliary-venous fistula led to a rapidly progressive and fatal bilhemia. We report this case as an infrequent complication of transhepatic catheterization.

Percutaneous translumbar inferior vena cava catheter placement for long-term hemodialysis treatment

Central venous access for long term dialysis has always been a major difficulty, especially in cases where the traditional sites are no longer available. We present a case of a pediatric patient where the usual sites were occluded and he needed a reliable venous access for his dialysis. The inferior vena cava has been used in adult patients, but no reports were found in the pediatric literature. We chose this site as an alternative for this patient. The catheter was placed via a percutaneous translumbar approach, and remained in place for almost 2 years until the patient received a renal transplant.

Stereotactic Technique of Catheter Placement in the Stump of the Superior Vena Cava in Children with Impaired Venous Access

The long-term survival of children with irreversible intestinal failure is often dependent on adequate central venous access for the administration of parenteral nutrition. In children with occlusion of major central thoracic veins, innovative techniques to establish venous access have been described in the literature. The present report describes an innovative stereotactic technique of catheter insertion in children with occluded internal jugular and brachiocephalic veins. The catheter is inserted percutaneously from the neck into the distal patent stump of the superior vena cava communicating with the right atrium.

A case of fatal cardiac tamponade during hemodialysis

A 27-year-old Hispanic man with a history of hypertension and end-stage renal disease for 4 years became unresponsive, apneic, and pulseless during hemodialysis. During his 4 year period on dialysis, vascular access had become increasingly difficult and ultimately a transhepatic catheter had been placed 9 months prior to this event. Resuscitation was unsuccessful. At autopsy, death was determined to be due to cardiac tamponade secondary to perforation of the right atrium by the transhepatic catheter. Cardiac tamponade is a rare cause of sudden death during hemodialysis with a long-standing catheter.

Vascular access for home intravenous therapy in children

This review article describes the vascular access devices available for long-term vascular access in children, describes the procedures for implanting them and the sites available for this purpose, discusses the complications associated with catheter placement and how to avoid them, and compares the various catheter systems in terms of their advantages and disadvantages.

Pediatric vascular access

Pediatric interventional radiologists are ideally suited to provide vascular access services to children because of inherent safety advantages and higher success from using image-guided techniques. The performance of vascular access procedures has become routine at many adult interventional radiology practices, but this service is not as widely developed at pediatric institutions. Although interventional radiologists at some children's hospitals offer full-service vascular access, there is little or none at others. Developing and maintaining a pediatric vascular access service is a challenge. Interventionalists skilled in performing such procedures are limited at pediatric institutions, and institutional support from clerical staff, nursing staff, and technologists might not be sufficiently available to fulfill the needs of such a service. There must also be a strong commitment by all members of the team to support such a demanding service. There is a slippery slope of expected services that becomes steeper and steeper as the vascular access service grows. This review is intended primarily as general education for pediatric radiologists learning vascular access techniques. Additionally, the pediatric or adult interventional radiologist seeking to expand services might find helpful tips. The article also provides education for the diagnostic radiologist who routinely interprets radiographs containing vascular access devices.

Management of end-stage central venous access in children referred for possible small bowel transplantation

The 3-year survival after small bowel transplantation (SBTx) has improved to between 73% and 88%. Impaired venous access for parenteral nutrition can be an indication for SBTx in children with chronic intestinal failure.

AIM

To report our experience in management of children with extreme end-stage venous access.

SUBJECTS

The study consisted of 6 children (all boys), median age of assessment 27 months (range, 13-52 months), diagnosed with total intestinal aganglionosis (1), protracted diarrhea (1), and short bowel syndrome (4), of which gastroschisis (2) and malrotation with midgut volvulus (2) were the causes. All had a documented history of more than 10 central venous catheter insertions previously. All had venograms, and 1 child additionally had a magnetic resonance angiogram to evaluate venous access. Five of 6 presented with thrombosis of the superior vena cava (SVC) and/or inferior vena cava.

METHODS

Venous access was reestablished as follows: transhepatic venous catheters (5), direct intra-atrial catheter via midline sternotomy (4), azygous venous catheters (2), dilatation of left subclavian vein after passage of a guide wire and then placing a catheter to reach the right atrium (1), radiological recanalization of the SVC and placement of a central venous catheter in situ (1), and direct puncture of SVC stump(1). Complications included serous pleural effusion after direct intra-atrial line insertion, which resolved after chest drain insertion (1), displacement of transhepatic catheter needing repositioning (2), and SVC stent narrowing requiring repeated balloon dilatation.

