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Percutaneous translumbar and transhepatic inferior vena caval catheters for prolonged vascular access in children
R G Azizkhan1, L A Taylor, P F Jaques
1Department of Surgery, University of North Carolina School of Medicine, Chapel Hill 27599-7210.
Insights
Percutaneous translumbar or transhepatic central venous catheters offer a viable alternative for children with caval occlusion, providing prolonged access when traditional methods fail. This technique demonstrated success with manageable complications in pediatric patients requiring parenteral nutrition.
Area of Science:
- Pediatric Surgery
- Interventional Radiology
- Vascular Access
Background:
- Central venous access in children with caval occlusion is challenging.
- Traditional methods like thoracotomy for SVC/IVC thrombosis are invasive.
- Percutaneous translumbar or transhepatic approaches offer new possibilities for central venous access.
Purpose of the Study:
- To report the experience with percutaneous translumbar or transhepatic tunneled right atrial catheters (RACs) in pediatric patients with superior and inferior vena cava (SVC, IVC) obstruction.
- To evaluate the efficacy and safety of this technique in a challenging patient population.
Main Methods:
- Seven pediatric patients with SVC and IVC obstruction received 15 RACs (11 transhepatic, 4 translumbar) between 1987-1991.
- Procedures were performed under general anesthesia with ultrasound guidance and Seldinger technique.
- Patients were primarily young children dependent on parenteral nutrition.
Main Results:
- The technique was successful in all seven children.
- Perioperative complications were minimal (extubation, aspiration pneumonia).
- Mechanical complications (dislodgement, thrombosis) occurred in 3/7 infants over 2,650 catheter days, managed by exchange or thrombolysis.
- Nine episodes of catheter sepsis occurred in 5 children, with 2 late deaths from infection.
Conclusions:
- Percutaneous translumbar or transhepatic RACs provide an excellent alternative for prolonged central venous access in pediatric patients with caval occlusion.
- While late catheter complications can occur, they are comparable to standard approaches.
- This technique is a valuable option when traditional vascular access is unavailable.
Abstract:
Central venous access for children with caval occlusion remains a major challenge to pediatric surgeons. Traditionally, children with superior and inferior vena cava (SVC, IVC) thrombosis have often required a thoracotomy to directly cannulate the azygos system or right atrium (RA). Recently, the possibility of placing tunneled RA catheters (RACs) by a percutaneous translumbar or transhepatic approach has become available. We report our experience of seven children with SVC and IVC obstruction who have received 11 transhepatic and 4 translumbar RACs from 1987 to 1991. All but one child was less than 2.5 years old and all were chronically dependent on parenteral nutrition. All catheters were placed in the angiography suite under general anesthesia using ultrasound guidance and Seldinger technique. This technique was successful in all seven children. Perioperative complications included accidental extubation in one patient and aspiration pneumonia in another. Mechanical complications requiring RAC replacement occurred 5 times in three infants (greater than 2,650 catheter days) and included catheter dislodgement (2) and thrombosis (3). In the patients with catheter thrombosis, the existing tract was successfully wired and the catheter exchanged on three occasions. Thrombolytic therapy was effective in restoring catheter patency on three other occassions. Nine episodes of catheter sepsis occurred in five children. Two late deaths occurred from infection. Of the five remaining children, four are dependent on total parenteral nutrition and have a translumbar or transhepatic catheter in situ and one child has adapted successfully to enteral feedings. Percutaneous translumbar or transhepatic IVC catheters provide excellent alternative routes for prolonged central venous access in those patients whose traditional vascular access sites are no longer available. Complications of the technique itself were minimal and although late catheter complications were not infrequent, they appear to be comparable to the standard approaches reported.