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Catheterization Variables
Source publication
We sought to determine if a higher dose of heparin would reduce arterial complications in patients weighing 10 kg or less undergoing cardiac catheterization to investigate congenital heart disease. Sixty patients were given either 100 (group A) or 150 (group B) IU x kg(-1) of heparin in a double-blinded randomized manner. Initial arterial access wa...
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Citations
... 1 Lower patient weight or younger patient age at the time of femoral artery access are associated with a significantly elevated risk of arterial injury. 3,4 Additional complications include iliofemoral stenosis, claudication, and possible leg length discrepancies. 5 Umbilical artery catheterization is a useful tool to administer fluid/medications, obtain blood gasses, and monitor blood pressure in critically ill neonates. ...
Catheter-based interventions are relatively rare in the neonate population but serve as an invaluable tool in managing many pathologies. Here we present a case report of a neonate with a vascular hepatic tumor managed by embolization via transumbilical access. In neonates, the small size of the common femoral artery makes cannulation difficult and is thought to increase the risk of catheter-associated thrombosis and ischemia. Often, these patients reside in the neonatal intensive care unit (NICU) and already have an umbilical artery catheter (UAC) in place, which can be used as an effective alternative route of vascular access to carry out life-saving interventions.
... Therefore, determining the optimal dose and monitoring the effects of UFH is necessary to reduce thromboembolism and bleeding complications (4). Although intravenous UFH loading doses between 50 and 150 IU/kg are recommended during PCC after sheath placement (2,(5)(6)(7)(8)(9), the commonly administered loading dose is 100 IU/kg (1,2,4,(10)(11)(12)(13)(14)(15)(16)(17). The activated clotting time (ACT) (1), activated partial thromboplastin time (aPTT) (9), anti-factor Xa (anti-FXa) (1,2,15), anti-factor IIa (anti-FIIa) (18), fibrinopeptide-A (2), and prothrombinaseinduced clotting time (9) were used to monitor the degree of heparinization (1,3,4,6,7,10,11,13,14,16,17,1 9). ...
... In another study in which 60 patients weighing <10 kg was included, loading doses of 100 and 150 IU/kg were compared and the mean ACT value was observed as 199 ± 53 and 259 ± 113 sec, respectively at the 20th minute after UFH administration. Hence, it is safe to administer a loading dose of 100 IU/kg or more and to maintain the ACT level for over 200 sec (6). Although different doses were administered in two studies, the reason for the similar clinical results may be that no significant difference could be detected. ...
... IU/kg UFH loading dose was administered, and the target ACT value was accepted as > 250 sec, it was reported that a final ACT value of > 250 sec did not prevent femoral arterial occlusion(7). Hence, the final ACT for UFH monitoring is important in planning the treatment of postprocedural femoral arterial occlusion after procedure(4).Different studies have reported that initial UFH loading doses of 50-150 IU/kg are sufficient in pediatric cardiology practice(5)(6)(7)(8)(9)15). In a study by Grandy et al., in which bolus doses of 50 and 100 IU/kg UFH were compared between patients with CHD, basal and for two-hour fibrinopeptide A and ACT values were measured to monitor the heparin anticoagulation effect. ...
... Traditionally, pediatric cardiac catheterization has been performed percutaneously via the femoral vessels largely due to experience and easier patient positioning on the catheterization table. However, in babies, especially those undergoing interventional procedures, the risk of femoral arterial vascular injury is much greater than in older children [1][2][3]. This increased risk of vascular injury in smaller infants has led to the development of alternative routes of vascular access, such as carotid, axillary, and umbilical arteries. ...
... As the femoral approach gained popularity in the 1970's and 80's, this approach became less favorable. However, long-term reports of femoral arterial complications during interventional catheterization of neonates, especially those < 4 kg in weight, or requiring larger sheaths for intervention, has led to widespread interest and experience in performing these interventions via alternative routes of vascular access including the carotid artery and axillary arteries [1][2][3][4][5]15]. In 2015, Choudhry et al.reported a small case series of 18 patients under 3 months of age who underwent PCA for congenital cardiac interventions. ...
