Alternate Routes for Children with Difficult Central Venous Access

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. 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 intercostal 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 I 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.