Radiologically Placed Venous Ports in Children

Inversion of Central Venous Ports in Children Under Six Years Old: A Retrospective Analysis of 154 Oncology Patients

Background Although some reports have evaluated the safety and efficacy of central venous port (CVP) placement in pediatric patients, the data about the inversion rate of the device and its risk factors are scarce. Therefore, this study aimed to evaluate the inversion rates of CVPs and their associated risk factors in pediatric patients. Methodology Between January 2010 and December 2021, 154 consecutive children (75 boys; median age, 28.5 months; range, 2-71 months) who underwent CVP placement at our center were included in this study. The primary outcome was the CVP inversion rate, and the secondary outcomes included technical success rate, intraoperative complications, and infectious complications. Intraoperative complications were evaluated according to the Society of Interventional Radiology guidelines. Patients under two years old were classified as the younger group and those aged ≥two years as the older group. Results The CVP inversion rate was 4.6% (n = 7/153), equivalent to 0.08 × 1,000 catheter-days. The inversion rate was significantly higher in the younger group (under two years old, 11.2%) than in the older group (≥two years old, 1.0%) according to the univariate analysis (p = 0.00576). The technical success rate was 99.4% (n = 153/154), and mild adverse events were observed during the procedure in three (1.9%) patients. Infectious complications were observed in 16 (10.5%) patients, equivalent to 0.19 × 1,000 catheter-days. Conclusions The CVP inversion rate was significantly higher in younger children (under two years old) than in older children (≥two years old).

Role of Interventional Radiology in Pediatric Cancer Patients

PURPOSE OF REVIEW

Pediatric interventional radiology (IR) is a growing subspecialty. Here, we review the current role of IR in children with cancer, which uses imaging such as ultrasound, fluoroscopy, and computed tomography to perform minimally invasive procedures. These include biopsy, needle localization, central venous access, thermal ablation, transarterial chemoembolization, transarterial radioembolization with yttrium-90, non-tunneled/tunneled drainage catheter placement, and lymphatic interventions.

RECENT FINDINGS

Although locoregional therapies for the treatment of cancer in adults are common, they are less common in children, perhaps due to the relative rarity of cancer in children, their typically better performance status, and paucity of comorbidities. Preliminary results from small-scale studies for ablation, transarterial chemoembolization, and transarterial radioembolization with yttrium-90 used in the front-line armamentarium of curative therapy are encouraging. Pediatric IR offers an array of minimally invasive procedures intended to diagnose and treat pediatric cancer patients. However, more research is required to determine the efficacy of locoregional therapy in children and to define the clinical scenarios where benefit is likely to be optimized.

Radiologic placement of Hickman catheters using intravenous sedation in pediatric patients under 20 kg

Surgeons generally perform Hickman catheter insertion in children under general anesthesia. At times, it is difficult to perform procedures with an anesthesiologist for an interventional radiologist. Several diagnostic and therapeutic procedures are efficiently and safely conducted using intravenous (IV) sedation in children with a pediatrician. This study aims to evaluate the efficacy and safety of radiologically placed Hickman catheters using IV sedation in children under 20 kg.Fifty-nine catheters were inserted in 45 children under IV sedation. With continuous monitoring of vital signs, IV midazolam and ketamine were slowly infused by a pediatrician. Mean age and body weights were 3.2 years and 15.2 kg, respectively. Acute leukemia was the most common disease for the procedure (72.9%). The location of the catheter tip was evaluated by measuring the height of the thoracic vertebra.Technical success rate was 100%, and IV sedation-related complications did not occur. The right internal jugular vein was accessed for 51 catheters (86.4%), and the mean procedure time was 21.5 minutes. The 2 vertebral body units below the carina were the cavoatrial junction on a fluoroscopy image. Mean catheter life was 285 days, and catheters were removed post-treatment (35.6%). During follow-up, complications occurred in 29 cases (1.72 per 1000 catheter-days). Catheter-related infections were suspected in 4 patients (6.8%), with 1 positive result.Radiological Hickman catheter placement in children under 20 kg using IV sedation by pediatricians is effective and safe, with minimal complications. The carina is a landmark to estimate the cavoatrial junction in pediatric patients.

