- Email: [email protected]
Initial experience with percutaneous transhepatic cardiac catheterization in infants and children
Initial Experience With Cardiac Catheterization Robert J. Sommer,
MD,
Richard
Percutaneous Transhepatic in Infants and Children J. Golinko,
MD,
and
Harold
A. Mitty,
MD
er, almost to the right margin of the spine (Figure 2). As the needle was withdrawn, dilute contrast material was injected slowly. When a hepatic vein was clearly idenroutes of central venous access. Since hemodynamic tified (Figure 3), a 0.018 floppy wire was advanced information may be critical in determining the feasibil- through the needle to the inferior vena cava and the right ity, timing, and type of surgery required for these chil- atrium (Figure 4). The coaxial dilator from the Neff Set dren, and interventional catheter therapy may increase was advancedover the wire to the right atrium. The 0.018 the likelihood of a successfuloutcome, alternative methods of obtaining venous accessfor catheterization may be life-saving. Recently, percutaneous central venous catheter placement via translumbar and transhepatic routes was shown to be safe and efficacious for delivering parenteral nutrition in children with bicaval obstruction.’ We used a modified percutaneous transhepatic technique to perform 12 cardiac catheterizations in 9 children with either bilateral femoral venous occlusion, superior vena cava occlusion, or both. In 7 of the 9 patients, and in 3 additional patients, we successfully placed a “tunneled” radiopaque silicone catheter,via the accessobtained, to provide chronic central access.
n children with complex congenital heart disease,mulIvenous tiple cardiac catheterizations and perioperative central lines may lead to occlusion of the conventional
. . .
Between February 1994 and February 1995, 12 cardiac catheterizations were performed in 9 children (age range 3 to 52 months, weight range 2.3 to 14.8kg) using a percutaneoustranshepatic approach.Indications for the procedure included bilateral femoral vein and superior vena cava obstruction (4 patients), bilateral femoral vein obstruction with a bidirectional Glenn shunt (2 patients), bilateral femoral vein obstruction and the need for catheter intervention in a patient scheduled to have a bidirectional Glenn shunt (1 patient), an interventional procedure in a small infant, posing a significant risk to femoral or internal jugular vessels (1 patient), and need for catheterization as well as chronic venous accessin a patient who would require multiple interventional catheter procedures in the future (1 patient). A commercially available kit (Neff Percutaneous Access Set, Cook Inc., Bloomington, Indiana), designed for percutaneous nephrostomy or biliary drainage, was used to obtain central venous access.The patient was placed in a supine position. Sedation was given as for routine catheterization. The abdomen was prepped and draped from the umbilicus to the right flank. Lidocaine was infiltrated at the site of entry. Under fluoroscopic guidance the “chiba” needle from the Neff Set was introduced into the liver in the right mid to anterior axillary line at the lower costal margin, was angled superiorly and posteriorly toward the intrahepatic inferior venacava (Figure 1A and B), and was advanced through the livFrom The Division of Pediatric Cardiology and The Division of Interventional Radiology, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, New York 10029. Manuscript received November 2, 1994; revised manuscript received and accepted Feb wary 27, 1995.
FIGURE 1. Angulation of the needle for percutaneous entry. (A) Anterior-posterior view: the needle is angled leftward and superior toward the confluence of he atic vein and inferior vena cava (arrows indicate course o P the needle). (6) Lateral view: left is anterior, right is posterior. The needle is aimed superiorly and posteriorly (arrows indicate direction). The diaphragmatic surface is marked with small arrowheads as a point of reference.
