Acta Chirurgica Belgica

ISSN: 0001-5458 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/tacb20

Alternate Routes for Children with Difficult Central

Venous Access

H.M. Saleh, A.S. Abdelaziz, E. Hefnawy & O. Mansour

To cite this article: H.M. Saleh, A.S. Abdelaziz, E. Hefnawy & O. Mansour (2008) Alternate
Routes for Children with Difficult Central Venous Access, Acta Chirurgica Belgica, 108:5,
563-568, DOI: 10.1080/00015458.2008.11680286

To link to this article: http://dx.doi.org/10.1080/00015458.2008.11680286

Published online: 11 Mar 2016.

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 Acta Chir Belg, 2008, 108, 563-568

Alternate Routes for Children with Difficult Central Venous Access

H. M. Saleh*, A. S. Abdelaziz**, E. Hefnawy***, O. Mansour***
Department of Vascular Surgery*, Ain Shams University ; Department of Surgery**, Beni-Suef University ; Department
of Surgery***, Cairo University.

Key words. Venous access ; children ; implantable venous access device ; intercostal veins ; inferior epigastric vein ;
gonadal vein.

Abstract. Background : Some children requiring chemotherapy, total parenteral nutrition, or repeated blood sampling
for long periods have no more axillary, internal jugular, external jugular, saphenous, or femoral veins available for
cannulation. In such patients, the central venous system can still be accessed via alternate routes e.g. the azygos vein,
the gonadal vein or the inferior epigastric vein.
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Patients and Methods : We report the use of :

1) The inferior epigastric vein for placement of the catheter into the IVC in 20 patients. 2) The right gonadal vein for
placement of the catheter using a retroperitoneal approach in five pediatric patients. 3) The second and third right inter-
costal veins for placement of the catheter by right intrapleural thoracotomy in five pediatric patients. Pre-procedural
assessment of the patency of these veins was done using colour Doppler ultrasonography and confirmation of occlusion
of common sites used for central venous access.
Results : A total of 38 implantable venous access devices (IVAD) were inserted in 30 patients. The average age at
operation was 1.4 years (range 1 month to 12 years). Infection was seen in two patients, venous thrombosis in two. The
average longevity of IVAD is 6.5 months. Recovery from the procedure was uncomplicated and the patients were able
to receive complete intravenous medication or nutritive mixtures after the insertion of the catheter.
Conclusion : The knowledge of alternate routes to obtain central venous access for children requiring chemotherapy,
total parenteral nutrition, or repeated blood sampling for long periods is critically important, and the azygos system, right
gonadal vein or the inferior epigastric vein can be used when standard accessible veins are unavailable.

