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Advanced central venous access techniques for occluded vessels in children
With Dr. Nathan Fagan · hosted by Dr. Jill Knepprath
Chapter 2 of 5
Surfacer system
Surfacer system for SVC recanalization
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What the experts said
The Surfacer is made by Merritt Medical and provides image-guided SVC recanalization using special equipment.
The 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.
The Surfacer technique involves burying a special catheter at the desired exit site and creating a target at 90 degrees for the expected exit point.
A special needle is driven through the catheter that has been pulled up to the skin surface.
4D intracardiac echo catheter is a new form of intravascular ultrasound used more commonly in cardiology for ablations or left atrial appendage occlusions.
The 4D intracardiac echo probe projects an ultrasound wave in 360 degrees.
The technique involves obtaining access from above with normal ultrasound, then using the special catheter to reconstruct images and guide the needle across the occlusion.
Nobody is currently using 4D intracardiac echo for central line recanalization yet.
4D intracardiac echo catheters are being used more for TIPS procedures, with the premise being whether needles can be guided intravascularly using these special probes.
When all traditional central access is lost, transhepatic and translumbar access are last-resort options.
There is debate about whether transhepatic or translumbar access is better.
Transhepatic access makes the most sense in pediatric patients because if there is bleeding or dislodgement, it is easier to access or control.
Translumbar access technique involves locating the IVC at the lumbar level using CT, guiding a needle down to obtain access, and then placing the line.
The Surfacer requires an open femoral vein, preferably on the right side, to be effective.
The X-ray machine is maneuvered so the marker on the catheter aligns with the planned exit point.
Once the wire exits the skin, through-and-through access is achieved.
The Surfacer technique is suitable for acute pediatric cases as opposed to chronic scarring seen in adult cases.
The 4D echo image can be reconstructed in any plane to guide the needle across an occlusion.
Transhepatic access involves a catheter being directly placed through the liver into the inferior vena cava.
Transhepatic access is a more complicated procedure with higher risk for thrombosis.
Translumbar access involves accessing the inferior vena cava from the back.