2025 Pediatric Surgery Update Course - Updates in Central Line Management

A teenager with a left subclavian dual-lumen port had a history of subclavian thrombus successfully treated with heparin, but the medial lumen would not flush while the lateral lumen functioned normally.

The non-flushing port was found to be simply not accessed correctly; re-accessing it allowed it to flush normally without any other intervention.

Removing and replacing a port for access issues without fluoroscopic evaluation risks losing potential future access sites and may contribute to the cascade creating 'vasculopath' patients with no upper or lower central access.

Sharp recanalization of the SVC can be performed using ultrasound to visualize the jugular vein and a combination of fluoroscopy and ultrasound to guide a small needle through the stenosis into the right atrium.

Two techniques for sharp recanalization include: (1) using a contrast-filled circle as a target from above while advancing a needle from the femoral vein below, and (2) inflating a contrast-filled balloon from below as a target for needle puncture.

The thoracic azygos approach for central access involves staying anterior and lateral to the carotid artery, using ultrasound guidance, and is described as similar to laparoscopic inguinal hernia repair in technique.

The Surface EKG system by Merit Medical allows image-guided SVC recanalization by advancing a catheter from the femoral vein to the occlusion site, defining a target exit point, and driving a needle through the catheter to create through-and-through access.

The Surface EKG technique works best when there is at least a remnant of vessel present to traverse, rather than complete chronic occlusion.

Intracardiac echocardiography (ICE) catheters project ultrasound waves 360 degrees and can reconstruct images in any plane, potentially allowing safer guidance of needles across vascular occlusions.

Traditional ICE catheters are 10 French, newer versions are 8 French, and some can be used in 7.5 French sheaths; 10 French is difficult in pediatric patients but 8 French is more feasible.

When dilating across tight vascular occlusions, balloons are used rather than traditional dilators, starting with small cardiac balloons (5mm) and progressively increasing size.

Transhepatic access may be easier to control if bleeding occurs or the catheter dislodges, particularly in pediatric patients, but weak evidence suggests higher thrombosis rates compared to translumbar access.

Two patients with transhepatic catheters experienced dislodgement into the peritoneal cavity due to respiratory movement, resulting in TPA infusion into the abdomen and severe complications.

Translumbar catheter dislodgement results in retroperitoneal bleeding which may be contained by muscle, whereas transhepatic dislodgement causes hemoperitoneum.