BRIEF REPORTS
1289
FIGURE 2. Anterior-posterior view: The needle (needle cated by orrow) is advanced through ihe liver, almost right margin of the spine. A small amount of contrast s&n in th< hepatic pkrenchyma where a test ir+ction been made.
tip indito the can be has
wire was exchanged for a 0.038 J-wire, and a standard 7Fr sheath was advanced over the wire to the junction of the inferior vena cava and right atrium. Catheterization was performed as through any other venous sheath. Central venous access was obtained in all patients. The time required for obtaining transhepatic access was not significantly different than for routine access (~15 minutes in all cases, and ~10 minutes in 10 of 12 cases). After sheath placement, complete right heart catheterization was performed using standard balloon-directed angiographic and end-hole catheters. Complete transseptal left-heart catheterization was accomplished easily in 4 patients with an atrial septal defect. Three of the patients underwent interventional balloon dilation procedures using the transhepatic access: 2 with branch pulmonary artery stenosis, and 1 with significant ad&c arch obstruction following lirst stage palliation of hypoplastic leftheart syndrome. There were no complications associated with transhepatic sheath placement, catheterization, or interventional procedures. One critically ill infant died during a cardiac catheterization in which a transhepatic sheath had been placed. At autopsy, death was considered to be unrelated to transhepatic catheter placement. Potential complications of obtaining central venous access through the liver are different from, but not significantly greater than, those of other routes. They include hemobilia, retroperitoneal bleeding, liver abscess formation, cholangitis, and pneumothorax. Eight of the 9 patients required persistent central venous access for perioperative management (4 patients), for long-term antibiotic therapy (3 patients) or for total parenteral nutrition (1 patient). Therefore, following catheterization, a 6.6Fr single-lumen or 7Fr double-lumen Broviac catheter (C.R. Bard Inc., Salt Lake City, Utah) was successfully placed in 7 of 8 patients using the existing transhepatic pathway. One failure occurred
1290
THE AMERICAN JOURNAL OF CARDIOLOGY3
VOL. 75
FIGURE 3. Anterior-posterior view: The hepatic veins [open arrowsj and inferior vena cava [dark arrow) are filled when contrast is i+cted within o hepatic vein. The contrast drains to the right atrium.
in a 2.3 kg infant, and was related to patient/equipment size. In 3 additional patients, a Broviac catheter was placed via the transhepatic approach, without concurrent cardiac catheterization, for hemodialysis (1 patient), for long-term home gancyclovir therapy (1 patient), or for replacement of dislodged transhepatic Broviac catheter (1 patient). Broviac catheter placement, for chronic central venous access, was accomplished in 10 of the 11cases attempted. The smallest patient who had successful Broviac catheter placement was 3.2 kg. Lidocaine was infiltrated subcutaneously, and a 3 to 4 cm subcutaneous “tunnel” was created, using a hemostat, that led away from the indwelling sheath. The Broviac catheter was cut to size and was advanced through the tunnel until the cuff of the catheter was positioned inside the hmnel. The indwelling sheath was exchanged for a peel-away sheath over a 0.038 wire. Through the peel-away sheath, the Broviac catheter tip was advanced to the right atrium, and the sheath was removed. The 2 small skin incisions were sutured. The catheter was anchored to the skin near the distal tunnel site. Catheter function and position (Figure 5) were checked before leaving the laboratory. Broviac catheters were left in place for 18 to 290 days (median 35). No Broviac catheter became occluded or infected during the time they were in place. There has been no clinical evidence of thromboembolic phenomena. One Broviac catheter became dislodged (into the peritoneum) 15 days after placement and was removed with no sequelae.’ In 2 of the first 4 patients, both of whom had right atria1 hypertension, significant blood loss requiring transfusion occurred during Broviac catheter placement. No subsequent patient required a transfusion, probably due in part to increased proficiency with the technique. No
JUNE 15, 1995
FIGURE 4. Anterior-posterior view: Following hepatic vein visualization, a platinum-tipped wire [open arrow) is passed through the needle [arrowheads) to the right atrium.
