Pediatric Surgery International

, Volume 34, Issue 5, pp 529–533 | Cite as

Obtaining central access in challenging pediatric patients

  • Cory N. Criss
  • Jake Claflin
  • Matthew W. Ralls
  • Samir K. Gadepalli
  • Marcus D. Jarboe
Original Article



Central catheter placement is one of the most commonly performed procedures by pediatric surgeons. Here, we present a case series of patients where central access was obtained at our institution with the utilization of a novel ultrasound-guided technique. This series represents the first of its kind where the native, parent vessels were inaccessible, resulting in a challenging situation for providers.


A retrospective chart review was performed in pediatric patients (0–17 years) at a tertiary care institution between July 2012 and November 2017 on all central line procedures where ultrasound was utilized to cannulate the brachiocephalic or superior vena cava in face of proximal occlusion. Our group has previous experience utilizing an image-guided in-plane approach to central line placement in the pediatric population. Demographics, operative characteristics, and postoperative complications were reviewed.


A total of 11 procedures were included in this case series where the BC (N = 9) or SVC (N = 2) were cannulated for access. Internal jugular vein cannulation was attempted on each patient unless preoperative imaging demonstrated occlusion. The median operative time was 43 ± 23 min. Most procedures were performed on the right sided (63%), with catheters ranging from 4.2F single lumen to 14F double lumen. Since being placed, three (27%) catheters have been removed, with one due to non-use, one due to sepsis, and the final one due to malposition.


With the continued need for long-term central access in the pediatric population, distal vein occlusion or inaccessibility can prove challenging when attempting to obtain central access. Here, demonstrated a safe alternative technique that provides an additional option in the pediatric surgeon’s armamentarium for patients with difficult central access.


Ultrasound Brachiocephalic Occluded IJ Image guidance Subclavian Internal jugular Central line Broviac Tunneled line Medi-port 





Internal jugular


Superior vena cava




End-stage renal disease





No funding to disclose.

Compliance with ethical standards

Conflict of interest

The authors have nothing to disclose.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standard.