Percutaneous carotid access (PCA) in infants has been reported in small multicenter cohorts, case reports and wider studies over the last 20 years. Compare outcomes after implementation of a systematic approach to PCA in a single center including an imaging follow-up protocol. Retrospective case–control study of PCA at Children’s Hospital Colorado was performed from January 2013 to December 2022. Seventy-four patients underwent 82 PCAs for cardiac catheterization. The median age (range) was 14 days (1–359), and weight was 3.25-kg (1.9–7.9). Median sheath size was 4-Fr (3.3–6). Seventy-seven interventions performed included PDA stenting, aortic valvoplasty, BTT shunt stenting, and coarctation stenting. Vascular access was performed using a modified 21 g butterfly needle. A protocolized approach was implemented in 2020 reversing the patient head-to-toe orientation on the catheterization table, maintaining intubation and sedation for 4-h during recovery and routine use of a specific vascular ultrasound protocol. Following these changes, time to access significantly improved with no major complications. Before 2020, two access related complications occurred. One requiring surgical vascular repair and one occlusive thrombus. A significant increase in sheath time in post-era was associated with increased case complexity. Longer sheath times were not associated with increased risk of vessel injury or thrombus. No neurological insults were reported. Our experience confirms that PCA is safe and achievable with preserved vessel patency regardless of patient weight or sheath size. A protocolized planning, recovery, and follow-up regimen is recommended to establish safe practice and identify and treat complications as necessary.
... Furthermore, arterial access time in our study was not found to be a risk factors for FAO which is in line with the results of a previous study [9]. The frequency of FAO can vary according to the time from sheath removal to the evaluation of the pulses [6,7,9,11,13,16] and the method of diagnosis [6,12,13,16,18,19,30]. ALAP and arterial thrombosis in infants can be subtle, and their diagnosis can easily be missed on physical examinations. ...
... Therefore, the time of diagnosis and treatment is vital for patients with ALAP. Studies have reported the diagnosis of ALAP 4, 6 [6,11,19] and 24 [12] hours after cardiac catheterization. Differences in diagnostic time can result in underestimation or overestimation of FAO frequency. ...
... Many studies have reported that FAO is more common in the younger age group, especially in infants and neonates with CHD [5,13,29], and is an independent risk factor for FAO [7,19,30]. Similarly, low body weight during PCC has also been identified as a risk factor for FAO [6,13,18,19]. The patient age at procedure was statistically lower in patients with ALAP or PFAO than in those without ALAP or PFAO, respectively (all p < 0.001). ...
Femoral arterial access is challenging in infants. Furthermore, after cardiac catheterization, femoral arterial occlusion (FAO) can be underestimated and easily missed on physical examination. Ultrasound is recommended for femoral arterial access and the correct diagnosis of FAO; however, few studies have reported its effectiveness.To investigate the frequency and risk factors of acute loss of the arterial pulse (ALAP) and persistent femoral arterial occlusion (PFAO) in infants with congenital heart disease who underwent ultrasound˗guided femoral arterial access (US-GFAA) and were diagnosed with FAO by ultrasound.We obtained data related to patient characteristics, access variables of US˗GFAA, and ultrasonography findings of the femoral artery from our pediatric cardiac catheterization database between August 2017 and August 2022. We divided the patients into groups based on the presence of ALAP and PFAO. We identified ALAP in 99 (19%) patients and PFAO in 21(4%) of 522 patients in the study. The median patient age was 132 days (interquartile range: 75˗202 days). The logistic regression analysis identified younger age, aortic coarctation, previous catheterization of the same femoral artery, larger sheath size (5F), and longer duration of cannulation as independent risk factors for ALAP and younger age as an independent risk factor for PFAO (all p < 0.05). This study showed that younger age at procedure was a risk factor for both ALAP and PFAO, while aortic coarctation, previous arterial catheterization, use of a larger sheath and longer duration of cannulation were risk factors for ALAP in infants. The majority of FAO is reversible and secondary to arterial spasm, and the of FAO increases inversely with patient age.
