Hickman to central venous catheter: A case of difficult venous access in a child suffering from acute lymphoblastic leukemia.

Chemotherapy in children suffering from cancer usually requires placement of an indwelling central venous catheter (CVC). A child may need to undergo repeated procedures because of infection and occlusion of previous access devices. We present a case of CVC insertion in a child suffering from acute lymphoblastic leukemia where an innovative technique was employed.

INTRODUCTION

Chemotherapy drugs are known to cause damage to the veins through which they are administered. Wider bore veins, especially the central veins, can receive chemotherapy better as the drug becomes diluted before coming in contact with the vascular endothelium. For this purpose, various devices such as peripherally inserted central catheter (PICC), central venous catheter (CVC), Hickman line, and chemo port (Port-a-Cath) are employed. While PICC and CVC are less expensive, usable up to a few weeks[1] and can be inserted in the chemotherapy unit itself, Hickman line and chemo port are costlier, can be used from months to a year,[2] and need the assistance of a surgical unit.

It is common for the indwelling CVCs to get infected in spite of best possible care.[34] The commonly preferred location of insertion of a Hickman's line or a chemo port is right internal jugular vein (RIJV),[5] but one has to look for other options once the line gets infected or occluded.[4] After RIJV, the next choices are right subclavian vein and left internal jugular vein (LIJV). The left subclavian vein is avoided due to high procedure-related risk[6] and the femoral veins because of their high risk of contamination.

This case posed a unique challenge for CVC replacement that was meted with innovative solution. Prior consent for case report publication was obtained from the parents after thorough explanation of the procedure.

CASE REPORT

A 4-year-old girl diagnosed with precursor-B cell acute lymphoblastic leukemia (ALL) was posted for chemo port insertion via her RIJV under general anesthesia (GA). Upon remission, the chemo port was removed on day-care basis. She had relapse of ALL and was advised a Hickman line insertion. She was taken to the operating room (OR) under platelet infusion cover. After induction of GA, an ultrasound scan of right neck revealed a thrombosed RIJV [Figure 1]. The right subclavian vein was difficult to image, and after failed attempts at right subclavian cannulation, LIJV was accessed under ultrasound guidance. A double-lumen Hickman line (Vygon) was inserted via LIJV under all aseptic measures. She was started on chemotherapy alongside higher antibiotics. She complained of pain at the Hickman line anchorage site. On examination, there was erythema with tenderness and induration up to T3 level. Suspecting chest wall infection, she was posted for urgent removal of the Hickman line under GA, with white blood cell count = 300/cumm, platelet count of 32,000/cumm, and hemoglobin of 9.2 g/dl. She was taken to OR with platelet transfusion. Removal of her Hickman line posed a unique challenge as the child would need a central venous access for continuation of her treatment. While her RIJV was thrombosed, right subclavian was difficult to access and LIJV already cannulated, the only option was to cannulate one of the femoral veins, but that would last not more than a few days because of infection. Open technique for the right subclavian vein cannulation was not considered because of low platelet count and existing chest wall infection. We came up with an innovative solution to this challenge.

Figure 1

Depicting the condition before the surgery. (a) Ultrasonogram of the right side of the neck showing a patent carotid artery (medial) but a thrombosed right internal jugular vein (arrow); (b) inflamed chest wall at the site of the Hickman line anchorage; (c) fluoroscope image of the Hickman line via the left internal jugular vein (before removal)

The operative area was painted and draped [Figure 2], and only the part of the neck from where the Hickman line entered the LIJV was exposed. The previous surgical incision in the neck was opened, and the Hickman line was carefully withdrawn one cm from the proximal end. After holding the Hickman line with a nontoothed forceps, it was cut with scalpel and a chemo port adapter needle was inserted into the lumen. A hepflush syringe was attached to the adapter and blood was aspirated to confirm the patency of the line. The position of the Hickman line was confirmed by fluoroscope. Now, the adapter needle was disconnected and the guidewire of a 5.5 Fr, 8 cm triple lumen CVC (Vygon) was threaded through the lumen. After confirming the position of the guidewire by fluoroscope, the Hickman line was taken out and CVC inserted over the guidewire. The position of the CVC was confirmed by fluoroscope, hemostasis obtained, sutured, and sterile adhesive dressing applied. The infected Hickman port site was uncovered. It was taken out after careful adhesiolysis. The area was cleaned, packed with betadine-soaked gauze and compressive dressing was applied. The catheter tip was sent for culture, which later came out to be sterile.

Figure 2

Depicting the procedure. (a) Incision in the neck has been re-opened and the Hickman line pulled out by 1 cm from the proximal end; (b) Hepflush syringe attached to the cut end of Hickman line by chemo port adapter needle and blood aspirated; (c) guidewire threaded via the cut end of the Hickman line; (d) fluoroscope image of the guidewire in place; (e) fluoroscope image of the central venous catheter threaded over the guidewire; (f) the triple lumen central venous catheter in place after taking out the guidewire

DISCUSSION

The incidence of venous occlusion following CVC insertion is higher, up to 25% with open cut-down and landmark-based techniques, whereas it is much lower (3%) for percutaneous ultrasound-guided techniques.[7] Hickman lines are associated with higher complication rates compared to a chemo port.[8] Use of ultrasound helps identifying central veins and reduces the risks of complications. Ultrasound scan for CVC insertion is usually done in the OR before the procedure. In case of children, it is done in the OR after inducing GA.

CVC-related infections consume great amount of healthcare resource and manpower as well as add to the morbidity and mortality of the primary disease. A central line care maintenance bundle should be followed in pediatric oncology units to protect the immunosuppressed children from potentially fatal infections.[9] In our patient, the ongoing infection and need of chemotherapy and antibiotic therapy demanded a central venous line as well as removal of the infected Hickman line. We devised an innovation that would answer both needs without involving another major central vein keeping in mind the future requirements of the patient.

In early infections of the chest wall, following a Hickman line insertion, the catheter lumen is usually sterile as the injection port is 8–10 cm distal from the site of anchorage in the chest wall and the Dacron sleeve prevents microbial colonization of the catheter. This makes usage of the lumen amenable for a further cannulation. Armed with this knowledge, we devised the above technique and provided the child with a central venous access through the same vein which harbored the Hickman line.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.