Introduction 3) The second and third right intercostal veins for place-
ment of the catheter by right intrapleural thoracotomy in
Long-term central venous access is an integral part of the five pediatric patients (Fig. 1 & 2).
treatment of children requiring chemotherapy, total par-
enteral nutrition, or repeated blood sampling (1). The
preferred route of access remains the superior vena cava 1. Patients and methods
(SVC). This can be performed easily using percutaneous
or open surgical techniques through the external jugular,
internal jugular, or subclavian veins (1). Long-term Patients
complications of such access devices include infection
and thrombosis (2, 3). When the SVC is thrombosed,
Thirty children (13 boys and 17 girls) presented to the
the inferior vena cava (IVC) can be accessed via the
hospital because of short gut syndrome caused by exten-
saphenous, femoral, or iliac routes (1, 4-6). However,
sive resection, due to necrotizing enterocolitis in the
in children who require prolonged and multiple venous
newborn period in 23 patients, multiple enterocutaneous
catheterization, the SVC and femoral veins may become
fistulas in two patients, non-Hodgkins lymphoma in
occluded, making central venous access a difficult
three patients, and haemophilia A in two patients.
problem. This report highlights the use of :
Previous multiple venous cut-down procedures had been
1) The inferior epigastric vein (IEV) for placement of performed, which had caused thrombosis of the inferior
the catheter into the IVC in 20 patients. vena cava and superior tributaries which vena cava
2) The right gonadal vein for placement of the catheter system had been previously used for catheterization.
using a retroperitoneal approach in five pediatric Useful alternate routes for central venous access will be
patients. summarized.
 564
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Fig. 1
The venous system (22)
Methods
Group I
This is a retrospective study involving the insertion of
central venous catheters and implantable venous access
devices (IVADs) via IEV in 25 children at a major pedi-
atric hospital spread over 15 years (1984 to 1999). The
data were collected from hospital notes and surgeon’s
personal records. The details recorded were (1) underly-
ing diagnosis, (2) the reason for using IEV, (3) indication
for removal of IVAD, (4) IVAD longevity, (5) blockage
of IVAD and its management, (6) details of IVAD infec-
tion and its subsequent course, and (7) other complica-
tions. The information on follow-up was obtained from
hospital notes.
Technique
Under general anaesthesia, after local anaesthetic infil-
tration, a skin crease incision is made over the internal
ring. The external oblique is opened, and the IEV is iso-
H. M. Saleh et al.
Fig. 2
The venous system (22)
lated from the artery. Any tethering branches of IEV in
the region are divided between ties or after diathermy.
The IEV is followed down until it can be seen joining the
external iliac vein, and the upper end of the IEV is ligat-
ed. Before the introduction, the catheter must be trimmed
to length so that the tip will lie in the right atrium.
Because the catheter has to pass posteriorly for some
distance, a few centimetres must be added to its length,
as it is laid out on the anterior wall of the abdomen and
thorax. The system is filled with heparinized saline
(10 U/mL). The catheter is then introduced into the IEV
through a venotomy, the IEV being angled so that the tip
of the catheter passes upward into the iliac vein and not
downward into the femoral vein (Fig. 3). Under the
image intensifier the tip of the catheter is confirmed as
being in the right atrium, and the IEV is ligated around
the catheter. The external oblique aponeurosis is closed
around the catheter.
Difficulty can be encountered :
As the catheter is introduced, there are two sites at which
difficulty can be encountered. In the groin, the tip can
 Alternate Routes for Children with Difficult Central Venous Access
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Fig. 3
Inferior epigastric vein access
travel inferiorly. This is overcome by placing inferiorly
directed traction on the tie around the vein as the tip is
introduced.
The second problem is that the tip sometimes passes
into one of the major tributaries (renal or hepatic) as it is
advancing up the inferior vena cava. This is recognised
easily on the image intensifier and, when it occurs, the
catheter is withdrawn slightly, twisted, and reintroduced.
There is always a slight curve in the catheter after it has
been stored in its package, so that twisting the catheter
moves the tip away from the tributary that it passes up.
Group II
The IVC was accessed previously through the saphe-
nous, femoral, and iliac veins on a number of occasions.
The iliac veins were inaccessible because of occlusion.
Doppler ultrasound scan showed SVC and iliofemoral
vein old thrombosis. Blood flow was seen in the
suprarenal IVC. It was therefore decided to access the
patient’s IVC via the right gonadal vein utilising a
retroperitoneal approach in five patients.
Technique
Under a general anaesthesia, the patient was placed in
the supine position with a rolled towel under the right
flank. An oblique incision was made in the right iliac
fossa, and the retroperitoneal plane was developed by
splitting the abdominal muscles in the direction of their
fibres. The peritoneum was bluntly elevated off the psoas
muscle, and the right gonadal vein was identified. The
565
Fig. 4
The right gonadal vein access
retroperitoneal veins, including the right gonadal vein,
