Central Venous Access Devices in Pediatric Malignancies: a Positon Paper of Italian Associaton of Pediatric Hematology and Oncology

J Vasc Access 2014; 00 (00): 000-000 JVA DOI: 10.5301/jva.5000314 ISSN 1129-7298 ORIGINAL ARTICLE Central venous access devices in pediatric malignancies: a positon paper of Italian Associaton of Pediatric Hematology and Oncology

Alessandro Crocoli1, Assunta Tornesello2, Mauro Pitrut3, Angelica Barone4, Paola Muggeo5, Alessandro Inserra1, Angelo Claudio Molinari6, Valeria Grillenzoni7, Viviana Durante8, Maria Pia Cicalese9, Giulio Andrea Zanazzo10, Simone Cesaro7

1 General and Thoracic Surgery Unit, Department of Surgery, Bambino Gesù Children’s Hospital, IRCCS, Rome - Italy 2 Pediatric Oncology Unit, Vito Fazzi Hospital, Lecce - Italy 3 Department of Surgery, “Agostno Gemelli” Catholic University, Rome - Italy 4 Pediatric Hematology and Oncology Unit, Department of Pediatrics, Azienda Ospedaliero-Universitaria di Parma, Parma - Italy 5 Pediatric Hematology and Oncology, Pediatric Clinic, Azienda Ospedaliero-Universitaria Policlinico, Bari - Italy 6 Thrombosis and Hemostasis Unit, Giannina Gaslini’s Children Hospital, Genova - Italy 7 Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona - Italy 8 Pediatric Surgery Unit, University Policlinic Hospital, Modena - Italy 9 Pediatric Immunology and Bone Marrow Transplantaton Unit, San Rafaele Telethon Insttute for Gene Therapy (HSR-TIGET), “San Rafa- ele” Scientfc Insttute, Milan - Italy 10 Insttute for Maternal and Child Health, IRCCS “Burlo Garofolo”, Trieste - Italy

ABSTRACT Introducton: Treatment of pediatric malignancies is becoming progressively more complex, implying the adop- ton of multmodal therapies. A reliable, long-lastng venous access represents one of the critcal requirements for the success of those treatments. Recent technical innovatons—such as minimally invasive procedures for placement, new devices and novel materials—have rapidly spread for clinical use in adult patents, but are stll not consistently used in the pediatric populaton. Methods: The Supportve Therapy Working Group of Italian Associaton of Hematology and Oncology (AIEOP) reviewed medical literature focusing on new aspects of central venous access devices (VADs) in pediatric patents afected by oncohematological diseases. Results: Appropriate recommendatons for clinical use in these patents have been discussed and formulated. Conclusions: The importance of the correct choice, management and use of VADs in pediatric oncohematological patents is a necessary prerequisite for an adequate standard of care, also considering the increased chances of cure and the longer life expectancy of those patents with modern therapies. Keywords: Central venous catheter, Hematology, Oncology, Pediatric malignancies, PICC, Port

Introducton a VAD with technical features which increase its stability in tme, with an expected duraton in the range of months and In recent decades, the increasing use of venous access de- years: this category includes tunneled cufed catheters and vices (VADs), either long term (LTVA) or medium term (MTVA), totally implantable venous ports. MTVA are VADs appropri- has provided a signifcant improvement in the treatment of ate for a prolonged but not unlimited tme (weeks or months) children afected by oncohematologic diseases. According and for a discontnuous use (1): they include tunneled non- to the currently accepted terminology (1), LTVA is defned as cufed central catheters, peripherally inserted central catheters (PICCs) and midline catheters. A reliable and long-lastng central VAD permits a safer Accepted: August 26, 2014 and easier administraton of chemotherapy, supportve drugs, hyperhydraton and hypertonic solutons, such as Corresponding author: total parenteral nutriton, than via the peripheral vein. Alessandro Crocoli, MD Placement of a central VAD can be performed by sur- General and Thoracic Surgery Unit geons, anesthesiologists, intensivists, interventonal radi- Department of Surgery and Centro Pediatrico Bambino Gesù Basilicata ologists, oncologists or even nurses, depending on the type Bambino Gesù Children’s Hospital of device and the choice of venous access. LTVA and MTVA IRCCS, Rome, Italy can be placed with diferent techniques (venous cutdown, [email protected] “blind” percutaneous venipuncture guided by anatomical

