Preserving central venous access in children who receive long-term parenteral nutrition can be challenging in some cases. As a result of multiple central venous line placements and sepsis, central vein thrombosis may occur (1). In patients with caval thrombosis (superior/inferior), thoracotomies to either directly cannulate the azygous vein or the right atrium may be used for venous access (2,3). More recently, a percutaneous transhepatic approach to the right atrium has been proposed, using lateral or anterolateral oblique routes (4–9).
We present a case in which all conventional central venous access routes were severely compromised and an innovative approach was undertaken: the right atrium was accessed transhepatically through a percutaneous epigastric approach that punctured the left hepatic vein. The technical aspects and pitfalls of the various transhepatic routes are reviewed.
The patient, born at 34 weeks of gestation, had neonatal midgut volvulus. Most of the small intestine was resected, and subsequently chronic intestinal failure developed. The patient was totally dependent on long-term parenteral nutrition. All conventional routes for central venous access progressively occluded because of numerous surgically placed central venous lines (CVL).
At 2.5 years of age, the patient was referred for urgent venous access, reassessment, and placement of a new CVL. Doppler ultrasound and conventional venography showed only the azygous and hepatic veins were patent, with a very short residual proximal stump of both superior and retrohepatic inferior vena cavae (SVC and IVC, respectively) (Fig. 1). A new percutaneous CVL placement through a transhepatic route was considered. However, this child had many dilated bowel loops, and the liver could not be entered below the ribs, at the previously recommended sites, and entry could be considered only at the xiphoid margin where a 1-cm liver edge was approachable.
A 6.6 French, single lumen, Broviac catheter was then inserted by puncturing the left hepatic vein (conventional percutaneous Seldinger technique). The catheter was positioned with the tip in the right atrium and tunneled. However, radiography 24 hours later showed the catheter tip had migrated into the peritoneal cavity. The dislodgement may have occurred with breathing, during which the anterior edge of the liver moves slightly in respect to the adjacent abdominal wall, allowing progressive CVL slipping. The catheter was reinserted with a similar approach but with surgical assistance. Surgery consisted of anchoring the edge of liver to the anterior abdominal wall, at and around the liver catheter entry site.
The abdomen was opened with a small subxiphoid incision to approach the anterior edge of the left liver lobe. With ultrasound and fluoroscopic guidance, a 22-guage needle was used to access the left hepatic vein. Using the Seldinger technique and a conventional peel-away sheath, the Hickman catheter was tunneled through the skin and positioned with the tip in the middle right atrium. The catheter entry site was stabilized by anchoring the liver edge to the abdominal wall (2-U prolene stitches around the catheter), and the abdomen was closed.
Further radiography confirmed good catheter positioning, and the catheter was successfully used for parenteral nutrition during the following months. During that time, oral feeding progressed and parenteral nutrition was weaned gradually and finally stopped. The catheter was removed 3 months later without any specific maneuver or complication.
The incidence of central venous vein thrombosis in children who require long-term central venous access is 5% to 10% (2,3). Recurrent access for CVL placement because of thrombosis or sepsis progressively exhausts possible access sites, in a few cases causing combined thrombosis of SVC and IVC, and is the most serious concern. For cases with combined SVC and IVC thrombosis, surgical or percutaneous cannulation of the lumbar IVC or azygous vein, or direct catheterization of the right atrium have been proposed (2–8). Each technique has reported advantages and disadvantages, including frequent catheter dislodgement (5–8).
Crummy et al. (10) first reported transhepatic CVL insertion in adults. This technique was subsequently reported in children (4,6,7,9). In all reported series, a lateral or an anterolateral route was used, and the right or middle hepatic vein was catheterized to access the IVC. In our case, an innovative approach was necessary because of the particular anatomy, with the liver being accessible directly only at the xiphoid area. Reported transhepatic CVL insertion techniques are safe with no perioperative morbidity. However, late catheter complications are frequent, and the risk of dislodgment, thrombosis, and sepsis is comparable with conventional CVL placement.
When the catheter is inserted transhepatically, possible dislodgment is a major concern because bleeding into the peritoneal cavity may follow (8). Bleeding also may occur when the catheter is removed intentionally. To prevent the later problem, Bergey et al. (9) proposed embolizing the track at catheter removal. Accidental dislodgment also may occur with growth spurts, and various solutions to this have been proposed. Azizkhan et al. (6) and Sommer et al. (8) recommended positioning the tip of the catheter at the right atrium–SVC junction and reassessing position of the line with radiography every 2 to 3 months. Robertson et al. (5) proposed positioning the tip of the catheter even higher in the SVC and reassessing with radiography at every outpatient visit.
Dislodgment may relate to movement (6,8). The movement of the liver edge, in respect to the abdominal wall, is more important at the anterior aspect than laterally or in the posterior aspect. This explains the rapid dislodgment in our case. We believe that using a true anterior approach makes surgically assisted placement mandatory, except in the few patients known to have significant adhesions between the liver and the abdominal wall, that is, after previous surgery.
In conclusion, this is the first report of CVL placement using a true anterior transhepatic approach to the left hepatic vein. This technique provides good, alternative CVL routing and is a valuable complementary tool for difficult cases. However, it requires a skilled interventional radiologist, and its use may be limited to selected patients in whom other routes are inappropriate or unavailable. Because of the risk of dislodgment, surgical anchoring is recommended. Radiography or ultrasound should be performed at 24 and 48 hours after placement before the line is used. The parents and nurses must receive clear instruction regarding the care of this line.
1. Ross P, Ehrenkranz R, Kleinman CS, et al. Thrombus associated with central venous catheters in infants and children. J Pediatr Surg 1989; 24:253–6.
2. Silverman SH, Stringel G. Two techniques for central catheter placement in the hypogastric and azygos veins. Pediatr Surg Int 1988; 3:63–8.
3. Oram-Smith JC, Mullen JL, Harken AH, et al. Direct right atrial catheterization for total parenteral nutrition. Surgery 1978; 83:274–6.
4. Cheung CH, Kong CK, Ng JW. Maintaining long term central venous access by repetitive hepatic vein cannulation. J Pediatr Surg 1995; 10:1533.
5. Robertson LJ, Jaques PF, Mauro MA, et al. Percutaneous inferior vena cava placement of tunnelled silastic catheter for prolonged vascular access in infants. J Pediatr Surg 1990; 25:596–8.
6. Azizkhan RG, Taylor LA, Jaques PF, et al. Percutaneous translumbar and transhepatic inferior vena cava catheter for prolonged vascular access in children. J Pediatr Surg
7. De Csepel J, Stanley P, Padua EM, et al. Maintaining long-term central venous access by repetitive hepatic vein cannulation. J Pediatr Surg 1994; 29:56–7.
8. Sommer RJ, Golinko RJ, Mitty HA. Initial experience with percutaneous transhepatic cardiac catheterization in infants and children. Am J Cardiol 1995; 75:1289–91.
9. Bergey EA, Kaye RD, Reyes J, et al. Transhepatic insertion of vascular dialysis catheter in children: a safe, life prolonging procedure. Pediatr Radiol
10. Crummy AB, Carlson P, McDermott JS, et al. Percutaneous transhepatic placement of Hickman catheter. AJR Am J Roentgenol 1989; 153:1317–8.