OUTCOME

Four children with permanent intestinal failure on assessment were offered SBTx, 3 of which were transplanted and were established on full enteral nutrition; the family of 1 child declined the procedure. In the remaining 2 children in whom bowel adaptation was still a possibility, attempts were made to provide adequate central venous access as feeds and drug manipulations were undertaken. One of them received liver and SBTx nearly 3 years after presenting with end-stage central venous access, because attempts to achieve independence from parenteral nutrition had failed. The other child died immediately after a transhepatic venous catheter placement, possibly from a nutritional depletion syndrome as no physical cause of death was found. Direct intra-atrial catheters in transplanted children proved to be adequate for the management of uncomplicated transplantation, although the usual infusion protocol had to be modified considerably, and the lack of access would have been critical if massive blood transfusion had been required during the transplant procedure.

CONCLUSION

It was possible to reestablish central venous access in all cases. However, this was time consuming and difficult to assemble a skilled team consisting of one of more: surgeon, cardiologist, interventional radiologist, and transplant anesthetist. Small bowel transplantation is easier and safer with adequate central venous access, and we advocate liaison with an SBTx center at an early stage.

Vascular Access in the Adult Home Infusion Patient

The dependence of IV hyperalimentation programs on the achievement and maintenance of reliable vascular access in the home infusion patient population has necessitated a review of the current methods used to establish and maintain adequate long-term vascular access. Vascular access device-related complications are significant contributors to the medical course and costs associated with the care of home parenteral nutrition (HPN) patients. The purpose of this manuscript is to review current thoughts on the establishment of long-term vascular access for HPN with regard to techniques used, device selection, and associated complications.

Percutaneous transhepatic venous access for hemodialysis

Percutaneous transhepatic venous access is an option for hemodialysis patients who have exhausted more traditional sites of venous access. Thirty-six transhepatic dialysis catheters were placed in 12 patients. The mean time of the catheters in situ was 24.3 days. Twenty-one catheters were replaced or removed because of catheter thrombosis, yielding a catheter thrombosis rate of 2.40 per 100 catheter-days. The line sepsis rate was 0.22 per 100 catheter-days. Poor patency rates were seen because of a high rate of late thrombosis. Transhepatic dialysis catheters should only be used as a last resort unless limitations of catheter thrombosis can be overcome.

Reoperative venous access

The maintenance of long-term venous access is critical to the livelihood of children in a variety of clinical situations, especially those who are dependent on parenteral nutrition. Whereas the traditional routes of either peripheral or central venous access are initially adequate, most of these sites eventually succumb to the pitfalls associated with long-term venous access. This review provides a comprehensive and multidisciplinary approach to the management of reoperative venous access with regard to preoperative planning and imaging and specific techniques in interventional radiology and surgery.

Pediatric interventional venous access

Venous access for therapy in sick children is very important, but sometimes also extremely challenging. With several advances in imaging modalities, the interventional radiologist can certainly help in these situations. This article reviews the indications, technique, and complications related to short- (peripherally inserted central catheter) and long-term (central venous lines, Port-a-catheters) venous accesses in children. A brief commentary is also made about retrieval of fragmented lines.

Unconventional venous access

Venous access is commonly thought of as the bread and butter of interventional radiologic procedures. However, in those patients who have undergone multiple previous central venous catheter placements, venous access can be a technical challenge for even the most seasoned interventional radiologist. Conventional access sites include the internal jugular veins (IJV) and subclavian veins (SCV). The former should be considered as the primary access site for all patients who will be catheter dependent for whatever reason. Before utilization of the SCV, the external jugular veins (EJV) should be used, especially in the dialysis population. Only after surgical hemodialysis access is no longer an option in the upper extremity should cannulation of the SCV be entertained. Once these usual access sites are no longer available, it may necessary to use an unconventional access method, including catheterization of the common femoral vein, catheterization of enlarged collateral vessels, recanalization of occluded veins, translumbar inferior vena cava (IVC) catheter placement, and transhepatic catheter placement. This chapter serves as a review of these techniques.