© 2014 Wichtg Publishing 2 Positon paper about central venous access devices in children with cancer landmarks, ultrasound-guided percutaneous puncture and TABLE I - Summary of AIEOP recommendatons cannulaton of the vein). Placement of a central line always carries potental risks for the patent, with relevant difer- Indicatons and selecton criteria ences in the type and severity of complicaton, depending For long-term treatments, ports should be preferred for on which vein, which technique and which device have been intermitent use and cufed tunneled catheters for frequent/ chosen. contnuous use. The objectve of this positon paper, promoted by the For short- to medium-term treatments, PICCs are a valid opton, Italian Associaton of Pediatric Oncology and Hematology but they should be inserted only when deep veins of the arm are (AIEOP) and developed by the Supportve Therapy Working of appropriate diameter. Group (ST-WG) of AIEOP, is to provide practcal recommenda- There is no evident advantage of silicon vs. polyurethane. tons for indicaton, choice, placement and removal of LTVA Double-lumen VADs should be used only in selected cases. and MTVA in pediatric oncohematologic patents. The pres- Catheters inserted in the femoral vein for medium- to long-term ent document also includes recommendatons on the preven- treatments should be tunneled away from the groin. ton of early and late noninfectve complicatons potentally related to VAD inserton. Preventon of early complicatons Ultrasound should be used for diagnosis of local pathologic conditons before the procedure and for diagnosis of procedure-related Methods complicatons. The ST-WG developed this positon paper in collaboraton Ultrasound is necessary to assess vein patency before the procedure and to choose the vein most appropriate in terms of caliber, with the AIEOP working groups on Infecton, Coagulaton, depth and positon. Surgery and Nursing. A joint commitee was established, in- cluding the ST-WG and one to two members from each of The internal diameter of the vein to be cannulated—as assessed by ultrasound—should be at least three tmes the external diameter the other working groups. During a preliminary meetng, of the catheter, so as to reduce the risk of venous thrombosis. the topics and the literature search were defned. In the Na- Ultrasound-guided venipuncture should be adopted, so as to tonal Library of Medicine’s MEDLINE database, we searched reduce the risk of early and late complicatons. all clinical papers (clinical trials, retrospectve studies, case reports, reviews and consensus papers) dealing with cen- Venous cannulaton by surgical cutdown should be avoided. tral venous access in pediatric cancer patents; only pa- “Blind” percutaneous puncture of central veins (“landmark” pers published between January 2001 and January 2014, in venipuncture) should be avoided. English language and available as full text, were considered. In newborn and infants, internal jugular vein and brachio-cephalic A frst selecton was performed by the ST-WG, excluding vein are usually the frst optons for ultrasound-guided central venous access. papers of poor relevance or not focused on MTVAs or LTVAs. All papers in full text were examined by each member Soon afer procedures potentally associated with pleural damage, of the joint commitee. During a second meetng, the com- pneumothorax should be excluded by ultrasound scan of the intercostal space. mitee discussed the clinical evidence of the most relevant papers in each area (indicaton/choice of the device; choice A specifcally and properly trained vascular team should be imple- mented, so to reduce both inserton-related and management- of access/inserton technique; preventon of mechanical related complicatons. complicatons; removal of the device) and specifc recommendatons were suggested. The ST-WG prepared a fnal Preventon of late mechanical complicatons document which was approved by the joint commitee in a Noncufed catheters should be permanently secured, preferably third meetng. by a sutureless device. The main recommendatons are summarized in Table I Cufed catheters should be secured for at least 2-4 weeks, prefer- and discussed below. ably by a sutureless device. Valved and nonvalved catheters have the same expected inci- Results and Discussion dence of complicatons. Removal Indicatons for the Positoning of LTVA and MTVA; Selecton of the Device Local anesthesia/sedaton is used to remove a cufed tunneled device whereas general anesthesia is usually needed to remove a port. The choice of the VAD should be based on the patent’s needs, taking into account duraton and type of oncology/ Afer removing the device, skin should be closed with absorbable hematology treatment. There is general consensus that any sutures and/or glue and an occlusive dressing should be applied for at least 48 hours. chemotherapy treatment in pediatric patents should be de- livered via an appropriate central venous access, as the risks Complete removal of the cuf is recommended. associated with the infusion of vesicant or irritant drugs Embolized fragments of the catheter should be removed by via a peripheral venous access are not acceptable. Many nonsurgical endovascular procedure. supportve therapies adopted in pediatric cancer patents, In case of device removal because of infecton, a new device should such as parenteral nutriton, also demand for a central line: be inserted at diferent tmes and using a diferent venous approach. most current guidelines state that peripheral lines (short AIEOP = Italian Associaton of Pediatric Oncology and Hematology; PICC = and long i.v. cannulas; midline catheters) are inappropriate peripherally inserted central catheter; VAD = vascular access device.