... The maintenance dose was initiated at 25 U/kg/h, as in previous studies. 3,8,13,15 Collateral circulation can develop in early stages due to increased angiogenesis in neonates. In fact, we detected collateral circulation in three patients on the third day. ...
... Several studies have identified the use of a larger sheath as an independent risk factor for arterial occlusion. 14,15,17 The incidence of arterial thrombosis in patients that weigh < 5 kg was 5.2% in patients with a 4F sheath and 12.9% in patients with a 5F sheath. 18 Because catheter and sheath systems with a lower profile than 4F were unavailable in our country, we placed a 4F sheath in the patients during the study and did not perform a comparison about the sheath size. ...
... 13,17,18 In our cohort, the cannulation time was significantly shorter than in previous studies. 7,13,15 The cannulation time was statistically longer in patients with acute loss of the arterial pulse than in those without acute loss of the arterial pulse. No significant difference was found between patients with and those without permanent femoral arterial occlusion. ...
Objective
We investigated frequency and risk factors of acute loss of the arterial pulse and permanent femoral arterial occlusion in neonates with CHD who underwent ultrasound-guided femoral arterial access.
Methods
We divided the patients into groups according to the presence of acute loss of the arterial pulse and permanent femoral arterial occlusion. We obtained data related to patient characteristics and access variables of ultrasound-guided femoral arterial access from our database of cardiac catheterisation between August, 2017 and May, 2021. We used an echocardiography-S6, 12-MHz linear probe, 21-gauge needle, 0.018"guidewire, and a 4F sheath for arterial access.
Results
Ultrasound-guided femoral arterial access was obtained in 323 (98.8%) of the 327 neonates. We identified acute loss of the arterial pulse in 130 (40.2%) patients and permanent femoral arterial occlusion in 19 (5.9%) patients. Median weight was 3.05 (Interquartile range (IQR): 2.80–3.40) kg, first attempt success rate was 88.2%, and median access time was 46 sec (IQR: 23–94). Logistic regression analysis identified coarctation of the aorta (odds ratio: 2.46; 95% CI: 1.30–4.66; p = 0.006) as independent risk factor for acute loss of the arterial pulse, but did not identify any independent risk factors for permanent femoral arterial occlusion.
Conclusions
This study showed coarctation of the aorta as an independent risk factor for acute loss of the arterial pulse, but did not identify any independent factors for permanent femoral arterial occlusion in neonates with CHD. Although most cases of acute loss of the arterial pulse resolve in the early period, the frequency of permanent femoral arterial occlusion remains high despite effective treatment.
... The maintenance dose was initiated at 25 U/kg/h, as in previous studies. 3,8,13,15 Collateral circulation can develop in early stages due to increased angiogenesis in neonates. In fact, we detected collateral circulation in three patients on the third day. ...
... 13,17,18 In our cohort , the cannulation time in was significantly shorter than in previous studies. 7,13,15 The cannulation time was statistically longer in patients with ALAP than in those without ALAP. No significant difference was found between patients with and those without PFAO. ...
... We obtained a shorter time in terms of arterial access time compared to those of studies that used traditional technique and US-GFAA. 2,5,7,13,15,20 Although a study reported that long access time increases the complications of the access site, 13 our study did not identify arterial access time as a risk factor in patients with ALAP and PFAO. ...