Venous Ports in Infants

PURPOSE

To evaluate technical success and the incidences of, and risk factors for, mechanical and infectious complications of venous port placement in infants.

MATERIALS AND METHODS

This was a retrospective single-institution cohort study of port placement in infants (age < 1 y) from January 2006 through June 2016 (mean age, 7.5 mo ± 3.3; mean weight, 8.1 kg ± 1.9). Age, weight, sex, side of placement, tip position, and indication for placement (chemotherapy vs other) were recorded. Total catheter-days (CDs), mechanical complications, and central catheter-associated bloodstream infections (CCABSIs) were identified.

RESULTS

During the study years, 64 ports were placed in 64 infants, with a technical success rate of 100%. The mean catheter life was 321 days (total range, 4-1,917 d; interquartile range [IQR], 107-421 d). There were 13 CCABSI events (0.63 per 1,000 CDs); of these, 8 (12.5% among 64 patients) required port removal for infection. There was an increase in CCABSIs in patients with left-sided port placement (relative risk [RR], 3.22; 95% confidence interval [CI], 1.02-10.14; P = .05). There were 8 mechanical complications of the port reservoir or catheter (0.39 per 1,000 CDs). Of these, 2 (3.1%) required removal. Patients in the lowest weight quartile were at an increased risk of mechanical complications (RR, 4.37; 95% CI, 1.09-17.48; P = .04).

CONCLUSIONS

Venous ports can be placed with a high rate of technical success in infants. Left-sided ports and low weight are associated with increased infectious and mechanical complications, respectively.

Ultrasonography-guided central venous port placement with subclavian vein access in pediatric oncology patients

BACKGROUND/PURPOSE

To evaluate the technical success and complications of image-guided central venous port (CVP) placement with subclavian vein (SCV) access in pediatric oncology population.

MATERIALS AND METHODS

Ninety-two children (52 boys, 40 girls; mean age, 8.5 years) underwent CVP implantation under local anesthesia with conscious sedation. SCV access was firstly attempted under ultrasonographic guidance and CVP implantation was performed under fluoroscopic guidance. Technical success, peri-procedural (<24h) complication, and post-procedural (>24h) complication were assessed.

RESULTS

In total, 102 CVPs were implanted in 92 children with a mean catheter time of 364 days (total, 38,224 days; range, 14-1911 days). In three small children, conversion of SCV access to internal jugular vein access yielded a primary technical success rate of 97.1% and overall technical success rate of 100%. Three minor peri-procedural complications were observed (2.9%) and seven post-procedural infectious complications occurred (infection rate, 6.7%; 0.18/1000 catheter days). No pneumothorax, catheter malposition, venous thrombosis, or mortality occurred.

CONCLUSION

Image-guided CVP placement with SCV access in a pediatric population was performed with high technical success and low complication rate without general anesthesia. This procedure can be taken into account as a choice of procedure when internal jugular venous access is not possible.

Infectious morbidity by catheter type in neutropenic children with cancer

BACKGROUND

Three central venous catheters types are commonly used in pediatric cancer: totally implantable catheters (ICs; eg, mediports, portacaths), tunneled externalized catheters (eg Broviac® or Hickman® catheters [Bard Medical]) and peripherally inserted central catheters. While previous studies have examined risks for catheter-related infections, this is the first large multicenter study to compare catheter-associated infectious morbidity through patient outcomes and hospital utilization.

METHODS

A historical cohort analysis was conducted using data from the Pediatric Health Information System reporting 1167 hospitalizations of neutropenic patients with childhood cancer and a central venous catheters. Multivariate analyses controlled for age, ethnicity, gender, malignancy category and transplant status. Outcomes included incidence of serious bacterial infection, mortality, duration of hospitalization, time and use of intensive care unit and antibiotic usage.

