Indian Journal of Pediatrics (March 2024) 91(3):221–222
https://doi.org/10.1007/s12098-023-04935-9
EDITORIAL COMMENTARY
Transhepatic Central Venous Catheterization: Unconventional
but Effective!
Nitin Dhochak1 · Rakesh Lodha1
Received: 3 November 2023 / Accepted: 3 November 2023 / Published online: 10 November 2023
© The Author(s), under exclusive licence to Dr. K C Chaudhuri Foundation 2023
Children with chronic diseases frequently require repeated
hospital admissions and intravenous infusions. This leads to
thrombosis and exhaustion of peripheral and commonly used
central venous access sites including femoral and neck veins
(subclavian vein, internal jugular vein, etc.). Conditions with
iliofemoral thrombosis or obstruction of distal inferior vena
cava (IVC) due to mass lesion may preclude use of lower
limb veins for infusions.
Access to proximal inferior vena cava with unconven-
tional approaches has been described in such a scenario.
Proximal IVC has been approached directly through a trans-
lumbar approach or by proximally draining veins like hepatic
veins and gonadal veins [1, 2]. Large non-collapsing hepatic
veins have been catheterized in children using the transhe-
patic approach for central line placement, dialysis catheter
placement and cardiac catheterization. The access requires
radiological guidance by ultrasound and fluoroscopy.
In this issue of the Journal, Onan et al. have described
their centre’s experience of 16 transhepatic central catheter
placement procedures in 12 children [3]. The procedure
was utilized as a last-resort scenario when all other sites
had already been used. Youngest child was aged 14 d, and
they used variety of catheters including multi-lumen central
line, dialysis catheter, as well as port catheters. Duration of
catheter patency ranged from 12 - 540 d. Commonest com-
plication was malposition in 6, intra-catheter thrombosis in
one, and infection in one procedure. One of the catheters
malpositioned with the tip in the peritoneal space. Authors
used prophylactic low molecular weight heparin (LMWH) in
all children which is not routinely recommended for central
venous catheters and has not been described in other studies.
Complications related to long-term LMWH have not been
described in the study.
* Rakesh Lodha
rlodha1661@gmail.com
1 chronic critical illness: the transhepatic approach. Indian J Pediatr.
Department of Pediatrics, All India Institute of Medical
Sciences, New Delhi, India
One of the largest pediatric series by Boe et al. described
92 transhepatic central venous catheterizations in children
with congenital heart diseases [4]. The success rate of the
procedure was 96%. The procedure was not without risks.
Eight children developed arrhythmia during the procedure;
among them, one child had heart block for 5 d [4]. The study
described 39.7 complications per 1000 catheter days. Use of
polyurethane catheters and duration of more than 21 d were
associated with increased frequency of complications. Other
studies with 11 and 19 transhepatic catheterization proce-
dures, respectively have reported similar findings [1, 5].
Though feasible, transhepatic catheterization should be
used only as last resort procedure for venous access. The
current study demonstrates the feasibility in children not
only for long term infusions but also for port catheters as
well as larger catheters for hemodialysis. The procedure
must be performed in experienced hands with ultrasound and
fluoroscopy guidance; as well as intensive care/ anesthesia
support for management of complications of arrhythmia and
bleeding. With the level of invasiveness, and limited safety
data, the procedure is best reserved as a last resort.
Declarations
Conflict of Interest None.
References
1. Azizkhan RG, Taylor LA, Jaques PF, Mauro MA, Lacey SR. Per-
cutaneous translumbar and transhepatic inferior vena caval cath-
eters for prolonged vascular access in children. J Pediatr Surg.
1992;27:165–9.
2. Chang MY, Morris JB. Long-term central venous access through
the ovarian vein. J Parenter Enteral Nutr. 1997;21:235–7.
3. Onan HB, Piskin FC, Sozutok S, Ekinci F, Yildizdas D. An alter-
native central venous access route for pediatric patients with
2023. https://​doi.​org/​10.​1007/​s12098-​022-​04219-8.
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4. Boe BA, Zampi JD, Yu S, Donohue JE, Aiyagari R. Transhepatic Publisher's Note Springer Nature remains neutral with regard to
central venous catheters in pediatric patients with congenital heart jurisdictional claims in published maps and institutional affiliations.
disease. Pediatr Crit Care Med. 2015;16:726–32.
5. Marshall AM, Danford DA, Curzon CL, Anderson V, Delaney JW.
Traditional long-term central venous catheters versus transhepatic
venous catheters in infants and young children. Pediatr Crit Care
Med. 2017;18:944–8.

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