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Myth busting the stigma of portable primary placement tunneled femoral vein central lines in children
S6
’
Sunday
3:18 PM
Scientific Session
Abstract No. 5
Transjugular intrahepatic portosystemic stent-shunt in children: technical feasibility and immediate and long-term efficacy
SUNDAY: Scientific Sessions
P. Goffette1, R. Reding2, C. de Magnée2, M. Abdalkader3, E. Sokal2; 1Saint-Luc University Hospital, Brussels, Belgium; 2St Luc University Hospital, Brussels, Belgium; 3 Boston Medical Center, Dorchester, MA Purpose: TIPSS is children is considered as a temporary and technically demanding procedure. We evaluate the technical feasibility and long-term efficacy of TIPSS in a contineous series of 22 children. Materials: Between 1995 and 2015, TIPSS implantation was considered in 22 children aged 2.5-14 years (med 6.5) and suffering from acute (4) or recurrent (18) variceal bleeding mostly due to Biliary atresia-related portal hypertension. A conventional jugular approach (enhanced by direct portal targetting in 4 and ultrasonic guidance in 3) or a combined pull-through transhepatic-transfemoral technique were used in respectively 14 and 8 patients. Results: TIPSS implantation succeeded in 20 patients (91%). Bare (various stents) or covered stent (Viatorr- Gore), calibrated between 6 and 10 mms, were inserted in respectively 15 and 5 patients. The mean reduction of the portosystemic gradient was 62% (34-74). Acute complications included 1 arterial injury, 1 portal rupture and 1 shunt thrombosis all successfully managed non-operatively. No recurrent bleeding was observed within the first 3 months follow-up. During the median follow-up of 12.5 year, delayed rebleeding due to shunt stenosis/occlusion occured in 5 patients and asymptomatic stenosis were diagnosed in 8. All strictures were successfully managed by balloon dilatation (4) or redo-stenting (9). Shunt reduction was performed at 6 months follow-up in one child suffering from intractable hepatic encephalopathy. Among the 18 patients primarily listed for transplantation, 11 were electively transplanted, 3 have been removed from the waiting list because improved liver function, 2 remain candidate and 2 died from sepsis or liver failure. The 2 remaining patients initially not considered for liver transplantation were sufficiently improved to become candidate and finally transplanted. Conclusions: TIPSS is feasible in Children despite technically demanding. This intervention should be considered mainly as a bridge to liver transplantation. However preserved liver function, if combined with a good long-term shunt patency, may delay or obviate the need for transplantation.
3:27 PM
Abstract No. 6
The additional financial cost of care in pediatric patients requiring long-term central venous access N. Kokabi1, G. Gadodia2, R. Palmer3, C. Hawkins4; 1Yale University School of Medicine, New Haven, CT; 2Virginia Mason Medical Center, Seattle, WA; 3Children’s Healthcare of Atlanta, Atalnta, GA; 4Emory University School of Medicine, Atlanta, GA Purpose: To investigate the prevalence and associated healthcare costs of central venous stenosis (CVS) in pediatric patients requiring long-term central venous access.
’
JVIR
Materials: This study was performed using the Pediatric Health Information System s (PHIS), a comparative pediatric database of patient encounters from 44 Children’s Hospitals across the United States. All patients with End Stage Renal Disease (ESRD) and Short Bowel Syndrome (SBS), two pediatric cohorts with high rates of central venous access, diagnosed between 2008-2015 were identified. The prevalence of patients with CVS in patients with central venous access in each cohort was calculated using reported International Classification of Diseases codes and Clinical Transaction Classifications. Cumulative mean length of stay (LOS) and charges associated with the care of patients with long-term central venous access with and without CVS were then compared using the t-test with significance set at 0.05. Results: 2894 patients [1566 (SBS) and 1328(ESRD)] were identified accounting for 7022 encounters [4633 (SBS) and 2389 (ESRD)]. Of these, 90 (5.7%) SBS patients and 94 (7.1%) ESRD patients were diagnosed with CVS [total ¼ 166 patients (6.9%); 204 encounters (8.5%)]. Cumulative mean LOS was significantly higher in the SBS patients with CVS (35 days) vs. those without CVS (18 days; po0.001). Similarly, cumulative mean LOS was significantly higher in ESRD patients with CVS (30 days) vs. those without CVS (20 days; po0.001). Furthermore, average cumulative charges in the SBS patients without CVS was significantly lower ($191 K USD) vs. for those with CVS ($365 K USD; po0.001). Similarly, average cumulative charges for ESRD patients without CVS was significantly lower ($241 K USD) vs. those with CVS ($465 K USD; po0.001). Conclusions: Central venous stenosis is a relatively common complication of long-term indwelling central venous access in children. The presence of CVS appears to be associated with increased length of stay in the hospital and subsequent cost of care in children. The findings should inform future research regarding the impact of long-term central venous access and how to optimally manage such patients particularly by IR.