FIGURE 5. Anterior-posterior view: Broviac catheter position prior to leaving the catheterization laboratory. The catheter tip (arrowheads) is in the high right atrium.
clinical bleeding occurred upon catheter removal in any patient. The transhepatic sheath was removed immediately in the catheterization laboratory after catheterization in 2 patients who did not receive chronic access. The Broviac catheter was removed from 5 patients at the bedside, 18 to 38 days after placement. The sheath was removed following repeat catheterization in 2 patients in whom the indwelling Broviac catheter had been usedfor access.The catheter is still in use in 3 other children. We postulate that, with chronic line placement,a fibrosed tract forms from the hepatic vein entry site to the skin, and becomesthrombosed by local compression following catheter/sheathremoval. The risk of significant intraabdominal bleeding with sheath removal immediately after catheterization is not known. Potential additional complications of chronic indwelling lines from a transhepatic route include BuddChiari syndrome, and the usual complications of chronic central venous access:catheter thrombosis, thromboembolic phenomena, and line sepsis.
would naturally guide the catheter to the foramen ovale and into the left atrium), and for transseptalpuncture to perform left-heart catheterization in patients with bilateral femoral venous obstruction (using a stiff sheathand a modified curve on the Brockenbrough needle). Other than for catheterization, additional indications for transhepatic venous accessmay include catheter placement for chemotherapyand transvenouspacemakerlead placement (as an alternative to thoracotomy) in patients with obstructed caval pathways.Defining the risks of and contraindications to the transhepatic techniques will require a larger seriesof patients with a longer follow-up period. Percutaneous transhepatic cardiac catheterization is a straightforward procedure that can be performed by experienced pediatric interventionalists with little additional training. We believe that this technique can be a valuable tool in the treatment of selected patients with complex congenital heart defects.
. . .
Future indications for transhepatic cardiac catheterization might include patients with congenitally interrupted inferior vena cava who require entranceto the left atrium and pulmonary veins (the transhepatic course
1. Azizkhan RG, Taylor LA, Ja@es PF. Mauro MA, Lacey SR. Percutaneous tmnslumbar and transhepatic inferior vena caval catheters for prolonged vascular access in children. J Pediarr Srrrg 1992:27:165-169. 2. Robertson LJ, Jaques PF, Mauro MA, Azi.kban RG, Robards J. Percutaneous inferior vena cava placement of tunneled silastic catheters for prolonged vascular access in infants. J Pediarr Surg 1990;25:596-598.
BRIEF REPORTS 1291
MD,
Richard
Percutaneous Transhepatic in Infants and Children J. Golinko,
MD,
and
Harold
A. Mitty,
MD
er, almost to the right margin of the spine (Figure 2). As the needle was withdrawn, dilute contrast material was injected slowly. When a hepatic vein was clearly idenroutes of central venous access. Since hemodynamic tified (Figure 3), a 0.018 floppy wire was advanced information may be critical in determining the feasibil- through the needle to the inferior vena cava and the right ity, timing, and type of surgery required for these chil- atrium (Figure 4). The coaxial dilator from the Neff Set dren, and interventional catheter therapy may increase was advancedover the wire to the right atrium. The 0.018 the likelihood of a successfuloutcome, alternative methods of obtaining venous accessfor catheterization may be life-saving. Recently, percutaneous central venous catheter placement via translumbar and transhepatic routes was shown to be safe and efficacious for delivering parenteral nutrition in children with bicaval obstruction.’ We used a modified percutaneous transhepatic technique to perform 12 cardiac catheterizations in 9 children with either bilateral femoral venous occlusion, superior vena cava occlusion, or both. In 7 of the 9 patients, and in 3 additional patients, we successfully placed a “tunneled” radiopaque silicone catheter,via the accessobtained, to provide chronic central access.
n children with complex congenital heart disease,mulIvenous tiple cardiac catheterizations and perioperative central lines may lead to occlusion of the conventional
. . .
