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Central Vein Recanalization and Rehabilitation in Pediatric Patients: Changing the Paradigm for Chronic Occlusions
Patrick M Sullivan1, Cheryl Takao1, Neil D Patel1
1Children's Hospital Los Angeles Heart Institute, Los Angeles, California.
Insights
Transcatheter recanalization effectively treats pediatric central venous occlusions, preserving access and relieving symptoms. Repeat procedures are common due to reocclusion, often linked to poor venous inflow.
Area of Science:
- Interventional Cardiology
- Pediatric Vascular Medicine
- Medical Device Technology
Background:
- Chronic total occlusions in pediatric central veins impede vascular access and increase morbidity.
- These occlusions are often linked to indwelling central venous lines or extracorporeal membrane oxygenation support.
- Limited access, limb swelling, and venous congestion symptoms necessitate intervention.
Purpose of the Study:
- To evaluate the efficacy and outcomes of transcatheter recanalization for central venous occlusions in pediatric patients.
- To assess the role of angioplasty and stenting in managing these complex venous occlusions.
- To identify factors associated with reocclusion and the need for repeat interventions.
Main Methods:
- Retrospective review of pediatric patients undergoing transcatheter recanalization for central venous occlusions between April 2013 and December 2019.
- Procedures included angioplasty and/or stenting of 68 occluded central veins in 29 patients.
- Data collected on indications, risk factors, procedural details, complications, and follow-up outcomes.
Main Results:
- No major complications occurred during 68 recanalization procedures (angioplasty in 26, stenting in 42 veins).
- Symptomatic improvement was observed in 80% of patients with venous congestion.
- Of 59 veins requiring follow-up, 52 (88%) remained patent after the most recent intervention, though reinterventions were common (44 procedures on 40 veins).
Conclusions:
- Transcatheter recanalization is a viable option for preserving central venous access and alleviating symptoms in pediatric patients.
- Reinterventions are frequently required due to reocclusion, restenosis, and somatic growth.
- Persistent upstream collateral vein decompression identified on venography is a significant predictor of reocclusion.
Background:
Chronic total occlusions in the central venous system limit access and increase morbidity in chronically ill pediatric patients. We report the results of transcatheter recanalization of occluded central veins using angioplasty and stenting.
Methods:
Patients undergoing successful intervention for venous chronic total occlusions at our institution between April 2013 and December 2019 were retrospectively reviewed.
Results:
Sixty-eight occluded central veins in 29 patients underwent recanalization with angioplasty (26 veins) or stenting (42 veins). The indications included limited access for catheterization or central line maintenance (19 patients), limb swelling (4 patients), superior vena cava syndrome (3 patients), and pleural effusion (3 patients). The primary risk factor for occlusion was a history of central venous lines after surgery or extracorporeal membrane oxygenation support in 76% of the patients. The median age and weight at the time of initial intervention were 5.8 years and 14.5 kg, respectively. There were no major complications. Of 10 patients with symptoms of venous congestion, 8 experienced symptomatic improvement. Twenty-two patients (59 veins) underwent 44 recatheterizations during a median follow-up duration of 288 days. Early reintervention was typically planned. The median time to recatheterization was 71 days. Twenty-one veins reoccluded and required repeat recanalization. Reocclusion was associated with persistent upstream collateral vein decompression, as determined using postintervention venography (odds ratio, 14.2; 95% CI, 3.3-62.6; P < .001), which was thought to indicate persistently poor venous inflow. Reinterventions were performed on 40 veins. Fifty-two veins that were followed up (88%) remained patent after the most recent intervention.
Conclusions:
Invasive transcatheter rehabilitation of occluded central veins has the potential to preserve critical access sites and improve the symptoms of venous congestion in pediatric patients. Reinterventions are common for reocclusion, restenosis, and somatic growth.
