title: A technique for re-utilizing catheter insertion sites in children with difficult central venous access.
abstract: Maintenance of central venous access in patients with chronic medical conditions such as short bowel syndrome demands forethought and ingenuity. We describe an innovative technique for re-utilizing central venous access sites in patients who have chronic central venous access needs. Records of patients undergoing this technique were reviewed between August 2012 and December 2015. The technique involves "cutting-down" to the sterile fibrous tunnel that naturally forms around tunneled catheters. The fibrous sheath is then isolated and controlled much as would be done for a venous "cut-down." A separate exit site is then created for the new catheter and it is tunneled to the "cut-down" site per routine. The non-functioning catheter is then removed from the surgical field. The proximal fibrous sheath is finally cannulated either directly with the new catheter or with a wire/dilator system. This technique effectively re-uses the same venous access point while allowing for a complete change of the physical line and external site. Twenty attempts at this technique were made in twelve patients; six patients underwent the site re-utilization procedure multiple times. Re-using the fibrous tunnel to re-cycle the internal catheter site was successful in seventeen of twenty attempts. All patients had chronic conditions leading to difficult long-term central venous access [short bowel syndrome (6), hemophilia (2), cystic fibrosis (1), chronic need for central IV access (3)]. Indications for catheter replacement included catheter occlusion/mechanical failure/breakage (9), dislodgement (6), infection (1), and inadequate catheter length due to patient growth (4). Broviac/Hickman catheter sites were most commonly re-used (13; one failure); re-using a portcath site was successful in 5 of 7 attempts. There were no short term infections or mechanical complications. We describe a novel technique for salvaging tunneled central venous catheter access sites. This technique is well suited for patients with difficult and long-term central venous access needs, particularly those with chronic conditions such as intestinal failure. It is specifically useful when tunneled lines are broken, precipitated or clotted and unamenable to wiring.
authors.affiliation: Kapiolani Medical Center for Women and Children, Honolulu, USA. sidney.johnson@kapionlani.org.|University of Hawaii School of Medicine, Honolulu, USA. sidney.johnson@kapionlani.org.
authors.forename: S M
authors.initials: SM
authors.lastname: Johnson
authors.affiliation: Kapiolani Medical Center for Women and Children, Honolulu, USA.|University of Hawaii School of Medicine, Honolulu, USA.
authors.forename: G M
authors.initials: GM
authors.lastname: Garnett
authors.affiliation: Kapiolani Medical Center for Women and Children, Honolulu, USA.|University of Hawaii School of Medicine, Honolulu, USA.
authors.forename: R K
authors.initials: RK
authors.lastname: Woo
mesh_terms: D002405:Catheterization, Central Venous / Q000379:methods*; D002408:Catheters, Indwelling; D002648:Child; D002908:Chronic Disease / Q000628:therapy; D020878:Device Removal / Q000379:methods*; D017743:Equipment Reuse; D006801:Humans; D008297:Male
keywords: Central venous access; Difficult central line; Short bowel syndrome; TPN access; Total parenteral nutrition