3:36 PM
Abstract No. 7
Myth busting the stigma of portable primary placement tunneled femoral vein central lines in children A. Chau1, K. Kukreja2, J. Hernandez3, S. Pimpalwar3, D. Ashton1; 1Texas Children’s Hospital, Houston, TX; 2 N/A, Bellaire, TX; 3N/A, Houston, TX Purpose: Single institution experience with primary tunneled common femoral vein (CFV) central line placement in an interventional radiology (IR) suite compared to a portable location. Materials: IRB approved retrospective review comparing IR suites vs. portable primary tunneled CFV central line placement (01/2014 to 12/2015). 248 primary femoral placements (1 day–21 years) were identified using EMR and collected into a Research Electronic Data Capture. Compared categorical variable using Fisher’s exact test was applied. Continuous variables were compared via Wilcoxon Rank Test. Results: 2379 pediatric patients received peripheral inserted and central lines, 248 were primary CFV tunneled-central lines. 143 patients (mean age: 217 days) were performed in the IR suite (technical success of 100%), with 15 (10.5%)
JVIR
’
Scientific Session
Sunday
Comparison of IR Suite versus Portable Placement of Tunneled
S7
rates were determined by the hospital team using central line-associated blood stream infection (CLASBI) criteria. Total catheter days, age of patient at catheter placement, catheter dwell time, reason for catheter placement, catheter size and CLABSI events were recorded. Results: 204 patients received a tunneled femoral noncuffed CVC and 203 patients received a PICC. In the tunneled femoral noncuffed CVC cohort, 111 subjects were male and 92 subjects were female with the total number of catheter days at 4238, average age of CVC placement at 69.0 days, average dwelling time of 20.9 days, and total infection rate of 0.025. In the PICC cohort, 112 subjects were male and 92 subjects were female with the total number of catheter days at 4089, average age of PICC placement at 11.7 days, average dwelling time of 20.4 days, and total infection rate of.020. This equates to a CLABSI event in 1.18/1000 catheter days for interventional radiology placed tunneled femoral noncuffed CVC s versus 0.98/1000 catheter days for neonatal intensive care PICCs. Conclusions: The infection rates are nearly identical for tunneled femoral noncuffed central venous catheters and peripherally inserted central catheters in neonates and infants.
Primary Femoral Central Venous Access IR Suite
Portable
Case #
143
105
Mean Age (days) Total # complications
217 15
231 14
Days of line
3260
3873
Infection rate per 1000 line days
2.15
0.78
3:45 PM
Abstract No. 8
Infection rate of tunneled femoral noncuffed central venous catheters versus peripherally inserted central catheters in neonates and infants: a single-institutional experience J. Lee1, D. Moe2, C. Peske3, N. Vo4; 1Medical College of Wisconsin Affiliated Hospitals—St Joseph, Milwaukee, WI; 2Childrens Hospital of Wisconsin, Wauwatosa, WI; 3 N/A, Sussex, WI; 4Medical College of Wisconsin and The Children's Hospital of Wisconsin, Milwaukee, WI Purpose: Feasibility and satisfactory outcomes of neonate and infant tunneled femoral noncuffed central venous catheters (CVCs) has been demonstrated in the literature. However, concerns exist regarding potential increased infection rates of femoral CVCs over traditional peripherally inserted central catheters (PICCs) due to relative proximity of femoral CVCs to the groin and diaper. This study's purpose is to compare the infection rate of image-guided interventional radiology placed tunneled femoral CVCs to non–image-guided neonatal intensive care unit placed PICCs in a large series of neonates and infants at a single institution. Materials: A retrospective review was performed for all neonates and infants receiving a tunneled femoral noncuffed CVC by interventional radiology or a PICC by neonatal intensive care between 2012 and 2014. Individual infection
3:54 PM
Abstract No. 9
Assessing the effect of multiple peripherally inserted central catheter insertions in a pediatric population: a single-center retrospective review C. Li1, J. Babb2, D. Sridhar2; 1New York University School of Medicine, New York, NY; 2NYU Langone Medical Center, New York, NY Purpose: To assess the effect of multiple peripherally inserted central catheter (PICC) insertions in pediatric patients using outcomes related to procedural complexity: anesthesia time, radiation dose, and fluoroscopy time. Materials: 361 consecutive patients under 15 years old who had PICC placement between 8/5/2011 and 8/5/2016 at a single university hospital were identified. Data were partitioned into Groups 1 to 4, denoting 1st, 2nd, 3rd, and 4th or