Vessel Perforation and False Tracking Resulting From Umbilical Artery Catheterization: A Case Report and Literature Review

Standard umbilical artery catheters used as diagnostic and neurointerventional guide catheters in the treatment of neonatal cerebrovascular malformations

BACKGROUND

Vascular access in neonates is limited by the small size of the femoral artery and the risk of complications, including thrombosis and limb ischemia. Although umbilical artery access has been described, previous reports detail exchange of the umbilical artery catheter (UAC) for a conventional arterial sheath, which can be difficult and cumbersome. We aim to describe direct use of the UAC as the sheath and guide catheter in neonatal patients requiring endovascular treatment for life-threatening intracranial arteriovenous shunts.

METHODS

We reviewed all cases between 2016 and 2021 of neonatal intervention using a direct UAC approach. We describe our technique of utilizing UACs for cerebral angiography and neurointerventions in newborns without catheter exchange, allowing for repeated, straightforward endovascular access in neonates across multiple interventions.

RESULTS

Seven consecutive neonates underwent endovascular neurointerventional procedures for the treatment of life-threatening, high-flow arteriovenous shunts using a direct UAC access technique without procedural morbidity. Five of seven patients underwent more than one procedure in the neonatal period, between day 1 and day 10 of life.

CONCLUSIONS

Use of the UAC itself as a diagnostic catheter for cerebral angiography or as a guide catheter for neurointerventions greatly facilitates endovascular interventions in newborns and is ideal for patients requiring multiple interventions in the neonatal period. This technique helps to mitigate the risk of neonatal femoral artery access and its complications, including thrombosis, dissection, spasm, stenosis, and limb ischemia.

Umbilical catheter placement aided by coronary guidewires

Catheterization of the umbilical vessels has proven to be an effective and relatively rapid method for gaining central vascular access in neonates. However, it can be technically difficult, the procedure may last 30 min or longer, and it can be associated with complications in some patients. We suggest using a coronary guidewire during catheterization of umbilical vessels to support the placement of umbilical catheters and significantly reduce a risk for complications. We tested the proposed technique in 6 successful ex vivo bench tests of catheterization of the umbilical vessels in stillborn piglets immediately after birth. We are confident that using coronary guidewire as a guiding tool during catheterization of the umbilical vessels is a rapid and safe method. We expect that it allows to obtain a vascular access with lower risk for dangerous procedural complications, which could be a lifesaving in critically ill patients. However, the approach needs to be validated in a comparative study in neonates.

Adverse events associated with umbilical catheters: a systematic review and meta-analysis

OBJECTIVE

To determine the incidence of adverse events (AEs) associated with umbilical catheters in the neonatal population.

STUDY DESIGN

Systematic review and meta-analysis of observational studies and randomized controlled trials published between 2010 and 2020.

RESULTS

In total 14,226 umbilical venous catheters (UVCs) and 4228 umbilical arterial catheters (UACs) were included. Overall, 13.4% of UVCs were associated with an AE (95% CI: 10.1-17.0) or 2.4 per 1000 catheter days (95% CI: 1.8-3.0). UACs had an AE rate of 9% (95% CI: 5.9-12.8) or 0.87 per 1000 catheter days (95% CI: 0.4-1.3). UVC malposition was the most common (41.7% [95% CI: 27.6-56.5]). Local injury from UAC taping was the most common AE in one study.

CONCLUSIONS

Umbilical catheters have a high incidence of AEs. Research into accurate methods of tip verification, tip surveillance, and securement is required.

Risk factors for umbilical vascular catheter-related adverse events: A scoping review

INTRODUCTION

Adverse events associated with umbilical catheters include malposition, bloodstream infections, thrombosis, tip migration, and extravasation, resulting in loss of vascular access and increased risk of morbidity and mortality. There is a need for greater understanding of risk factors associated with adverse events to inform safe practice.

