Vascular Access in Children With Congenital Heart Defects

Vascular access in pediatric cardiac patients is an inherently complex topic. Many clinicians struggle to understand the “plumbing,” let alone the implications that particular cardiovascular anatomic and physiologic derangements and our strategies of palliation have for children, both for the present and the future. Each choice a clinician makes regarding where and how to place a vascular access device (VAD), the length and diameter of the catheter, the surveillance and maintenance practices for the catheter, the duration the catheter is left indwelling, the types of therapies administered through the catheter, the blood sampled through the catheter, and the decision to remove the catheter can have major implications for a child’s future candidacy for additional catheterization and surgery. Simultaneously accounting for all of these factors can result in an incomprehensible morass. Through the Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC), we have employed the use of an expert panel and the RAND Corporation and University of California, Los Angeles appropriateness methodology (which is similar to the approach that was used in the development of the Michigan Appropriateness Guide for Intravenous Catheters)1 in an attempt to distil the multitude of patient-, catheter-, and condition-related factors into a reasonable and straightforward framework. miniMAGIC2 provides a starting point for the multidisciplinary discussions that necessarily precede the individualized decisions surrounding vascular access in the congenital cardiac population. These recommendations do not necessarily reflect policy of the American Academy of Pediatrics (Table 1).In neonates and infants who require vascular access, it is critical to choose devices and insertion sites that minimize the likelihood of long-term vessel damage, thrombosis, and occlusion.For children with complex congenital heart disease, it is important to understand the long-term trajectory of their palliation strategy (ie, functionally univentricular physiology versus biventricular circulation) as well as their stage of palliation if functionally univentricular. For example, such understanding is critical in deciding whether to place a peripherally inserted central catheter in the arm or the leg of an infant or whether to place a femoral or jugular short-term central venous access device (CVAD) in the operating room before cardiac surgery. In general, a strategy that preserves the patency of upper extremity veins for patients with functionally univentricular physiology undergoing staged palliation is paramount.Patients undergoing biventricular repair generally have fewer risks associated with upper extremity catheters, and the known issues of thrombosis and infection inherent to femoral VADs should be taken into account.3 In patients who require future cardiac catheterization through femoral veins, these vessels should be preserved when possible (eg, patients with Tetralogy of Fallot with pulmonary atresia and patients receiving cardiac transplant who will need multiple endomyocardial biopsies).Although data on many unusual routes of access (ie, intracardiac and transthoracic, umbilical, transhepatic, and translumbar routes) are sparse, these routes should be considered as options. In particular, the umbilical vein can provide a free CVAD route for neonates requiring several days of central access without jeopardizing any longer-term access sites, but care must be taken to ensure such catheters remain central and to remove them promptly when they are no longer needed. Similarly, the use of transthoracic intracardiac right atrial or common atrial lines can help preserve both upper and lower extremity veins.Vessel visualization with ultrasound should be employed whenever achievable to minimize vessel trauma and the number of access attempts.It is usually inappropriate to dedicate additional lumens of a central venous line for blood sampling because of the risks posed by additional lumens.4Totally implantable venous devices do not have much of a role in the congenital cardiac population.We thank Vineet Chopra, Amanda Ullman, and the entire miniMAGIC panel, from whom we learned a tremendous amount during the process of creating and disseminating these guidelines.