Background: In neonates, securing femoral arterial access is challenging and time consuming even in experienced hands. Data on frequency and risk factors of ALAP and PFAO are scarce in neonates with CHD. We investigated frequency and risk factors of acute loss of the arterial pulse (ALAP) and permanent femoral arterial occlusion (PFAO) in neonates with congenital heart disease (CHD) underwent ultrasound˗guided femoral arterial access (US˗GFAA). Methods: We divided the patients into groups according to the presence of ALAP and PFAO. We obtained data related to patient characteristics and access variables of US˗GFAA from our database of pediatric cardiac catheterization between August 2017 and May 2021. We used an echocardiography˗S6, 12˗MHz linear probe, 21˗gauge needle, and a 0.018”guidewire for arterial access. A 4˗French sheath (7cm) was placed in all patients. Results: US˗GFAA was obtained in 323(98.8%) of the 327 neonates. We identified ALAP in 130(40.2%) patients and PFAO in 19(5.9%) patients. Median weight was 3.05(IQR: 2.80˗3.40) kg, first attempt success rate was 88.2% and median access time was 46 sec (IQR: 23˗94). Logistic regression analysis identified coarctation of the aorta (Odds ratio: 2.46; 95% CI: 1.30˗4.66; P=0.006) as independent risk factor for ALAP, but did not identify any independent risk factors for PFAO. Conclusion: This study showed that coarctation of the aorta is an independent risk factor for ALAP in neonates with CHD underwent US˗GFAA and placed a 4˗French sheath. Although most cases of ALAP resolve in the early period, the frequency of PFOA remains high despite effective treatment.
... Femoral arterial (FA) access is a commonly used technique in pediatric interventional cardiology. Unfortunately, it carries the risk of several complications including loss of pedal pulse (LOP) [1][2][3][4][5][6][7][8][9][10][11][12][13], retroperitoneal hematoma, pseudoaneurysm, arteriovenous fistula, and arterial thromboembolism [2][3][4][5][6]. Many of these complications are common in pediatric population and are thought to occur secondary to vasospasm, thrombus formation or due to inadvertent access into the superficial or profunda femoral artery [14]. ...
To evaluate whether avoidance of a risk factor associated with loss of pulse (LOP) following femoral artery (FA) catheterization in infants identified from previous study, was associated with decreased incidence of LOP during a prospective evaluation. Since initiation of routine ultrasound guided femoral arterial access (UGFAA) for infants undergoing catheterization in Jan 2003–Dec 2011 (Period-1), our incidence of LOP had stayed steady. Prospective evaluation between Jan 2012–Dec 2014 (Period-2), identified FA-diameter < 3 mm as risk factor for LOP. Between Jan 2015–Dec 2018 (Period-3), an initiative to avoid UGFAA for FA-diameter < 3 mm was implemented to determine whether that led to a decreased incidence of LOP. FA-diameter was measured prior to USGFAA and ratio of outer diameter of arterial sheath to luminal diameter of cannulated artery (OD/AD ratio) was calculated during Periods-2 and 3. The incidence and risk factors for LOP were assessed during the three periods. FA-access rates dropped significantly during Period-3 (56.7% vs. 93.8% and 90.4% during Periods-1 and 2, respectively, p < 0.001). Incidence of LOP in Period-3 decreased to 2.7% compared to 12.5% (Period-1) and 17.4% (Period-2) (p < 0.001). By multivariate analysis, FA size < 3 mm and an OD/AD ratio > 40% were the only significant independent predictors for LOP (OR 6.48, 95% CI 2.3–11.42, p < 0.001 and OR 4.16, 95% CI 1.79–8.65, p < 0.01, respectively). Access of femoral artery < 3 mm and OD/AD ratio > 50% are associated with increased incidence of LOP. Avoidance of these factors may help decrease complications in infants undergoing cardiac catheterizations.
... One major complication of cardiac catheterization in infants and children is the arterial thrombosis. As stated in the literature, the ratio of incidence of femoral venous thrombosis after cardiac catheterization is 0-20% for infants and children, and the ratio of incidence of femoral arterial thrombosis is 0.8-40% [10][11][12][13][14][15][16] . In another study, the ratio of incidence of venous thrombosis in cyanotic congenital heart diseases in infants younger than 6 months was found to be 50%, while the ratio of incidence of arterial thrombosis was 70% 17 . ...
