Comparison of complications between pediatric peripherally inserted central catheter placement techniques.

BACKGROUND: Peripherally inserted central catheter (PICC) is among the most common procedures performed in children in the hospital setting. PICC insertion can be simplified with the use of a sheathed needle as an alternative to the modified Seldinger technique. OBJECTIVE: To retrospectively evaluate PICC placement for the technique used and the incidence of complications at a large pediatric tertiary care center. MATERIALS AND METHODS: We retrospectively reviewed all PICC placements at a single institution over a 4-year period. We reviewed patient records for demographic data, PICC placement technique, catheter size and number of lumens, and the incidence of complications (i.e. multiple attempted puncture sites, phlebitis and vessel thrombosis). We analyzed complication rates between two placement techniques using a chi-square test. RESULTS: We identified 8,816 successful PICC placements, 4,749 (53.9%) in males and 4,067 (46.1%) in females. The average age of the patients for which a line was placed was 5.6 years (range 1 day to 45 years). A direct sheathed needle puncture technique was used in 8,362 (94.9%) placements and a modified Seldinger technique was used in 454 (5.1%). Complications occurred in 312 (3.7%) of direct sheathed needle puncture placements versus 17 (3.7%) of modified Seldinger placements (P = 0.99). Multiple puncture sites were required in 175 (2.1%) attempted direct sheathed needle puncture placements compared with 8 (1.7%) attempted modified Seldinger placements (P = 0.63). Phlebitis occurred in 94 (1.1%) direct sheathed needle puncture lines versus 5 (1.1%) modified Seldinger placed lines (P = 0.96). Vessel thrombosis occurred in 43 (0.5%) direct sheathed needle puncture lines versus 4 (0.9%) modified Seldinger placed lines (P = 0.30). CONCLUSION: The direct peel-away sheathed needle vessel puncture technique and the modified Seldinger technique used to place PICC lines in children have similar complication rates.

Cryoablation of low-flow vascular malformations.

PURPOSE: We aimed to evaluate the safety and effectiveness of cryoablation in the treatment of low-flow malformations, specifically venous malformation (VM) and fibroadipose vascular anomaly (FAVA). METHODS: We conducted a retrospective review of 11 consecutive patients with low-flow malformations (14 lesions; 9 VM, 5 FAVA), median lesion volume 10.8 cm3, (range, 1.8-55.6 cm3) with a median age of 19 years (range, 10-50 years) who underwent cryoablation to achieve symptomatic control. Average follow-up was at a median of 207 days postprocedure (range, 120-886 days). Indications for treatment included focal pain and swelling. Technical success was achieved if the cryoablation ice ball covered the region of the malformation that corresponded to the patient's symptoms. Clinical success was considered complete if all symptoms resolved and partial if some symptoms persisted but did not necessitate further treatment. RESULTS: The technical success rate was 100%. At 1-month follow-up, 13 of 14 lesions (93%) had a complete response and one (7%) had a partial response. At 6-month follow-up 12 of 13 (92%) had a complete response and 1 (8%) had a partial response. A total of 6 patients underwent primary cryoablation. Out of 9 VM cases, 7 had prior sclerotherapy and 2 had primary cryoablation. Out of the 5 FAVA cases, 1 had prior sclerotherapy and the remaining 4 cases underwent primary cryoablation. There were 3 minor complications following cryoablation including 2 cases of skin blisters and 1 case of transient numbness. These complications resolved with conservative management. CONCLUSION: Cryoablation is safe and effective in the treatment of low-flow vascular malformations, either after sclerotherapy or as primary treatment.

Extrahepatic pseudoaneurysms and ruptures of the hepatic artery in liver transplant recipients: endovascular management and a new iatrogenic etiology.

PURPOSE: To characterize extrahepatic pseudoaneurysm regarding incidence and etiology and determine the effectiveness of endovascular management. METHODS: A retrospective audit of 1,857 liver transplants in two institutions was performed (1996-2009). Recipients' demographics, clinical presentation, transplant type, biliary anastomosis, and presence of biliary endoprostheses were noted. Pseudoaneurysms were classified into iatrogenic (associated with biliary endoprosthesis or angioplasty) or spontaneous extrahepatic pseudoaneurysms. Spontaneous and iatrogenic pseudoaneurysms were compared for time from transplant, presenting symptoms, location in the arterial anatomy, and 3-month graft survival. Arterial patency and 6-month graft survival were calculated. RESULTS: Twenty pseudoaneurysms were found (1.1 %, 20/1,857): 9 (0.5 % of transplants, 9/1,857) were spontaneous and 11 (0.6 % of transplants, 11/1,857) were "iatrogenic" (due to minimally invasive procedures: 4 angioplasty and 7 biliary endoprostheses). Sixty percent (12/20) underwent endovascular management (4 coil embolization and 8 stent-grafts). Technical success was 83 % (10/12) with a mean arterial patency of 70 % (follow-up mean, 4.9; range, 0-18 months). The 1-, 3-, and 6-month graft survival was 70, 40, and 35 %, respectively. CONCLUSIONS: Due to minimally invasive procedures, posttransplant extrahepatic pseudoaneurysms are no longer an exclusive complication of the transplant surgery itself. Endovascular management is effective to stabilize patients but has not improved historic postsurgical graft survival.

Embolization therapy for traumatic splenic lacerations.

PURPOSE: This study was designed to evaluate the clinical success, complications, and transfusion requirements based on the location of and agents used for splenic artery embolization in patients with splenic trauma. METHODS: A retrospective study was performed of patients with splenic trauma who underwent angiography and embolization from September 2000 to January 2010 at a level I trauma center. Electronic medical records were reviewed for demographics, imaging data, technical aspects of the procedure, and clinical outcomes. RESULTS: Fifty patients were identified (34 men and 16 women), with an average age of 48 (range, 16-80) years. Extravasation was seen on initial angiography in 27 (54%) and was absent in 23 (46%). All 27 patients with extravasation were embolized, and 18 of 23 (78.2%) without extravasation were embolized empirically. Primary clinical success was similar (>75%) across all embolization locations, embolic agents, and grades of laceration treated. Of 45 patients treated, 9 patients (20%) were embolized in the main splenic artery, 34 (75.6%) in the splenic hilum, and 2 (4.4%) were embolized in both locations. Partial splenic infarctions developed in 47.3% treated in the splenic hilum compared with 12.5% treated in the main splenic artery. There were four (8.9%) mortalities: two occurred in patients with multiple critical injuries and two from nonbleeding etiologies. CONCLUSIONS: Embolization of traumatic splenic artery injuries is safe and effective, regardless of the location of treatment. Embolization in splenic hilar branches may have a higher incidence of infarction. The grade of laceration and agents used for embolotherapy did not impact the outcomes.