subsequent PICC insertion. PICC exchanges and insertions without fluoroscopy were excluded from outcome analysis but counted toward number of PICCs. Mixed model ANCOVA was used to compare outcomes between groups while adjusting for gender, age, and weight. Results: Radiation dose and fluoroscopy time increased significantly between Groups 1 vs. 2 (p ¼ 0.013; p ¼ 0.005) and 1 vs. 4 (p ¼ 0.010; p ¼ 0.002). Anesthesia time increased significantly between Groups 1 vs. 4 (p ¼ 0.044) and with trend toward difference between Groups 1 vs. 2 (p ¼ 0.062). Comparison of Groups 3 vs. 4 showed significant difference in fluoroscopy time (p ¼ 0.044), with trend toward difference in anesthesia time and radiation dose. Trends which did not meet significance may reflect small size of Groups 3 and 4 (n ¼ 15; n ¼ 20). No significant interaction was identified between any outcome and age at time of insertion (p40.44), age at first PICC (p40.50), gender (p40.12) or weight (p40.40). Conclusions: Our data suggest that difficulty of PICC placement in pediatric patients increases after the first PICC,
SUNDAY: Scientific Sessions
complications: infection (7), malposition (2), bleeding (0), thrombosis (1), and line malfunction (5). The infection per thousand line days was 2.15. There were 105 patients (mean age: 231 days) with portable placement (technical success 100%) with 14 (13.3%) complications: infection (3), malposition (5), bleeding (0), thrombosis (2), and line malfunction (4). Infection rate was 0.78 per 1000 line days. There was no statistical significance for complication rate between portable versus IR suite placements (p-value of 0.6251) Distribution of the type of complications was not significantly different (p-value of 0.3984). The infection rate per 1000 line days was not significantly different (p-value 0.1408 by midP). Conclusions: In a cohort of pediatric patients receiving primary CFV tunneled-central lines the complication and infection rate performed in a portable setting does not significantly increase compared to the lines placed in IR suite. Fear of increased infection from portable placement is busted.
’
’
Sunday
3:18 PM
Scientific Session
Abstract No. 5
Transjugular intrahepatic portosystemic stent-shunt in children: technical feasibility and immediate and long-term efficacy
SUNDAY: Scientific Sessions
P. Goffette1, R. Reding2, C. de Magnée2, M. Abdalkader3, E. Sokal2; 1Saint-Luc University Hospital, Brussels, Belgium; 2St Luc University Hospital, Brussels, Belgium; 3 Boston Medical Center, Dorchester, MA Purpose: TIPSS is children is considered as a temporary and technically demanding procedure. We evaluate the technical feasibility and long-term efficacy of TIPSS in a contineous series of 22 children. Materials: Between 1995 and 2015, TIPSS implantation was considered in 22 children aged 2.5-14 years (med 6.5) and suffering from acute (4) or recurrent (18) variceal bleeding mostly due to Biliary atresia-related portal hypertension. A conventional jugular approach (enhanced by direct portal targetting in 4 and ultrasonic guidance in 3) or a combined pull-through transhepatic-transfemoral technique were used in respectively 14 and 8 patients. Results: TIPSS implantation succeeded in 20 patients (91%). Bare (various stents) or covered stent (Viatorr- Gore), calibrated between 6 and 10 mms, were inserted in respectively 15 and 5 patients. The mean reduction of the portosystemic gradient was 62% (34-74). Acute complications included 1 arterial injury, 1 portal rupture and 1 shunt thrombosis all successfully managed non-operatively. No recurrent bleeding was observed within the first 3 months follow-up. During the median follow-up of 12.5 year, delayed rebleeding due to shunt stenosis/occlusion occured in 5 patients and asymptomatic stenosis were diagnosed in 8. All strictures were successfully managed by balloon dilatation (4) or redo-stenting (9). Shunt reduction was performed at 6 months follow-up in one child suffering from intractable hepatic encephalopathy. Among the 18 patients primarily listed for transplantation, 11 were electively transplanted, 3 have been removed from the waiting list because improved liver function, 2 remain candidate and 2 died from sepsis or liver failure. The 2 remaining patients initially not considered for liver transplantation were sufficiently improved to become candidate and finally transplanted. Conclusions: TIPSS is feasible in Children despite technically demanding. This intervention should be considered mainly as a bridge to liver transplantation. However preserved liver function, if combined with a good long-term shunt patency, may delay or obviate the need for transplantation.