RESULTS

Neutropenic cancer patients with totally ICs (n = 429) have a statistically significant approximately 50% decrease in length of hospitalization (P < 0.001), risk for requiring an intensive care unit stay (P = 0.002), documented serious bacterial infection (P = 0.001) and days on antibiotics (P < 0.001) when compared with patients with tunneled externalized catheters (n = 463). Similar differences were found comparing hospitalizations of patients with ICs to those with peripherally inserted central catheters (n = 275). No difference in mortality was observed among catheters groups.

CONCLUSIONS

In neutropenic pediatric oncology patients with a central venous catheters, ICs are associated with the least hospital utilization including shortest duration of hospitalization, intensive care unit time and antibiotic therapy when compared with tunneled external catheters and peripherally inserted central catheters. The impact of differences in catheter-associated infectious morbidity on patient outcomes and hospital utilization should be included in clinical decision making.

Transbrachial access for radiologic manipulation of problematic central venous catheters in a pediatric population

A transfemoral venous approach is the current standard for accessing malpositioned and fractured central venous catheters (CVCs). The purpose of this study was (1) to describe a transbrachial approach for correction and (2) to assess the success and failure of this method in a pediatric population. A 12-year retrospective review of all patients referred for correction of malpositioned, retained, and fractured CVCs was conducted. Based on the performing interventionalist's preference, transbrachial or transfemoral venous sheaths where placed under ultrasonographic guidance. Diagnostic angiographic catheters and snares were used to manipulate the catheters. Patients who underwent the transfemoral approach received postprocedural monitoring for 4 hours, whereas patients who underwent the transbrachial approach were allowed unrestricted activity immediately after hemostasis was obtained. Technical success of malpositioned lines was defined (1) by final position in the superior vena cava or at the cavoatrial junction on postprocedural imaging or (2) by successful removal of retained catheter fragments, if present. Transbrachial approach was used for access in 11 patients. Problematic lines included malpositioned (n = 10) and retained (n = 1) lines. The ipsilateral arm was used for transbrachial entry in 7 patients. Initial use of angiographic catheters was attempted in 7 cases, of which 4 were successful. All 3 unsuccessful cases had tips positioned in the contralateral brachiocephalic vein, and these were successfully repositioned using snares. A combination of snares and angiographic catheters was used in 2 cases. Snares were used for all other cases. Technical success by way of the transbrachial approach was observed in all cases. Periprocedural follow-up demonstrated no immediate complications. We conclude that the transbrachial approach is a suitable alternative to the transfemoral approach for catheter tip position correction. Tip malposition in the contralateral brachiocephalic vein suggests higher rate of conversion to use of snare devices.

Central vein dilatation prior to concomitant port implantation

Implantation of subcutaneous port systems is routinely performed in patients requiring repeated long-term infusion therapy. Ultrasound- and fluoroscopy-guided implantation under local anesthesia is broadly established in interventional radiology and has decreased the rate of complications compared to the surgical approach. In addition, interventional radiology offers the unique possibility of simultaneous management of venous occlusion. We present a technique for recanalization of central venous occlusion and angioplasty combined with port placement in a single intervention which we performed in two patients. Surgical port placement was impossible owing to occlusion of the superior vena cava following placement of a cardiac pacemaker and occlusion of multiple central veins due to paraneoplastic coagulopathy, respectively. In both cases the affected vessel segments were dilated with balloon catheters and the port systems were placed thereafter. After successful dilatation, the venous access was secured with a 25-cm-long, 8-Fr introducer sheath, a subcutaneous pocket prepared, and the port catheter tunneled to the venipuncture site. The port catheter was introduced through the sheath with the proximal end connected to a 5-Fr catheter. This catheter was pulled through the tunnel in order to preserve the tunnel and, at the same time, allow safe removal of the long sheath over the wire. The port system functioned well in both cases. The combination of recanalization and port placement in a single intervention is a straightforward alternative for patients with central venous occlusion that can only be offered by interventional radiology.