OBJECTIVES

The aim of the study was to summarise the existing evidence regarding risk factors for umbilical catheter-related adverse events to inform the undertaking of future research.

REVIEW METHOD USED

A scoping review of peer-reviewed original research and theses was performed.

DATA SOURCES

The US National Library of Medicine National Institutes of Health, Embase, EMcare, and ProQuest Dissertations and Theses were the data sources.

REVIEW METHODS

Informed by the Joanna Briggs Institute Reviewer's Manual, all types of original research studies reporting adverse events published in English from 2009 to 2020 were eligible for inclusion. Studies where umbilical artery catheter and umbilical venous catheter data could not be extracted separately were excluded.

RESULTS

Searching identified 1954 publications and theses, 1533 were excluded at screening, and 418 were assessed for eligibility at full text. A total of 89 studies met the inclusion criteria. A range of potential risk factors for umbilical arterial and venous catheters were identified. Longer dwell time and prematurity were associated with increased risk of bloodstream infection and thrombosis in cohort studies. Case studies detailed analogous factors such as insertion techniques and lack of catheter surveillance during dwell warrant further investigation.

CONCLUSIONS

We identified a vast range of patient, device, and provider risk factors that warrant further investigation. There was a lack of large cohort studies and randomised controlled trials to demonstrate the significance of these risk factors. Improvement in methods to ensure correct catheter tip location and to detect adverse events early is essential. In addition, policy needs to be developed to guide clinicians in catheter surveillance measures to reduce the risk of adverse events.

Are there changes to regional tissue oxygenation and circulation following umbilical artery catheter placement? A prospective cohort study in newborn infants

AIM

The use of umbilical arterial catheters (UACs) is a standard of care in monitoring critically unwell infants. Serious vascular complications are rare but when they do occur, they can be associated with significant morbidity, risking limb loss or even death. Near infra-red spectroscopy has the potential to monitor limb perfusion. Our study investigates changes in tissue oxygenation and perfusion in the abdominal and leg circulation following UAC insertion.

METHODS

A prospective observational study performing ultrasound pulsed Doppler measurements in the coeliac, superior mesenteric artery, renal arteries and the femoral arteries as well as near infrared spectroscopy measurements of both thighs at three time points (immediately before = Time 1, 1 h after = Time 2 and 24 h after UAC insertion = Time 3).

RESULTS

We monitored 30 infants, the mean gestational age was 30 weeks (24-41) and the mean birthweight was 1720 g (600-4070 g). We observed statistically significant changes (P < 0.05) in pulse Doppler measurements in coeliac (mean peak systolic velocity (PSV): Time 1 = 70.51, Time 2 = 61.75; resistive index (RI): Time 1 = 0.75, Time 2 = 0.67), superior mesenteric (PSV: Time 1 = 41.72, Time 2 = 36.10; RI: Time 1 = 0.92, Time 2 = 0.87), renal (same side end-diastolic velocity: Time 1 = 1.98, Time 2 = 3.80; RI: Time 1 = 0.93, Time 2 = 0.87; opposite side end-diastolic velocity: Time 1 = 2.62, Time 2 = 3.84; RI: Time 1 = 0.92, Time 2 = 0.85) and femoral arteries (same side PSV: Time 1 = 72.75, Time 2 = 62.18; opposite side PSV: Time 1 = 81.89, Time 2 = 62.74). Tissue oxygenation in lower limbs remained unaffected (same side (mean): Time 1 = 68.59, Time 2 = 68.99, Time 3 = 66.40, opposite side: Time 1 = 67.72, Time 2 = 66.92, Time 3 = 65.40). All infants on clinical examination had normal lower limb perfusion, lower limb arterial pulses and normal perfusion to the gluteal region before and after insertion of UAC.

CONCLUSIONS

While sub-clinical changes in perfusion occur in abdominal and leg circulation, these changes are not consistent across vessels and regional tissue oxygenation remains unaffected.