... Few studies compare unfractionated heparin (UFH) protocols within the dosage range of 50 to 150 U/ kg [10][11][12][13] . The current suggestion is to use 100-150 units per kg body weight bolus UFH and an additional bolus dose during the treatment 21 . ...
Objective: Cardiac catheterization is one of the basic procedures applied in the diagnosis and treatment of cardiovascular diseases. Development of thrombosis is a serious complication of catheterization. In this study, the frequency and the factors affecting the development of arterial thrombosis were prospectively evaluated in neonates who were subjected to diagnostic or interventional cardiac catheterization.
Methods: Twenty newborns that received femoral artery catheterization within 6-month period were enrolled in this study. Blood samples were taken for complete blood count, prothrombin, activated partial thromboplastin time, INR ratio and mutations of factorV Leiden, prothrombin 20210A, methylenetetrahydrofolate reductase C667T and A1298 before the procedure. 100 U/kg bolus of heparin was infused during catheterization. 28 U/kg/hour infusion of heparin was given to the patients with clinically suspected thrombosis during first few hours after catheterization. Doppler ultrasonography was performed in all patients within 6 hours after catheterization.
Results: The gestational age of patients ranged from 31 to 40 weeks (median 39). Mean birth weight was 2996 ± 589 (1880-4000 gr). Arterial thrombosis was detected in 10 patients by Doppler USG. On development of arterial thrombosis, patient age, gender, diagnosis, treatments, platelet count, hemoglobin, prothrombin and activated partial thromboplastin time values, FactorV Leiden, prothrombin 20210A, methylenetetrahydrofolate reductase C667T and A1298 mutations were found as not impacting (p>0.05). Those who were found to have thrombosis in Doppler ultrasonography had lower INR levels compared to others (p= 0.023).
Conclusions: The rate of femoral arterial thrombosis in newborns after catheterization detected by Doppler ultrasonography was 50% in this study. Our data suggest that early clinical assessment for the diagnosis of thrombosis may be misleading but Doppler ultrasonography may be helpful early detection. Further studies are needed to prediction appropriate drugs and/or doses for prevention of thrombosis after arterial catheterization in newborns.
... In most cases the smallest commercially available conductance catheter for human use (4F dependent on manufacturer requiring a 5F long sheath) is too large for neonates and small infants. Besides that it may not be possible to place such a large catheter in a neonate or infant, catheter related complications like arterial thrombosis increase with catheter size and the use of long sheaths [10][11][12]. Moreover, conductance technology requires repeated volume calibration to a reference method (e.g. ...
Background
Pressure-volume loops (PVL) provide vital information regarding ventricular performance and pathophysiology in cardiac disease. Unfortunately, acquisition of PVL by conductance technology is not feasible in neonates and small children due to the available human catheter size and resulting invasiveness. The aim of the study was to validate the accuracy of PVL in small hearts using volume data obtained by real-time three-dimensional echocardiography (3DE) and simultaneously acquired pressure data.
Methods
In 17 piglets (weight range: 3.6–8.0 kg) left ventricular PVL were generated by 3DE and simultaneous recordings of ventricular pressure using a mini pressure wire (PVL3D). PVL3D were compared to conductance catheter measurements (PVLCond) under various hemodynamic conditions (baseline, alpha-adrenergic stimulation with phenylephrine, beta-adrenoreceptor-blockage using esmolol). In order to validate the accuracy of 3D volumetric data, cardiac magnetic resonance imaging (CMR) was performed in another 8 piglets.