Between February 1994 and February 1995, 12 cardiac catheterizations were performed in 9 children (age range 3 to 52 months, weight range 2.3 to 14.8kg) using a percutaneoustranshepatic approach.Indications for the procedure included bilateral femoral vein and superior vena cava obstruction (4 patients), bilateral femoral vein obstruction with a bidirectional Glenn shunt (2 patients), bilateral femoral vein obstruction and the need for catheter intervention in a patient scheduled to have a bidirectional Glenn shunt (1 patient), an interventional procedure in a small infant, posing a significant risk to femoral or internal jugular vessels (1 patient), and need for catheterization as well as chronic venous accessin a patient who would require multiple interventional catheter procedures in the future (1 patient). A commercially available kit (Neff Percutaneous Access Set, Cook Inc., Bloomington, Indiana), designed for percutaneous nephrostomy or biliary drainage, was used to obtain central venous access.The patient was placed in a supine position. Sedation was given as for routine catheterization. The abdomen was prepped and draped from the umbilicus to the right flank. Lidocaine was infiltrated at the site of entry. Under fluoroscopic guidance the “chiba” needle from the Neff Set was introduced into the liver in the right mid to anterior axillary line at the lower costal margin, was angled superiorly and posteriorly toward the intrahepatic inferior venacava (Figure 1A and B), and was advanced through the livFrom The Division of Pediatric Cardiology and The Division of Interventional Radiology, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, New York 10029. Manuscript received November 2, 1994; revised manuscript received and accepted Feb wary 27, 1995.
FIGURE 1. Angulation of the needle for percutaneous entry. (A) Anterior-posterior view: the needle is angled leftward and superior toward the confluence of he atic vein and inferior vena cava (arrows indicate course o P the needle). (6) Lateral view: left is anterior, right is posterior. The needle is aimed superiorly and posteriorly (arrows indicate direction). The diaphragmatic surface is marked with small arrowheads as a point of reference.
BRIEF REPORTS
1289
FIGURE 2. Anterior-posterior view: The needle (needle cated by orrow) is advanced through ihe liver, almost right margin of the spine. A small amount of contrast s&n in th< hepatic pkrenchyma where a test ir+ction been made.
tip indito the can be has
wire was exchanged for a 0.038 J-wire, and a standard 7Fr sheath was advanced over the wire to the junction of the inferior vena cava and right atrium. Catheterization was performed as through any other venous sheath. Central venous access was obtained in all patients. The time required for obtaining transhepatic access was not significantly different than for routine access (~15 minutes in all cases, and ~10 minutes in 10 of 12 cases). After sheath placement, complete right heart catheterization was performed using standard balloon-directed angiographic and end-hole catheters. Complete transseptal left-heart catheterization was accomplished easily in 4 patients with an atrial septal defect. Three of the patients underwent interventional balloon dilation procedures using the transhepatic access: 2 with branch pulmonary artery stenosis, and 1 with significant ad&c arch obstruction following lirst stage palliation of hypoplastic leftheart syndrome. There were no complications associated with transhepatic sheath placement, catheterization, or interventional procedures. One critically ill infant died during a cardiac catheterization in which a transhepatic sheath had been placed. At autopsy, death was considered to be unrelated to transhepatic catheter placement. Potential complications of obtaining central venous access through the liver are different from, but not significantly greater than, those of other routes. They include hemobilia, retroperitoneal bleeding, liver abscess formation, cholangitis, and pneumothorax. Eight of the 9 patients required persistent central venous access for perioperative management (4 patients), for long-term antibiotic therapy (3 patients) or for total parenteral nutrition (1 patient). Therefore, following catheterization, a 6.6Fr single-lumen or 7Fr double-lumen Broviac catheter (C.R. Bard Inc., Salt Lake City, Utah) was successfully placed in 7 of 8 patients using the existing transhepatic pathway. One failure occurred
1290
THE AMERICAN JOURNAL OF CARDIOLOGY3
VOL. 75
FIGURE 3. Anterior-posterior view: The hepatic veins [open arrowsj and inferior vena cava [dark arrow) are filled when contrast is i+cted within o hepatic vein. The contrast drains to the right atrium.
