Percutaneous translumbar and transhepatic inferior vena caval catheters for prolonged vascular access in children.

Central venous access for children with caval occlusion remains a major challenge to pediatric surgeons. Traditionally, children with superior and inferior vena cava (SVC, IVC) thrombosis have often required a thoracotomy to directly cannulate the azygos system or right atrium (RA). Recently, the possibility of placing tunneled RA catheters (RACs) by a percutaneous translumbar or transhepatic approach has become available. We report our experience of seven children with SVC and IVC obstruction who have received 11 transhepatic and 4 translumbar RACs from 1987 to 1991. All but one child was less than 2.5 years old and all were chronically dependent on parenteral nutrition. All catheters were placed in the angiography suite under general anesthesia using ultrasound guidance and Seldinger technique. This technique was successful in all seven children. Perioperative complications included accidental extubation in one patient and aspiration pneumonia in another. Mechanical complications requiring RAC replacement occurred 5 times in three infants (greater than 2,650 catheter days) and included catheter dislodgement (2) and thrombosis (3). In the patients with catheter thrombosis, the existing tract was successfully wired and the catheter exchanged on three occasions. Thrombolytic therapy was effective in restoring catheter patency on three other occassions. Nine episodes of catheter sepsis occurred in five children. Two late deaths occurred from infection. Of the five remaining children, four are dependent on total parenteral nutrition and have a translumbar or transhepatic catheter in situ and one child has adapted successfully to enteral feedings. Percutaneous translumbar or transhepatic IVC catheters provide excellent alternative routes for prolonged central venous access in those patients whose traditional vascular access sites are no longer available. Complications of the technique itself were minimal and although late catheter complications were not infrequent, they appear to be comparable to the standard approaches reported.