Transhepatic access makes the most sense because if there's bleeding or if it gets dislodged, particularly in pediatric patients, I. Like it's easier to get to or control.
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.
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.
2025 Pediatric Surgery Update Course - Updates in Central Line Management
▶Ep 1 · 0:25
quoteplease don't forget about your friends interventional radiology. So we're really happy to help you with these problems.↗
▶Ep 1 · 1:00
quoteif you take anything away from this talk today, it's the power of friendship.↗
▶Ep 1 · 1:18
clinicalA 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.↗
▶Ep 1 · 4:00
clinicalThe non-flushing port was found to be simply not accessed correctly; re-accessing it allowed it to flush normally without any other intervention.↗
▶Ep 1 · 4:30
opinionRemoving 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.↗
▶Ep 1 · 4:30
quoteDon't forget about, don't forget about us in IR. I know sometimes we can be busy, and like I said, we're a loophain hard to find. But we can help you with really, really simple problems↗
▶Ep 1 · 5:10
quoteI think that simple things like this are kind of what start that cascade, right? Like odds are, if they would have pulled the left subclaiming port, they may have put a one on the right side totally fine. But now, maybe the left side would have went down and now we've lost a potential point for future access, which is a huge problem.↗
▶Ep 1 · 6:40
clinicalSharp 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.↗
▶Ep 1 · 7:20
clinicalTwo 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.↗
▶Ep 1 · 10:13
clinicalThe 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.↗
▶Ep 1 · 13:03
clinicalThe 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.↗
▶Ep 1 · 14:10
opinionThe Surface EKG technique works best when there is at least a remnant of vessel present to traverse, rather than complete chronic occlusion.↗
▶Ep 1 · 15:50
clinicalIntracardiac echocardiography (ICE) catheters project ultrasound waves 360 degrees and can reconstruct images in any plane, potentially allowing safer guidance of needles across vascular occlusions.↗
▶Ep 1 · 18:20
clinicalTraditional 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.↗
▶Ep 1 · 20:00
clinicalWhen dilating across tight vascular occlusions, balloons are used rather than traditional dilators, starting with small cardiac balloons (5mm) and progressively increasing size.↗
▶Ep 1 · 21:54
clinicalTranshepatic 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.↗
▶Ep 1 · 23:00
quotethere's an old principle that you can jab anything with a 21 gauge needle and get away with it. And boy, do they take that to an extreme.↗
Advanced central venous access techniques for occluded vessels in children
▶Ep 5 · 0:29
clinicalThe Surfacer is made by Merritt Medical and provides image-guided SVC recanalization using special equipment.↗
▶Ep 5 · 0:42
opinionThe Surfacer works best when there is at least a remnant of vessel that can be traversed, and may be safer than direct needle puncture into the right atrium.↗
▶Ep 5 · 0:42
quoteIt's going to work the best when there is at least a remnant of something there that you can get through, but if there is something, this might be safer than me trying to jab a needle down there and get into the right atrium.↗
▶Ep 5 · 0:59
clinicalThe Surfacer technique involves burying a special catheter at the desired exit site and creating a target at 90 degrees for the expected exit point.↗
▶Ep 5 · 1:15
clinicalA special needle is driven through the catheter that has been pulled up to the skin surface.↗
▶Ep 5 · 1:32
clinical4D intracardiac echo catheter is a new form of intravascular ultrasound used more commonly in cardiology for ablations or left atrial appendage occlusions.↗
▶Ep 5 · 1:48
clinicalThe 4D intracardiac echo probe projects an ultrasound wave in 360 degrees.↗
▶Ep 5 · 2:14
clinicalThe technique involves obtaining access from above with normal ultrasound, then using the special catheter to reconstruct images and guide the needle across the occlusion.↗
clinicalNobody is currently using 4D intracardiac echo for central line recanalization yet.↗
▶Ep 5 · 2:26
clinical4D intracardiac echo catheters are being used more for TIPS procedures, with the premise being whether needles can be guided intravascularly using these special probes.↗
▶Ep 5 · 2:34
clinicalWhen all traditional central access is lost, transhepatic and translumbar access are last-resort options.↗
opinionThere is debate about whether transhepatic or translumbar access is better.↗
▶Ep 5 · 2:43
opinionTranshepatic access makes the most sense in pediatric patients because if there is bleeding or dislodgement, it is easier to access or control.↗
▶Ep 5 · 2:43
quoteTranshepatic access makes the most sense because if there's bleeding or if it gets dislodged, particularly in pediatric patients, I. Like it's easier to get to or control.↗
▶Ep 5 · 3:07
clinicalTranslumbar access technique involves locating the IVC at the lumbar level using CT, guiding a needle down to obtain access, and then placing the line.↗
