Transarterial fiducial marker placement: A novel technique

skin with an indelible skin marker. A 7-cm, 21-gauge micropuncture needle (Micropuncture Introducer Set; Cook, Inc, Bloomington, Indiana) was placed longitudinally over the patient’s anterior thigh with the tip of the needle approximately 5 mm cephalad to the planned venous puncture site, and a site 15 mm cephalad to the needle hub was marked on the skin with the indelible skin marker as the catheter exit site. The needle tip was advanced through the catheter exit site and was directed under ultrasound guidance through the subcutaneous tissues toward the planned venous puncture site. When the needle tip was visualized at the planned venous puncture site, it was advanced into the femoral vein. Under fluoroscopic guidance, a 0.018-inch microwire (Micropuncture Introducer Set) was advanced into the inferior vena cava, and the micropuncture coaxial dilator was placed (Micropuncture Introducer Set). The microwire was used to measure the length of the catheter from the inferior cavoatrial junction to the catheter exit site, subtracting 3 cm to account for the hub of the micropuncture coaxial dilator. The coaxial dilator was exchanged for a 6-F peel-away sheath (PowerLine kit; Bard, Salt Lake City, Utah; for PowerHohn placement, PeelAway Introducer; Cook, Inc) over a 0.035-inch J wire (PowerLine or PowerHohn kit; Bard). A 6-F dual-lumen polyurethane catheter with Dacron cuff (PowerLine or PowerHohn; Bard) was advanced through the peel-away sheath. A radiograph was obtained to confirm appropriate catheter position. The catheter was secured to the skin with a catheter stabilization device (StatLock; Bard, Covington, Georgia). There were no immediate procedure-related complications, and no catheter revisions were needed between placement and removal. The total series access site service interval was 261 catheter days (mean, 65 d; median, 55 d; range, 8‐143 d). Three catheters were removed because intravenous therapy had been completed. One catheter was removed 143 days after placement secondary to catheter colonization, which was classified as a late (4 30 d) catheter-related infection. This was a grade C complication according to the Society of Interventional Radiology (SIR) classification of complications by outcome (4) given the increase in level of care (catheter removal and antibiotic therapy). Details regarding patient and catheter characteristics are presented in the Table. Our mean dwell time of 65 days compares favorably with the reported mean dwell time of 66 days (range, 1‐ 765 d) for tunneled hemodialysis catheters placed via different venous accesses in a large pediatric population (5). Three of the four catheters in our series were removed because intravenous therapy had been completed, suggesting that catheters placed using this technique remain functional until they are no longer needed. In summary, the single-incision technique is feasible for placing femoral tunneled central venous catheters in infants with upper central venoocclusive disease. Although this small series suggests that the single-incision technique has promising dwell times, a much larger series is needed to evaluate clinical outcomes.