Skin erosion over totally implanted vascular access devices in children

Factors affecting mechanical complications of central venous access devices in children

PURPOSE

Factors leading to mechanical complications following insertion of central venous access devices (CVADs) in children are poorly understood. We aimed to quantify the rates and elucidate the mechanisms of these complications.

METHODS

Retrospective (2016-2021) review of children (< 18 years old) receiving a CVAD. Data, reported as number of cases (%) and median (IQR), were analysed by Fisher's exact test, chi-squared test and logistic regression analysis.

RESULTS

In total, 317 CVADs (245 children) were inserted. Median age was 5.0 (8.9) years, with 116 (47%) females. There were 226 (71%) implantable port devices and 91 (29%) Hickman lines. Overall, 54 (17%) lines had a mechanical complication after 0.4 (0.83) years from insertion: fracture 19 (6%), CVAD migration 14 (4.4%), occlusion 14 (4.4%), port displacement 6 (1.9%), and skin tethering to port device 1 (0.3%). Younger age and lower weight were associated with higher risk of complications (p < 0.0001). Hickman lines had a higher incidence of complications compared to implantable port devices [24/91 (26.3%) vs 30/226 (13.3%); p = 0.008].

CONCLUSION

Mechanical complications occur in 17% of CVADs at a median of < 6 months after insertion. Risk factors include younger age and lower weight. Implantable port devices have a lower complications rate.

LEVEL OF EVIDENCE

Level 4: case-series with no comparison group.

Iatrogenic vascular trauma and complications of vascular access in children

Vascular access is frequently a critical component of the diagnostic and therapeutic procedures required to manage childhood illnesses, including many emergent conditions and critical illnesses. Vascular access in the pediatric population presents unique challenges, and many clinical and technical factors must be considered to avoid complications that can occur with vascular access procedures. This article reviews various aspects of vascular access and associated iatrogenic trauma in children, including risk factors, management of complications, and preventive measures to avoid complications. It is only with a comprehensive understanding of the topic that vascular access in children can be performed safely, effectively, and efficiently.

Risk profile of subcutaneous port placement in small children

BACKGROUND/PURPOSE

Long-term central venous access is a safe and common procedure in children. However, complications with devices are a reality. Smaller children are thought to have a higher rate of complication after port placement, and some surgeons avoid placing ports with an arbitrary weight cutoff out of concern for surgical site morbidity.

METHODS

We performed a multi-institutional retrospective review of 500 patients less than 5 years of age undergoing port placement at three large volume children's hospitals from 2014 to 2018. Patients were divided by weight greater than or less than 10 kg at the time of insertion. Statistical analysis was performed to evaluate for differences in outcomes between the two groups.

RESULTS

The majority of ports were placed for chemotherapy access (71.8%). Other indications included long-term infusions (18.8%) and difficult chronic IV access (9.4%). Of the 500 charts reviewed, 110 (22%) experienced some documented complication (28.9% <10 kg, 20.6% >10 kg, p = 0.096). There were no differences between the two groups in terms of the type or timing of complications. Overall, 16.3% of ports required removal prior to the end of therapy owing to a complication. Complication rate per day with the port in place was not different between the two groups (<10 kg: 0.68 complications/1000 port-days vs >10 kg 0.44 complications/1000 port-days, p = 0.068).

CONCLUSION

Weight less than 10 kg was not associated with a significantly higher incidence of any type of port complication in our cohort. This suggests that concern for complications should not exclude children less than 10 kg from port placement.

TYPE OF STUDY

Multi-institutional retrospective review.

LEVEL OF EVIDENCE

Level III.

Risks of long-term port use in enzyme replacement therapy for lysosomal storage disorders

Totally implantable vascular access devices (TIVADs) are commonly used in conjunction with enzyme replacement therapy (ERT) for lysosomal storage disorders (LSDs). This case series describes potential complications associated with long-term TIVAD use, such as compromise of skin integrity, infection, or port failures. Best practices and skilled specialists are essential for minimizing complications from long-term TIVAD use for ERT.

Implantable central venous access device in infants: Long-term results

BACKGROUND

The management of central venous access device (CVAD) is extremely difficult in babies and small infants (BSI). We therefore compared the long-term results and complications of CVAD in BSI with those in children.

METHODS

One hundred and twenty patients were divided into two groups as follows: age <1 year or weight <10 kg (group A; 25 patients); and age ≧1 year and weight ≧10 kg (group B; 95 patients). The clinical results were retrospectively compared between the groups.

RESULTS

Mean age and weight were 12.5 ± 5.9 months and 8.2 ± 1.2 kg in group A, and 78.8 ± 58.9 months and 20.9 ± 13.6 kg in group B. Operation time was 57 ± 29 min in group A and 52 ± 21 min in group B (P = 0.38). The catheter was advanced with difficulty into the central vein in five and in 16 patients (P = 0.77), and surgical complications occurred in one and in seven patients in groups A and B, respectively (P > 0.99). The CVAD remained in place for 627 ± 494 and 550 ± 414 days (P = 0.47) and was removed before treatment completion in five and in 14 patients in groups A and B, respectively (P = 0.54).

CONCLUSION

The clinical results for CVAD in BSI did not differ from those in children. CVAD are useful and safe for the treatment of BSI with serious diseases.

Central venous catheter database: an important issue in quality assurance

BACKGROUND/PURPOSE

The purpose of this study was to analyze the factors that affect the longevity of central venous catheters.

METHODS

Comprehensive clinical data recorded during insertion and removal of totally implantable devices (TID) and tunneled lines (TL) from October 1988 to January 2009 were analyzed. Univariate and multivariate Cox proportional hazards regression models were used to identify clinical factors that predict catheter longevity.

RESULTS

Information was available for 1167 central venous catheter insertions in 858 patients, 648 TID and 509 TL. Univariate analysis detected longer device longevity in the following: TID longer than TL (P < .0001), catheter tip in the superior vena cava (SVC)/right atrial junction (P < .0001), and right side greater than left (P = .002). Shorter device longevity was observed in lines used for total parenteral nutrition (P < .0001) and young age (P < .0001). Multivariate model detected the following: hazard of removal for TID is 0.304 that of TL (P < .0001) and SVC is 0.525 that of other locations (P = .0005). Hazard decreases by 5.4% for every 1-year increase in patient age (P < .0004).

CONCLUSION

Multiple confounding factors were encountered. However, the single most important factor in catheter longevity that is influenced by the surgeon is tip location in the SVC/right atrial junction.