Is Intraoperative Fluoroscopy Necessary for Central Venous Port System Placement in Children?

Abstract

Introduction Central venous port (CVP) placement is traditionally performed under fluoroscopy guidance. However, efforts for radiation dose reduction in children have allowed the introduction of ultrasound guidance (USG) and anatomic landmarks as an alternative technique for CVP placement. The aim of this study is to determine whether intraoperative fluoroscopy (IF) is required to confirm the correct position of the catheter tip in children.

Patients and Methods A prospective, single-center study was performed between July and December 2017. Standard venous access site was the right internal jugular vein under USG. Estimated catheter length (ECL) was measured using anatomic landmarks. Ideal catheter length (ICL) was measured after placement under fluoroscopy guidance in the same patient. Age, sex, radiation dose, and complications were also analyzed. A t-test for paired samples and intraclass correlation coefficient were performed to analyze results.

Results A total of 30 consecutive patients aged 7 ± 2 years underwent CVP placement. The mean ECL was 17.1 ± 1.8 cm, while the mean ICL was 17.7 ± 1.8 cm. The mean difference between measurements was 0.28 cm (95% confidence interval [CI], –0.29 to 0.86; p = 0.324). Intraclass correlation coefficient analysis showed an agreement of 0.95 (95% CI, 0.91–0.98) between measurements. Mean radiation exposure during the procedure was 1.060.78 mGym² during 0.34 ± 0.6 minutes. There were no complications registered during CVP placement.

Conclusion The correlation between IF and USG and anatomically guided catheter tip placement is optimal. These results suggest that fluoroscopy and the radiation exposure it entails can be safely avoided in selected children.

Keywords

children - central venous port systems - tip placement - radiation exposure - intraoperative fluoroscopy

• References

• 1 Belin RP, Koster Jr JK, Bryant LJ, Griffen Jr WO. Implantable subcutaneous feeding chamber for noncontinuous central venous alimentation. Surg Gynecol Obstet 1972; 134 (03) 491-493
• 2 Niederhuber JE, Ensminger W, Gyves JW, Liepman M, Doan K, Cozzi E. Totally implanted venous and arterial access system to replace external catheters in cancer treatment. Surgery 1982; 92 (04) 706-712
• 3 Sousa B, Furlanetto J, Hutka M. , et al; ESMO Guidelines Committee. Central venous access in oncology: ESMO Clinical Practice Guidelines. Ann Oncol 2015; 26 (Suppl. 05) v152-v168
• 4 Bishop L, Dougherty L, Bodenham A. , et al. Guidelines on the insertion and management of central venous access devices in adults. Int J Lab Hematol 2007; 29 (04) 261-278
• 5 Strauss KJ, Goske MJ, Kaste SC. , et al. Image gently: ten steps you can take to optimize image quality and lower CT dose for pediatric patients. Am J Roentgenol 2010; 194 (04) 868-873
• 6 Frush DP, Donnelly LF, Rosen NS. Computed tomography and radiation risks: what pediatric health care providers should know. Pediatrics 2003; 112 (04) 951-957
• 7 Wildgruber M, Köhler M, Brill R. , et al. Impact of low dose settings on radiation exposure during pediatric fluoroscopic guided interventions. Eur J Radiol 2018; 100: 1-6
• 8 Haycock GB, Schwartz GJ, Wisotsky DH. Geometric method for measuring body surface area: a height-weight formula validated in infants, children, and adults. J Pediatr 1978; 93 (01) 62-66
• 9 Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. Am J Roentgenol 2001; 176 (02) 289-296
• 10 Zacharias C, Alessio AM, Otto RK. , et al. Pediatric CT: strategies to lower radiation dose. Am J Roentgenol 2013; 200 (05) 950-956
• 11 Miccini M, Cassini D, Gregori M, Gazzanelli S, Cassibba S, Biacchi D. Ultrasound-guided placement of central venous port systems via the right internal jugular vein: are chest X-ray and/or fluoroscopy needed to confirm the correct placement of the device?. World J Surg 2016; 40 (10) 2353-2358
• 12 Kim WY, Lee CW, Sohn CH. , et al. Optimal insertion depth of central venous catheters--is a formula required? A prospective cohort study. Injury 2012; 43 (01) 38-41
• 13 Yevzlin AS, Song GU, Sanchez RJ, Becker YT. Fluoroscopically guided vs modified traditional placement of tunneled hemodialysis catheters: clinical outcomes and cost analysis. J Vasc Access 2007; 8 (04) 245-251
• 14 Wang G, Guo L, Jiang B, Huang M, Zhang J, Qin Y. Factors influencing intracavitary electrocardiographic P-wave changes during central venous catheter placement. PLoS One 2015; 10 (04) e0124846
• 15 Wu C-Y, Fu J-Y, Wu C-F. , et al. Dose intraoperative fluoroscopy precisely predict catheter tip location via superior vena cava route?. Medicine (Baltimore) 2015; 94 (49) e2199
• 16 Ahn SJ, Kim H-C, Chung JW. , et al. Ultrasound and fluoroscopy-guided placement of central venous ports via internal jugular vein: retrospective analysis of 1254 port implantations at a single center. Korean J Radiol 2012; 13 (03) 314-323
• 17 Gebauer B, El-Sheik M, Vogt M, Wagner H-J. Combined ultrasound and fluoroscopy guided port catheter implantation--high success and low complication rate. Eur J Radiol 2009; 69 (03) 517-522
• 18 Centers for Disease Control and Prevention. Emergency Preparedness and Response. Available at: https://emergency.cdc.gov/radiation/measurement.asp . Accessed November 9, 2018
• 19 Mettler Jr FA, Huda W, Yoshizumi TT, Mahesh M. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology 2008; 248 (01) 254-263
• 20 Keil AP, Richardson DB. Quantifying cancer risk from radiation. Risk Anal 2018; 38 (07) 1474-1489
• 21 Royal HD. Effects of low level radiation-what's new?. Semin Nucl Med 2008; 38 (05) 392-402