Trans-umbilical access in the neonate with sheath preservation for intervention

High-flow vascular malformations in neonates may require emergent embolization to prevent or treat congestive heart failure when intervention is indicated.1 While transfemoral access is the traditional approach, this route may be complicated by the sheath size (typically 4F in our experience, as a smaller sheath system may prove suboptimal) needed for embolization. This is especially true when (1) multiple acute interventions are anticipated during the neonatal period and/or (2) when it is preferred to spare femoral access for future treatments in infancy or childhood.1-3 The safety and feasibility of using transumbilical (TU) access via the umbilical artery and maintaining an indwelling sheath post-procedurally has been previously described and indeed does spare the femoral arteries for later treatments; however, this technique has not yet been sufficiently demonstrated or reported to the extent that it could be easily reproduced.1-10 In this technical video, we detail the required materials and demonstrate a step-by-step guide to obtaining TU access in the context of neonatal vascular malformation embolization. Our practice has utilized this technique for decades and we hope that by sharing our methods with the neurointerventional community we may make this rarely performed procedure a feasible option for proceduralists (see video 1) . neurintsurg;17/12/1404/V1F1V1Video 1Technical instructional video for trans-umbilical access in the neonate with sheath preservation for intervention.