Transhepatic catheterization using ultrasound-guided access

Point-of-Care-Ultrasound in Pediatrics: A Review and Update

Point-of-Care-Ultrasound (POCUS) has encountered a tremendous expansion in patient care. POCUS has taken a central role during invasive procedures. POCUS has expanded to most subspecialties from adult to pediatric and neonatal health care. POCUS in pediatrics has also become part of specific critical situations such as myocardial function assessment during cardiac arrest, extracorporeal membrane oxygenation deployment and neurological evaluation. In this review we will go over the most important historical aspects of POCUS. We will also review important aspects of POCUS in the intensive care unit, cardiologist evaluation and in the emergency department among others.

Transhepatic device closure of atrial septal defect in children associated with interrupted inferior vena cava

Percutaneous transcatheter closure of fossa ovalis atrial septal defect (FOASD) is an established procedure. When femoral venous approach is unfeasible due to interrupted inferior vena cava (IVC) or occluded femoral veins, other interventional methods through transjugular, transhepatic approach, or surgical closure can be performed. We report two cases of transhepatic device closure of FOASD associated with IVC interruption successfully performed without any complications.

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 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.

Three-dimensional magnetic resonance imaging overlay to assist with percutaneous transhepatic access at the time of cardiac catheterization

Multimodality image overlay is increasingly used for complex interventional procedures in the cardiac catheterization lab. We report a case in which three-dimensional magnetic resonance imaging (3D MRI) overlay onto live fluoroscopic imaging was utilized to safely obtain transhepatic access in a 12-year-old patient with prune belly syndrome, complex and distorted abdominal anatomy, and a vascular mass within the liver.

Percutaneous transhepatic access for catheter ablation of cardiac arrhythmias

AIMS

Femoral venous access may be limited in certain patients undergoing electrophysiology (EP) study and ablation. The purpose of this study is to review a series of patients undergoing percutaneous transhepatic access to allow for ablation of cardiac arrhythmias.

METHODS AND RESULTS

Six patients with a variety of cardiac arrhythmias and venous abnormalities underwent percutaneous transhepatic access. Under fluoroscopic and ultrasound guidance, a percutaneous needle was advanced into a hepatic vein and exchanged for a vascular sheath over a wire. Electrophysiology study and radiofrequency ablation was then performed. All tachycardias, including atrial tachycardia, atrial flutter, atrioventricular nodal tachycardia, and atrial fibrillation, were ablated. Procedural times ranged from 227 to 418 min. Fluoroscopy times ranged from 32 to 95 min. There were no complications. All six patients have been arrhythmia-free in follow-up (5-49 months, mean 23.1 months).

CONCLUSION

Percutaneous transhepatic access is safe and feasible in patients with limited venous access who are undergoing EP study and ablation for a range of cardiac arrhythmias.

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.

Transhepatic vascular access for diagnostic and interventional procedures: Techniques, outcome, and complications

Early or multiple cardiac catheterizations may result in occlusion of the femoral veins prohibiting their use. The internal jugular or sub-clavian approach may be an appropriate alternative. However, these approaches may not be suitable in patients with surgical interruption of the superior vena cava. In other patients, they may not allow easy access to certain areas of the heart. The transhepatic approach is an important alternative route for performing cardiac catheterization and interventions. Depending on the planned procedure, it may be the preferred route to perform the cardiac catheterization even in the presence of patent femoral veins. The indications, technical details and potential complications of this approach are discussed.

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.

Vascular access and management of its complications

Vascular access is needed to realize the potential of therapeutic cardiac catheterization and may consume up to 25% of the entire procedure time. Repeat interventions and multiple cardiac surgeries may result in incremental loss of access sites. The following article discusses general aspects of vascular access, imaging tools to facilitate access, the various access sites with technical approach, advantages, and specific complications. Strategies for vessel protection and management of acute bleeding and iatrogenic fistulas are presented. Also, strategies for vessel restoration after acute and chronic vascular occlusion are reviewed.

Transcatheter techniques in the management of perioperative vascular obstruction

The role of transcatheter intervention for the treatment of vascular obstruction is well documented in the preoperative or remote postoperative settings. More recently, the roles of angioplasty and stent implantation have been advocated as intraoperative and immediate postoperative strategies. As one considers the inherent advantages in this cooperative approach to congenital heart disease, the development of a truly hybrid interventional suite seems imperative.