3:27 PM
Abstract No. 6
The additional financial cost of care in pediatric patients requiring long-term central venous access N. Kokabi1, G. Gadodia2, R. Palmer3, C. Hawkins4; 1Yale University School of Medicine, New Haven, CT; 2Virginia Mason Medical Center, Seattle, WA; 3Children’s Healthcare of Atlanta, Atalnta, GA; 4Emory University School of Medicine, Atlanta, GA Purpose: To investigate the prevalence and associated healthcare costs of central venous stenosis (CVS) in pediatric patients requiring long-term central venous access.
’
JVIR
Materials: This study was performed using the Pediatric Health Information System s (PHIS), a comparative pediatric database of patient encounters from 44 Children’s Hospitals across the United States. All patients with End Stage Renal Disease (ESRD) and Short Bowel Syndrome (SBS), two pediatric cohorts with high rates of central venous access, diagnosed between 2008-2015 were identified. The prevalence of patients with CVS in patients with central venous access in each cohort was calculated using reported International Classification of Diseases codes and Clinical Transaction Classifications. Cumulative mean length of stay (LOS) and charges associated with the care of patients with long-term central venous access with and without CVS were then compared using the t-test with significance set at 0.05. Results: 2894 patients [1566 (SBS) and 1328(ESRD)] were identified accounting for 7022 encounters [4633 (SBS) and 2389 (ESRD)]. Of these, 90 (5.7%) SBS patients and 94 (7.1%) ESRD patients were diagnosed with CVS [total ¼ 166 patients (6.9%); 204 encounters (8.5%)]. Cumulative mean LOS was significantly higher in the SBS patients with CVS (35 days) vs. those without CVS (18 days; po0.001). Similarly, cumulative mean LOS was significantly higher in ESRD patients with CVS (30 days) vs. those without CVS (20 days; po0.001). Furthermore, average cumulative charges in the SBS patients without CVS was significantly lower ($191 K USD) vs. for those with CVS ($365 K USD; po0.001). Similarly, average cumulative charges for ESRD patients without CVS was significantly lower ($241 K USD) vs. those with CVS ($465 K USD; po0.001). Conclusions: Central venous stenosis is a relatively common complication of long-term indwelling central venous access in children. The presence of CVS appears to be associated with increased length of stay in the hospital and subsequent cost of care in children. The findings should inform future research regarding the impact of long-term central venous access and how to optimally manage such patients particularly by IR.
3:36 PM
Abstract No. 7
Myth busting the stigma of portable primary placement tunneled femoral vein central lines in children A. Chau1, K. Kukreja2, J. Hernandez3, S. Pimpalwar3, D. Ashton1; 1Texas Children’s Hospital, Houston, TX; 2 N/A, Bellaire, TX; 3N/A, Houston, TX Purpose: Single institution experience with primary tunneled common femoral vein (CFV) central line placement in an interventional radiology (IR) suite compared to a portable location. Materials: IRB approved retrospective review comparing IR suites vs. portable primary tunneled CFV central line placement (01/2014 to 12/2015). 248 primary femoral placements (1 day–21 years) were identified using EMR and collected into a Research Electronic Data Capture. Compared categorical variable using Fisher’s exact test was applied. Continuous variables were compared via Wilcoxon Rank Test. Results: 2379 pediatric patients received peripheral inserted and central lines, 248 were primary CFV tunneled-central lines. 143 patients (mean age: 217 days) were performed in the IR suite (technical success of 100%), with 15 (10.5%)
JVIR
’
Scientific Session
Sunday
Comparison of IR Suite versus Portable Placement of Tunneled
S7
rates were determined by the hospital team using central line-associated blood stream infection (CLASBI) criteria. Total catheter days, age of patient at catheter placement, catheter dwell time, reason for catheter placement, catheter size and CLABSI events were recorded. Results: 204 patients received a tunneled femoral noncuffed CVC and 203 patients received a PICC. In the tunneled femoral noncuffed CVC cohort, 111 subjects were male and 92 subjects were female with the total number of catheter days at 4238, average age of CVC placement at 69.0 days, average dwelling time of 20.9 days, and total infection rate of 0.025. In the PICC cohort, 112 subjects were male and 92 subjects were female with the total number of catheter days at 4089, average age of PICC placement at 11.7 days, average dwelling time of 20.4 days, and total infection rate of.020. This equates to a CLABSI event in 1.18/1000 catheter days for interventional radiology placed tunneled femoral noncuffed CVC s versus 0.98/1000 catheter days for neonatal intensive care PICCs. Conclusions: The infection rates are nearly identical for tunneled femoral noncuffed central venous catheters and peripherally inserted central catheters in neonates and infants.