in a 2.3 kg infant, and was related to patient/equipment size. In 3 additional patients, a Broviac catheter was placed via the transhepatic approach, without concurrent cardiac catheterization, for hemodialysis (1 patient), for long-term home gancyclovir therapy (1 patient), or for replacement of dislodged transhepatic Broviac catheter (1 patient). Broviac catheter placement, for chronic central venous access, was accomplished in 10 of the 11cases attempted. The smallest patient who had successful Broviac catheter placement was 3.2 kg. Lidocaine was infiltrated subcutaneously, and a 3 to 4 cm subcutaneous “tunnel” was created, using a hemostat, that led away from the indwelling sheath. The Broviac catheter was cut to size and was advanced through the tunnel until the cuff of the catheter was positioned inside the hmnel. The indwelling sheath was exchanged for a peel-away sheath over a 0.038 wire. Through the peel-away sheath, the Broviac catheter tip was advanced to the right atrium, and the sheath was removed. The 2 small skin incisions were sutured. The catheter was anchored to the skin near the distal tunnel site. Catheter function and position (Figure 5) were checked before leaving the laboratory. Broviac catheters were left in place for 18 to 290 days (median 35). No Broviac catheter became occluded or infected during the time they were in place. There has been no clinical evidence of thromboembolic phenomena. One Broviac catheter became dislodged (into the peritoneum) 15 days after placement and was removed with no sequelae.’ In 2 of the first 4 patients, both of whom had right atria1 hypertension, significant blood loss requiring transfusion occurred during Broviac catheter placement. No subsequent patient required a transfusion, probably due in part to increased proficiency with the technique. No
JUNE 15, 1995
FIGURE 4. Anterior-posterior view: Following hepatic vein visualization, a platinum-tipped wire [open arrow) is passed through the needle [arrowheads) to the right atrium.
FIGURE 5. Anterior-posterior view: Broviac catheter position prior to leaving the catheterization laboratory. The catheter tip (arrowheads) is in the high right atrium.
clinical bleeding occurred upon catheter removal in any patient. The transhepatic sheath was removed immediately in the catheterization laboratory after catheterization in 2 patients who did not receive chronic access. The Broviac catheter was removed from 5 patients at the bedside, 18 to 38 days after placement. The sheath was removed following repeat catheterization in 2 patients in whom the indwelling Broviac catheter had been usedfor access.The catheter is still in use in 3 other children. We postulate that, with chronic line placement,a fibrosed tract forms from the hepatic vein entry site to the skin, and becomesthrombosed by local compression following catheter/sheathremoval. The risk of significant intraabdominal bleeding with sheath removal immediately after catheterization is not known. Potential additional complications of chronic indwelling lines from a transhepatic route include BuddChiari syndrome, and the usual complications of chronic central venous access:catheter thrombosis, thromboembolic phenomena, and line sepsis.
would naturally guide the catheter to the foramen ovale and into the left atrium), and for transseptalpuncture to perform left-heart catheterization in patients with bilateral femoral venous obstruction (using a stiff sheathand a modified curve on the Brockenbrough needle). Other than for catheterization, additional indications for transhepatic venous accessmay include catheter placement for chemotherapyand transvenouspacemakerlead placement (as an alternative to thoracotomy) in patients with obstructed caval pathways.Defining the risks of and contraindications to the transhepatic techniques will require a larger seriesof patients with a longer follow-up period. Percutaneous transhepatic cardiac catheterization is a straightforward procedure that can be performed by experienced pediatric interventionalists with little additional training. We believe that this technique can be a valuable tool in the treatment of selected patients with complex congenital heart defects.
. . .
Future indications for transhepatic cardiac catheterization might include patients with congenitally interrupted inferior vena cava who require entranceto the left atrium and pulmonary veins (the transhepatic course
1. Azizkhan RG, Taylor LA, Ja@es PF. Mauro MA, Lacey SR. Percutaneous tmnslumbar and transhepatic inferior vena caval catheters for prolonged vascular access in children. J Pediarr Srrrg 1992:27:165-169. 2. Robertson LJ, Jaques PF, Mauro MA, Azi.kban RG, Robards J. Percutaneous inferior vena cava placement of tunneled silastic catheters for prolonged vascular access in infants. J Pediarr Surg 1990;25:596-598.
BRIEF REPORTS 1291