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PCA safe for interventional cardiac catheterization in infants
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Percutaneous carotid access can be safely performed in pediatric patients, including small infants, and yields a higher patency rate than access via surgical cutdown, according to results from a recent retrospective review.
The analysis included data from 42 pediatric patients who underwent 47 catheterization attempts via percutaneous carotid access at Texas Children’s Hospital and Children’s Healthcare of Atlanta between July 2006 and November 2014 (median age, 20 days; median weight, 3.2 kg). All patients underwent follow-up imaging within 24 hours of treatment. Five patients required a second catheterization after the index attempt.
Among the intervention attempts, 44 were successful. The most common interventions were stenting or stent redilation of the ductus arteriosus (n = 18), balloon aortic valvuloplasty (n = 11) and stenting or angioplasty of Blalock-Taussig shunts (n = 6). Two patients required an additional intervention at a different access site. The time to access was 5.5 ± 5.3 minutes, with the sheaths remaining in the carotid for a median of 56 minutes, according to the researchers.
No patients exhibited thrombus or aspiration of thrombus on or near the sheath, with minimal blood loss on withdrawal. Manual compression was used to achieve hemostasis in all patients, with no surgical bleeding control required, and no patients experienced rebleeding.
Within 24 hours of treatment, three patients experienced carotid thrombosis, including two with complete occlusion and one with nonocclusive thrombus. The researchers noted that activated clotting time (ACT) levels did not differ between these patients and the rest of the cohort (median, 385 vs. 279 seconds; P = .862). One patient had resolved thrombosis and two had mild residual narrowing after treatment with heparin; none developed proximal or distal clot progression beyond the common carotid artery. One patient required surgical intervention due to an access-related complication, but had normal carotid caliber and flow pattern after the procedure.
Evaluable 30-day imaging data were available for 42 patients, and results indicated a normal carotid in 95%. Two patients exhibited mild luminal narrowing. Among 19 patients with additional imaging data (range, 32 days to 9.2 years after percutaneous carotid access), 17 had normal carotid arteries, whereas the two patients with luminal narrowing on 30-day follow-up continued to exhibit mild stenosis. No patients exhibited neurological sequelae attributable to percutaneous carotid access, the researchers wrote.
“In addition to demonstrating that [percutaneous carotid access] results in long-term carotid patency rates that are superior to published reports of surgical cutdown, we think that the time required to establish sheath placement is likely to be much shorter using the percutaneous approach,” they wrote. “It is unlikely that surgical cutdown could ever match the speed and ease of vascular access that the percutaneous technique affords.”
The researchers said their study was retrospective, and the results may not be generalizable to a larger patient population. However, they wrote, “We have demonstrated that [percutaneous carotid access] for interventional cardiac catheterization in infants and children can be performed rapidly, with no clinical evidence of neurological sequelae, and an excellent carotid patency rate on follow-up imaging. Given these favorable outcomes, we propose that surgical cutdown is no longer routinely required in infants and children to establish carotid access for interventional cardiac catheterizations.” – by Adam Taliercio
Disclosure: One researcher reports consulting for B-Braun Interventional Systems, Janssen Pharmaceutical, Medtronic and St. Jude Medical.
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