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Subclavian Thrombus
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Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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If you pull the port catheter out in the setting of vessel narrowing, you have not lost any potential access for interventional radiology to work to maintain it. — Nathan Fein, Update Course Rewind 2025: Updates in Central Line Management · 1:40
Update Course Rewind 2025: Updates in Central Line Management
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Dr. Nathan Fagan, a Pediatric Interventional Radiologist from Akron Children's Hospital, presents a clinical scenario on central line management from the 13th Annual Pediatric Surgery Update Course. He discusses diagnosing and managing a ma
video2:57 · Jun 2026
Central line troubleshooting and vascular access preservation in pediatric patients
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Dr. Nathan Fagan, a Pediatric Interventional Radiologist from Akron Children's Hospital, presents a clinical scenario on central line management from the 13th Annual Pediatric Surgery Update Course. He discusses diagnosing and managing a ma
podcast2:57 · Nov 2026
The Surface EKG technique works best when there is at least a remnant of vessel present to traverse, rather than complete chronic occlusion. — Nathan Fagan, 2025 Pediatric Surgery Update Course - Updates in Central Line Management · 14:10
2025 Pediatric Surgery Update Course - Updates in Central Line Management
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On August 26th, the largest Pediatric Surgery course in the world each year was held, where top hospital experts from around the US will discuss this year’s changes in practices and innovation. Learn more about the future of pediatric surge
video25:42 · Aug 2025
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Expert statements from the recordings in this collection.
Update Course Rewind 2025: Updates in Central Line Management
The patient was a teenager with a left subclavian dual lumen port and a history of subclavian thrombus that was successfully treated with heparin.
clinicalNathan Fein0:23 ↗
The medial lumen of the port would not flush, while the lateral lumen functioned normally.
clinicalNathan Fein0:31 ↗
The chest X-ray was normal.
Host summaryJill Knepprath summarizes what Dr. Nathan Fein said — not the host's own clinical position0:39 ↗
Fluoroscopic dye study showed contrast welling up around the port and in the pocket itself, not going to the reservoir, when pushing very hard.
clinicalNathan Fein0:59 ↗
The port malfunction was due to improper accessing; re-accessing the port resolved the issue and it flushed normally.
clinicalNathan Fein1:10 ↗
The hematology oncology team wanted the port removed immediately and had scheduled the patient for removal and replacement.
clinicalNathan Fein1:22 ↗
An unnecessary port removal procedure could have sacrificed future vascular access.
Host summaryJill Knepprath summarizes what Dr. Nathan Fein said — not the host's own clinical position1:27 ↗
Ultrasound suggested possible narrowing around the port catheter itself.
clinicalNathan Fein1:37 ↗
If you pull the port catheter out in the setting of vessel narrowing, you have not lost any potential access for interventional radiology to work to maintain it.
opinionNathan Fein1:40 ↗
Vasculopaths are patients who have no upper and lower central access, no normal access.
clinicalNathan Fein1:54 ↗
Interventional radiology can perform sharp recanalization of the SVC for vasculopaths.
clinicalNathan Fein2:06 ↗
Sharp SVC recanalization uses ultrasound to visualize the jugular vein and a combination of fluoroscopy and ultrasound to guide a small needle through the area of stenosis, through the SVC beyond the stenosis, and into the right atrium.
clinicalNathan Fein2:11 ↗
In sharp SVC recanalization, the interventionist can approach from below via the femoral vein to drive a needle through a target to connect the two sides, then perform balloon angioplasty, stent placement, and line placement.
clinicalNathan Fein2:29 ↗
Before removing a malfunctioning central line, ensure appropriate access first.
Host summaryJill Knepprath summarizes what Dr. Nathan Fein said — not the host's own clinical position2:42 ↗
For patients who have lost central venous access, consult interventional radiology to restore access using specialized techniques.
Host summaryJill Knepprath summarizes what Dr. Nathan Fein said — not the host's own clinical position2:49 ↗
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.
clinicalNathan Fagan1:18 ↗
The non-flushing port was found to be simply not accessed correctly; re-accessing it allowed it to flush normally without any other intervention.
clinicalNathan Fagan4:00 ↗
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.
opinionNathan Fagan4:30 ↗
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.
clinicalNathan Fagan6:40 ↗
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.
clinicalNathan Fagan7:20 ↗
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.
clinicalNathan Fagan10:13 ↗
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.
clinicalNathan Fagan13:03 ↗
The Surface EKG technique works best when there is at least a remnant of vessel present to traverse, rather than complete chronic occlusion.
opinionNathan Fagan14:10 ↗
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.
clinicalNathan Fagan15:50 ↗
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.
clinicalNathan Fagan18:20 ↗
When dilating across tight vascular occlusions, balloons are used rather than traditional dilators, starting with small cardiac balloons (5mm) and progressively increasing size.
clinicalNathan Fagan20:00 ↗
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.
clinicalNathan Fagan21:54 ↗
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.
clinical23:40 ↗
Translumbar catheter dislodgement results in retroperitoneal bleeding which may be contained by muscle, whereas transhepatic dislodgement causes hemoperitoneum.
clinical24:30 ↗
Central line troubleshooting and vascular access preservation in pediatric patients
The patient was a teenager with a left subclavian dual lumen port and a history of subclavian thrombus that was successfully treated with heparin.
clinicalNathan Fein0:23 ↗
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