Primary Femoral Central Venous Access IR Suite
Portable
Case #
143
105
Mean Age (days) Total # complications
217 15
231 14
Days of line
3260
3873
Infection rate per 1000 line days
2.15
0.78
3:45 PM
Abstract No. 8
Infection rate of tunneled femoral noncuffed central venous catheters versus peripherally inserted central catheters in neonates and infants: a single-institutional experience J. Lee1, D. Moe2, C. Peske3, N. Vo4; 1Medical College of Wisconsin Affiliated Hospitals—St Joseph, Milwaukee, WI; 2Childrens Hospital of Wisconsin, Wauwatosa, WI; 3 N/A, Sussex, WI; 4Medical College of Wisconsin and The Children's Hospital of Wisconsin, Milwaukee, WI Purpose: Feasibility and satisfactory outcomes of neonate and infant tunneled femoral noncuffed central venous catheters (CVCs) has been demonstrated in the literature. However, concerns exist regarding potential increased infection rates of femoral CVCs over traditional peripherally inserted central catheters (PICCs) due to relative proximity of femoral CVCs to the groin and diaper. This study's purpose is to compare the infection rate of image-guided interventional radiology placed tunneled femoral CVCs to non–image-guided neonatal intensive care unit placed PICCs in a large series of neonates and infants at a single institution. Materials: A retrospective review was performed for all neonates and infants receiving a tunneled femoral noncuffed CVC by interventional radiology or a PICC by neonatal intensive care between 2012 and 2014. Individual infection
3:54 PM
Abstract No. 9
Assessing the effect of multiple peripherally inserted central catheter insertions in a pediatric population: a single-center retrospective review C. Li1, J. Babb2, D. Sridhar2; 1New York University School of Medicine, New York, NY; 2NYU Langone Medical Center, New York, NY Purpose: To assess the effect of multiple peripherally inserted central catheter (PICC) insertions in pediatric patients using outcomes related to procedural complexity: anesthesia time, radiation dose, and fluoroscopy time. Materials: 361 consecutive patients under 15 years old who had PICC placement between 8/5/2011 and 8/5/2016 at a single university hospital were identified. Data were partitioned into Groups 1 to 4, denoting 1st, 2nd, 3rd, and 4th or subsequent PICC insertion. PICC exchanges and insertions without fluoroscopy were excluded from outcome analysis but counted toward number of PICCs. Mixed model ANCOVA was used to compare outcomes between groups while adjusting for gender, age, and weight. Results: Radiation dose and fluoroscopy time increased significantly between Groups 1 vs. 2 (p ¼ 0.013; p ¼ 0.005) and 1 vs. 4 (p ¼ 0.010; p ¼ 0.002). Anesthesia time increased significantly between Groups 1 vs. 4 (p ¼ 0.044) and with trend toward difference between Groups 1 vs. 2 (p ¼ 0.062). Comparison of Groups 3 vs. 4 showed significant difference in fluoroscopy time (p ¼ 0.044), with trend toward difference in anesthesia time and radiation dose. Trends which did not meet significance may reflect small size of Groups 3 and 4 (n ¼ 15; n ¼ 20). No significant interaction was identified between any outcome and age at time of insertion (p40.44), age at first PICC (p40.50), gender (p40.12) or weight (p40.40). Conclusions: Our data suggest that difficulty of PICC placement in pediatric patients increases after the first PICC,
SUNDAY: Scientific Sessions
complications: infection (7), malposition (2), bleeding (0), thrombosis (1), and line malfunction (5). The infection per thousand line days was 2.15. There were 105 patients (mean age: 231 days) with portable placement (technical success 100%) with 14 (13.3%) complications: infection (3), malposition (5), bleeding (0), thrombosis (2), and line malfunction (4). Infection rate was 0.78 per 1000 line days. There was no statistical significance for complication rate between portable versus IR suite placements (p-value of 0.6251) Distribution of the type of complications was not significantly different (p-value of 0.3984). The infection rate per 1000 line days was not significantly different (p-value 0.1408 by midP). Conclusions: In a cohort of pediatric patients receiving primary CFV tunneled-central lines the complication and infection rate performed in a portable setting does not significantly increase compared to the lines placed in IR suite. Fear of increased infection from portable placement is busted.
’