were dilated because of thrombosis of the iliofemoral
system. Care was taken to distinguish the gonadal vein
from the ureter. The vein was isolated using vascular
loops. A SILASTIC (Dow Corning, Midland, MI)
catheter with an implantable port (INFUKT & IN-PORT,
FB Medical, Puiseux le Hauberger, France) was inserted
through a transverse venotomy in the gonadal vein. The
venotomy was repaired with 7-0 Prolene sutures. The tip
of the catheter was positioned just inside the right atrium
via the IVC, aided by fluoroscopic imaging (Fig. 4). The
catheter was then tunnelled through the subcutaneous tis-
sues and the reservoir port was fixed in a subcutaneous
pocket in the lower anterior chest wall. Care was taken to
leave adequate length of catheter in the retroperitoneum
to reduce tension at the venotomy site.
At 10 months follow-up there have been no catheter-
related complications. The system is flushed regularly
with a dilute heparin solution (10 U/mL) to maintain
patency.
Group III
In five patients central venous catheters were inserted via
the intercostal veins.
 566
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Fig. 5
The azygos vein and its relations with the intercostal veins
1 Indicates azygos vein
2 and 3, second and third intercostal veins
4 superior vena cava (from TANNURI U. et al., 2005) (27).
Anatomy
The posterior intercostal veins lie above the intercostal
artery and nerve in the subcostal groove. This neuromus-
cular bundle lies between the intercostal muscles and
pleura. There are 12 intercostal veins. The first vein
drains directly into the right brachiocephalic vein. The
second and third veins join together to form a single
trunk, called the right superior intercostal vein, which
empties into the azygos vein (Fig. 5 & 6). The lower 9
veins, from the fourth on, drain directly into the azygos
vein, which enters the chest through the aortic hiatus. It
runs to the right of the vertebral column and, at the fourth
thoracic vertebral body, arches forward over the root of
the lung to join the superior vena cava (1-3).
Technique
Under general anaesthesia, right posterior thoracotomy
incision (4-6 cm) was made in the fourth intercostal
space. After entering the pleural cavity, the right upper
H. M. Saleh et al.
Fig. 6
Right posterior intercostal venous access
pulmonary lobe was retracted inferiorly and the azygos
vein & the intercostal tributaries were identified. It was
noted that all these veins were engorged because of the
superior vena cava thrombosis. The second or third inter-
costal vein was identified and dissected to mobilize a
small segment from the surrounding soft tissue. Two
nonabsorbable sutures were placed around the vein to
achieve proximal and distal vascular control. Afterward,
the distal vein was ligated, and a transverse venotomy
was performed. The silastic catheter (6F caliber) was
introduced into the intercostal and azygos veins and the
tip was located in the right atrium, under radiological
assistance. After these procedures, the catheter was pal-
pated in the superior vena cava to confirm the correct
placement. The catheter was tunnelled from the
intrapleural space to the subcutaneous tissue. Finally, the
port was placed and fixed to the anterior chest wall. The
intercostal tube was inserted and the thoracotomy was
closed in layers. The chest drain tube was removed 3 or
4 days postoperatively.
Results
Recovery from the procedure was uncomplicated for
all patients. The catheters & ports could be used
immediately after the insertion.
In 30 patients (13 boys and 17 girls), 38 central
venous catheters (diameter of the catheter ranging from
4.2 :8 Fr.) were inserted, 28 via IEV (22 were right sided
and 3 had metachronous bilateral), 5 via the right
gonadal vein, and 5 via the intercostal veins. Short gut
syndrome was the underlying disease in the majority,
non-Hodgkins lymphoma in 3, and haemophilia A in 2.
In all patients the procedure was carried out because no
other sites were available. The average age at operation
was 1.4 years (range 1 month to 12 years). The mean
 Alternate Routes for Children with Difficult Central Venous Access
Table I
Routes for long-term central venous access in children
Superior Inferior Right atrium (7)
vena cava (1, 19) vena cava (1, 4)
Superficial temporal Femoral Direct right atrial
catheterization
External jugular Inferior epigastric
Internal jugular Saphenous
Common facial Iliac
Subclavian Translumbar IVC
Cephalic Transhepatic IVC
Axillary
Intercostal
Azygos
operating time was 50.8 minutes (range, 34 minutes to
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65 minutes). Blockage of IVADs requiring a change of
chamber alone occurred in 11 patients : in 7 it was
changed once, in 3 it was changed on two occasions, and
in 1it was changed 3 times. Infection of the port occurred
in two children, and both had removal of IVAD.
Thrombosis was seen in two patients. At 6 months fol-
low-up there have been no catheter-related complica-
tions. The average longevity of IVAD is 6.5 months.
Discussion
For infants and children who need long-term central
venous access, a number of approaches have been
described in the literature for the placement of catheter
devices in the SVC or IVC (Table I). Long-term catheter-
related complications include infection and thrombosis
(8, 9). This may lead to the use of multiple catheteriza-
tion and the eventual depletion of commonly used
venous access routes. Patients with SVC and iliofemoral
venous thrombosis pose a particularly difficult problem.
In these situations useful alternatives are placement of a
catheter via :
1) The inferior epigastric vein