Results
Correlation between CMR- and 3DE-derived volumes was good (enddiastolic volume: mean bias -0.03ml ±1.34ml). Computation of PVL3D in small hearts was feasible and comparable to results obtained by conductance technology. Bland-Altman analysis showed a low bias between PVL3D and PVLCond. Systolic and diastolic parameters were closely associated (Intraclass-Correlation Coefficient for: systolic myocardial elastance 0.95, arterial elastance 0.93, diastolic relaxation constant tau 0.90, indexed end-diastolic volume 0.98). Hemodynamic changes under different conditions were well detected by both methods (ICC 0.82 to 0.98). Inter- and intra-observer coefficients of variation were below 5% for all parameters.
Conclusions
PVL3D generated from 3DE combined with mini pressure wire represent a novel, feasible and reliable method to assess different hemodynamic conditions of cardiac function in hearts comparable to neonate and infant size. This methodology may be integrated into clinical practice and cardiac catheterization programs and has the capability to contribute to clinical decision making even in small hearts.
... Femoral arterial access utilizing palpation for identification of anatomical landmarks is a common technique employed by both adult and pediatric cardiac catheterization labs. Although effective, this method has been shown to be associated with undesirable complications such as loss of pedal pulse (LOP) [1][2][3][4][5][6][7][8][9][10][11][12][13], dissections, retroperitoneal hematoma, pseudoaneurysms, arteriovenous fistulas, and arterial thromboembolism [2][3][4][5][6]. Many of these complications occur because of inadvertent access into the superficial or the profunda femoral artery (FA) [14]. ...
... Ultrasound-guided femoral arterial access (UGFAA) is being utilized at many centers during cardiac catheterization in children [5,15]. Previously established factors associated with either LOP or arterial injury in younger patients [6,7,11,12,15] include but are not limited to the use of larger catheters [6,9,11,13,16], interventional procedures performed through the artery, longer procedural times, and need for repeat cardiac catheterizations [5,6,8,9,[11][12][13]. The prevalence of LOP in children while using UGFAA has not been described. ...
... Ultrasound-guided femoral arterial access (UGFAA) is being utilized at many centers during cardiac catheterization in children [5,15]. Previously established factors associated with either LOP or arterial injury in younger patients [6,7,11,12,15] include but are not limited to the use of larger catheters [6,9,11,13,16], interventional procedures performed through the artery, longer procedural times, and need for repeat cardiac catheterizations [5,6,8,9,[11][12][13]. The prevalence of LOP in children while using UGFAA has not been described. ...
Objectives:
The objectives of this study were to describe the prevalence, mechanisms, and identify risk factors for acute loss of arterial pulse (LOP) in children who had ultrasound-guided femoral arterial access (UGFAA) during cardiac catheterization.
Background:
LOP is a known complication in children following femoral arterial (FA) access for cardiac catheterization. The prevalence of LOP requiring treatment ranges between 4% and 8%.
Methods:
A prospective study was performed including 486 cardiac catheterizations using UGFAA in children ≤18 years over a 3 years period. Ultrasound and Doppler evaluations were performed prior to and at the end of the procedure.
Results:
LOP was identified in 33 cases (6.8%) with 23 (4.7%) requiring treatment. For children ≤6 months, the prevalence of LOP requiring treatment was 13.6%. FA diameter <3 mm was the only significant independent predictor for LOP (OR: 8.44, 95% CI: 2.07-34.5, P < 0.001). Smaller patient size, number of access attempts, time required for access, operator experience, sheath size, and length of procedure were not found to be significant predictors. Children with LOP had a greater percentage decrease in vessel diameter (median 62% vs 18%, P < 0.001) compared to those without LOP. FA thrombus was diagnosed only in 9 patients (27% of those with LOP).
Conclusions:
The prevalence of LOP requiring treatment is 4.7% when UGFAA is used during pediatric cardiac catheterizations. Arterial spasm was more common than thrombus as a cause of LOP. FA diameter <3 mm was the only independent predictor for LOP in this carefully designed prospective study. © 2016 Wiley Periodicals, Inc.