© 2014 Wichtg Publishing Crocoli et al 3 for delivering solutons with high osmolarity, or pH >9 or <5 TABLE II - Central venous catheters commonly used in the pediatric (2). Short-term central venous access—such as nontunneled populaton centrally inserted central venous catheters (CVCs)—are ap- Long term (tunneled, cufed external VADs) propriate for intrahospital use and/or for a short period of tme, but not as a long-standing venous access (1). Most Material Tip Lumen French children with malignancies require a reliable, stable venous Broviac Silicon No valve 1 2.7, 4.2, 6.6, access for discontnuous, extrahospital use: this is usually 7, 9.6 achieved by MTVA or LTVA, depending on the expected duraton of need for the access. Hickman Silicon No valve 2 7, 12 Noncufed PICCs are commonly considered as MTVA (1, 3); Leonard Silicon No valve 2 10 they may be a valid opton for short- and medium-term du- Groshong Silicon Distal valve 1 or 2 5.5, 7 8, 9 ratons of treatment, partcularly when general anesthesia is contraindicated, since they can be inserted at bedside under ProLine P.I. PUR No valve 1 or 2 5, 6 local anesthesia and/or mild sedaton (4-7). Though currently Medium term (PICCs) considered appropriate partcularly for medium-term venous Silicon PICC Silicon No valve 1 or 2 3, 4, 5 access (3), there is a growing evidence—partcularly in adult cancer patents—that they might be used for a long period of Groshong Silicon Distal valve 1 or 2 4, 5 tme (8, 9). PICC Considering LTVA, there is no striking diference in terms of Solo, PASV P.I. PUR Proximal 1 or 2 or 3 3, 4, 5, 6 general clinical performance between tunneled cufed cath- PICC valve eters (such as Broviac, Hickman, Leonard, cufed Groshong, PASV PICC PUR Proximal 1 or 2 4, 5 ProLine) and totally implanted venous ports, although in chil- valve dren who require frequent venous access for blood sampling, parenteral nutriton and complex intravenous therapies, such PUR PICC PUR No valve 1 or 2 4, 5 as those eligible for high-dose chemotherapy and hematopoi- P.I. PUR PICC P.I. PUR No valve 1 or 2 or 3 3, 4, 5, 6 etc stem cell transplant, tunneled cufed catheters are usually preferred. On the other hand, children requiring less intensive PASV = pressure-actvated safety valve; P.I. = power injectable; PICC = peripherally inserted central catheter; PUR = polyurethane; VAD = vascular access support and undergoing chemotherapy schedules with a 3-6 device. week interval, or adolescents, who may not accept an external device, are eligible for a port. In other words, venous ports are recommended for prolonged but intermitent vascular ac- the catheter should be equal or smaller than one third of the cess while tunneled cufed catheters are recommended for internal diameter of the vein: for example, a 3 Fr (=1 mm) prolonged but frequent/contnuous vascular access (10-12). catheter is appropriate for a vein whose diameter is 9 Fr Cufed PICCs are now available and may have a future role as (3 mm) or larger (13, 16, 22, 23). LTVAs, as an alternatve opton to centrally inserted tunneled Double-lumen catheters, either LTVA or MTVA, are indi- cufed catheters. cated in patents undergoing hematopoietc stem cell transplantaton, in critcally ill patents and in any patent needing Choice of material chronic infusion of noncompatble solutons, such as the case of pediatric patents candidate to both parenteral nutriton MTVAs and LTVAs are made of catheters of diferent ma- and chemotherapy (12, 24, 25), although some data sug- terials, either silicon or polyurethane. There is no evidence of gest that the use of double-lumen devices might be associ- any diference between silicon and polyurethane in terms of ated with a higher risk of infecton compared to single-lumen risk of infectve and thrombotc complicatons in the adult or devices (18). in the pediatric populaton (13, 14). Silicon catheters have tra- ditonally been the frst choice for LTVA in pediatric patents Choice of the vein (11, 15-18), although polyurethane catheters—and specially power injectable polyurethane catheters, which are made Central lines are characterized by the locaton of the tp of third-generaton polyurethanes—are as biocompatble as of the catheter close to the cavo-atrial juncton, either in silicone catheters but less fragile; also, they are compatble the lower third of the superior vena cava or in the upper with higher fow rates and are ideal for injecton of contrast part of the atrium: this can be achieved by cannulaton of medium (19). either central or peripheral veins. For centrally inserted Table II summarizes the main types of external long-term VADs, veins on the right side are preferred, so that the cath- and medium-term CVCs. eter may follow a direct path toward the atrio-caval juncton. Data in adult patents suggest that the inserton on Caliber of catheter the right side may be associated with a lower incidence of thrombosis (26), although pediatric data in this regard are The outer caliber of the catheter should be decided on not available. In the preultrasound era, the internal jugular the basis of the inner diameter of the vein, so as to prevent vein was considered the frst choice, in terms of anatomical venous thrombosis (20). The caliber of vein should be mea- locaton and accessibility, while the “blind” puncture and sured by ultrasound scan (21). Ideally, the outer diameter of cannulaton of the subclavian vein was considered to be