In 1980 DONAHOE and KIM (10) first described the use
of the inferior epigastric vein in children in a group
of neonates in whom no other access was available. The
use of IEV for the placement of IVADs in children is
described here for the first time. The percentage of infec-
tious complications in IVADs is reported to be 9% to
32% (11-16). We had an infection rate of 10% in this
series. Infection of the port occurred in 2 children. A
pediatric series detected unsuspected thrombosis in 2 of
the 10 patients (20%) after placement of IVADs in the
upper half of the body (16). This thrombosis was detect-
ed by Doppler ultrasonography. We did not encounter the
problem of venous thrombosis in any of the 20 patients
with groin placement of the port. Blockage of the IVAD
is the most common complication. It was seen in
567
11 patients, in all of whom it was amenable to change of
chamber only. The life span of each device is good and
change of portal is a relatively minor procedure.
Blockage was almost always at the outlet of the por-
tal. The dependent position of the portal may contribute
to blockage. Clinically, blockage can occur gradually
or suddenly. Sometimes a slow increase in resistance
to injection can be detected. Under these circumstances,
urokinase or streptokinase can be used to improve flow.
This study does not include those figures. More often,
injection suddenly stops. Alternating aspiration and
injection sometimes clears this problem and the device
may function for months without further problems until
it finally blocks permanently. The iliac position of
the port makes it very conveniently accessible for
heparinization. A number of patients’ parents have
learned to perform this themselves.
2) The gonadal vein
A useful alternative is placement of a catheter via the
gonadal vein to the right atrium using an open retroperi-
toneal approach. The advantage of this technique is
the direct exposure of the vein before catheterization.
In children who have extensive thrombosis of the
iliofemoral system and lower IVC, the favourable venous
drainage anatomy of the gonadal vein bypasses the
occlusion. In our patients, as has been described in
adults, the gonadal vein was dilated, making identifica-
tion and cannulation easy (17, 18). However, care must
be taken to leave an adequate length of the catheter in the
retroperitoneum to avoid dislodgement. The right
gonadal vein was chosen because it drains directly into
the IVC.
3) The intercostal veins
The right posterior intrapleural thoracotomy offers
access to the azygos vein system, superior vena cava, and
right atrium for central venous cannulation under direct
vision. In our 5 patients, the procedures were well toler-
ated, and the catheter could be used over long periods. In
the children with no central vein available, the cannula-
tion of the intercostal veins is advantageous because the
presence of many intercostal veins, all with equal access
to the azygos system, allows multiple cannulations.
There are only 4 reports in the literature about the use
of the intercostal veins for prolonged central venous can-
nulation and parenteral nutrition. In all of these reports,
the authors used techniques different from these herein
reported. MALT and KEMPSTER (19) first described the
direct insertion of a Hickman catheter into the azygos
vein and superior vena cava cannulation through an
intrapleural thoracotomy. POKORNY et al. (20) described
this procedure in two pediatric patients requiring total
parenteral nutrition, but in contrast to our cases, they
accessed the intercostal veins by the extrapleural route.
NEWMAN et al. (21) and CRONEN et al. (22) used the
 568
intercostal vein cannulation through a small posterior
intercostal incision without the need for thoracotomy.
The advantage of the approach described in the pres-
ent paper over the technique of azygos vein cannulation
described by POKORNY et al. (20) is that many intercostal
veins can be cannulated. We preferred the direct
intrapleural catheterization of the intercostal vein instead
of the extrapleural approach proposed by NEWMAN et
al. (21) because we considered that the central placement
of the catheter would be very difficult because of the pre-
vious multiple and prolonged catheterizations.
The present report is the first description of the use of
the intercostal vein for the introduction of an implantable
port for parenteral nutrition solution administration. The
use of this device has proven that the incidences of infec-
tion and mobilization are smaller than those of the exter-
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nal catheters (23-26). Then, in patients with difficult vas-
cular access, we recommend the use of implantable ports
instead of external catheters. In addition, in our pediatric
oncology patients and children who are submitted to a
home parenteral nutrition programme, we have realized
that implantable ports are easier to care for and more
readily accepted by children and parents.
Conclusion
Nowadays, long-term central venous access has become
increasingly common and the number of children
dependent on total parenteral nutrition on the waiting
list for intestinal transplantation is increasing. Thus, the
knowledge of alternate routes to obtain central venous
access, such as that presented in this report, is critically
important today.
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Hossam M. Saleh, PhD, MRCS
Department of Vascular Surgery
Ain Shams University Hospital
Ramses Street, Abbasia
Cairo-Egypt
Tel. : 002-0108249203 (mobile)
E-mail : hosamsaleh2003@yahoo.com