  1. 1.
    Brass P et al (2015) Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev 1:Cd006962PubMedGoogle Scholar
  2. 2.
    Calvert N et al (2004) Ultrasound for central venous cannulation: economic evaluation of cost-effectiveness. Anaesthesia 59(11):1116–1120CrossRefPubMedGoogle Scholar
  3. 3.
    Hind D et al (2003) Ultrasonic locating devices for central venous cannulation: meta-analysis. Bmj 327(7411):361CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Dassinger MS et al (2015) Use of real-time ultrasound during central venous catheter placement: results of an APSA survey. J Pediatr Surg 50(7):1162–1167CrossRefPubMedGoogle Scholar
  5. 5.
    Doniger SJ et al (2009) Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients. Pediatr Emerg Care 25(3):154–159CrossRefPubMedGoogle Scholar
  6. 6.
    Petroski A et al (2015) Predictors of difficult pediatric intravenous access in a community emergency department. J Vasc Access 16(6):521–526CrossRefPubMedGoogle Scholar
  7. 7.
    Tammam TF, El-Shafey EM, Tammam HF (2013) Ultrasound-guided internal jugular vein access: comparison between short axis and long axis techniques. Saudi J Kidney Dis Transpl 24(4):707–713CrossRefPubMedGoogle Scholar
  8. 8.
    Arul GS et al (2009) Ultrasound-guided percutaneous insertion of Hickman lines in children. Prospective study of 500 consecutive procedures. J Pediatr Surg 44(7):1371–1376CrossRefPubMedGoogle Scholar
  9. 9.
    Bruzoni M et al (2013) A prospective randomized trial of ultrasound- vs landmark-guided central venous access in the pediatric population. J Am Coll Surg 216(5):939–943CrossRefPubMedGoogle Scholar
  10. 10.
    Smitherman AB et al (2015) The incidence of catheter-associated venous thrombosis in noncritically ill children. Hosp Pediatr 5(2):59–66CrossRefPubMedGoogle Scholar
  11. 11.
    Shah SH et al (2015) Clinical risk factors for central line-associated venous thrombosis in children. Front Pediatr 3:35CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Fallon EM et al (2014) Neonates with short bowel syndrome: an optimistic future for parenteral nutrition independence. JAMA Surg 149(7):663–670CrossRefPubMedGoogle Scholar
  13. 13.
    Breschan C et al (2018) A retrospective analysis of the clinical effectiveness of supraclavicular, ultrasound-guided brachiocephalic vein cannulations in preterm infants. Anesthesiology 128(1):38–43CrossRefPubMedGoogle Scholar
  14. 14.
    Thompson ME (2017) Ultrasound-guided cannulation of the brachiocephalic vein in infants and children is useful and stable. Turk J Anaesthesiol Reanim 45(3):153–157CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Breschan C et al (2011) Consecutive, prospective case series of a new method for ultrasound-guided supraclavicular approach to the brachiocephalic vein in children. Br J Anaesth 106(5):732–737CrossRefPubMedGoogle Scholar
  16. 16.
    Merchaoui Z et al (2017) Supraclavicular approach to ultrasound-guided brachiocephalic vein cannulation in children and neonates. Front Pediatr 5:211CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Shingarev R, Allon M (2012) Peripherally inserted central catheters and other intravascular devices: how safe are they for hemodialysis patients? Am J Kidney Dis 60(4):510–513CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    El Ters M et al (2012) Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients. Am J Kidney Dis 60(4):601–608CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Di Nardo M et al (2014) Ultrasound-guided left brachiocephalic vein cannulation in children with underlying bleeding disorders: a retrospective analysis. Pediatr Crit Care Med 15(2):e44–e48CrossRefPubMedGoogle Scholar
  20. 20.
    Guilbert AS et al (2013) Supraclavicular ultrasound-guided catheterization of the subclavian vein in pediatric and neonatal ICUs: a feasibility study. Pediatr Crit Care Med 14(4):351–355CrossRefPubMedGoogle Scholar
  21. 21.
    Matsuura J et al (2011) Mediastinal approach to the placement of tunneled hemodialysis catheters in patients with central vein occlusion in an outpatient access center. J Vasc Access 12(3):258–261CrossRefPubMedGoogle Scholar
  22. 22.
    Oulego-Erroz I et al (2016) Comparison of ultrasound guided brachiocephalic and internal jugular vein cannulation in critically ill children. J Crit Care 35:133–137CrossRefPubMedGoogle Scholar
  23. 23.
    Granata A, Zanoli L, Trezzi M, Londrino F, Basile A, Fiorini F, Ricciardi B, Di Nicolò P (2017) Anatomical variations of the left anonymous trunk are associated with central venous catheter dysfunction. J Nephrol. Google Scholar
  24. 24.
    Breschan C et al (2015) Ultrasound-guided supraclavicular cannulation of the right brachiocephalic vein in small infants: a consecutive, prospective case series. Paediatr Anaesth 25(9):943–949CrossRefPubMedGoogle Scholar
  25. 25.
    Zhou L et al (2017) Catheterization via direct cannulation of superior vena cava for a hemodialysis patient with an original dysfunctional catheter on the left internal jugular vein. Front Med 11(3):445–448CrossRefPubMedGoogle Scholar
  26. 26.
    Church JT, Jarboe MD (2017) Vascular access in the pediatric population. Surg Clin North Am 97(1):113–128CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Cory N. Criss
    • 1
  • Jake Claflin
    • 2
  • Matthew W. Ralls
    • 1
  • Samir K. Gadepalli
    • 1
  • Marcus D. Jarboe
    • 1
  1. 1.Section of Pediatric Surgery, Department of SurgeryMichigan Medicine, C.S. Mott Children’s and Von Voigtlander Women’s HospitalAnn ArborUSA
  2. 2.University of Michigan School of MedicineAnn ArborUSA

Personalised recommendations