© 2014 Wichtg Publishing 4 Positon paper about central venous access devices in children with cancer more dangerous, especially if the patent was a newborn In adult patents, the use of ultrasound guidance to select or infant. In the ultrasound era, many diferent optons and puncture the vein is clearly associated with a signifcant- for central venous cannulaton are now available (internal ly higher rate of success and a signifcantly lower incidence jugular, external jugular, brachio-cephalic, subclavian and of mechanical, infectve and thrombotc complicatons if axillary veins) (21). The most appropriate vein should be compared to surgical “cutdown” or “blind percutaneous tech- chosen afer proper ultrasound examinaton, considering niques” (21). Ultrasound permits visibility of the progression the caliber of the vein and the potental risk associated of the needle in the target vessel, reducing the likelihood of with its cannulaton (13, 21). accidental arterial puncture or accidental damage to nerves PICCs can be placed in any deep vein of the arm between and other surrounding structures (21). the elbow and axilla (brachial vein, basilic vein, axillary vein Though the evidence in pediatric patents is stll limited, and even cephalic vein in selected cases), but since the mini- most studies suggest that ultrasound guidance should be- mum size of the PICC is 3 Fr there is a limited indicaton in come the state of the art of venipuncture in children and newborns and infants due to the smaller venous caliber (13, neonates, as it is already in adults (13, 30-32). The most im- 19). There is no clear recommendaton as regards choos- portant advantage of ultrasound is to allow the choice of ing lef vs. right side, while the deep veins of the upper arm the most appropriate vein afer a scan of all possible optons (brachial and basilic veins, which can be cannulated by ul- (21). By ultrasound guidance, puncture and cannulaton of trasound guidance) should be preferred over the superfcial the vein are quicker and easier, as well as associated with veins of the antecubital fossa (2). Side, vein and puncture fewer complicatons; moreover, the reduced invasiveness site should be decided afer proper ultrasound scan of the of the procedure consistently reduces the risk of infecton vasculature of the arm (21). The presence of veins of insuf- at the inserton site and the risk of catheter-related throm- cient diameter (such as <3 mm or <4 mm when, respectvely, bosis (13, 30, 33-36). a 3 Fr or 4 Fr catheter is required) is a contraindicaton to Also, ultrasound permits real-tme diagnosis of pre- PICC inserton. existng vascular anomalies (malformatons, anatomic vari- LTVA (tunneled cufed catheters and ports) as well as ants or thrombosis) and of early complicatons (hematoma MTVA (tunneled noncufed long catheters) are sometmes postnjecton, extravasaton, dissecton of the vessel or ste- also inserted by the femoral access, with the tp of the cath- nosis, pneumothorax, etc.) (12, 37). eter in the upper porton of the inferior vena cava: this can be In patents with a previous placement of a venous access or a suitable opton in patents with superior vena cava obstruc- other risk factors for venous thrombosis (surgery of the neck ton syndrome. The most relevant complicaton of femoral or superior vena cava syndrome), ultrasound allows the assess- access is infecton: should this route be chosen for a LTVA or ment of the patency of the vessel to be cannulated (12, 21). MTVA, tunneling has to be performed away from the groin, The central veins in adults and children that can be cannu- along the thigh with exit site on the side of the knee or up- lated under ultrasound guidance are the internal jugular vein, ward to the periumbilical region, so as to reduce the risk of the external jugular vein (in its deeper path), the brachial- infecton by germs originatng from the groin (7, 13, 23). cephalic, subclavian (usually by a supraclavicular approach), the axillary vein (by infraclavicular approach) and the cephalic Placement of LTVA and MTVA in pediatric patents vein (in the infraclavicular region). In newborns and infants, the only veins of signifcant size apt to be cannulated are usu- Before the introducton of ultrasound guidance in clinical ally the internal jugular and brachio-cephalic (13, 31). practce, placement of centrally inserted catheters by “blind” Afer the ultrasound-guided puncture of the vessel, a venipuncture or venous cutdown had been widely used in guidewire is inserted and directed to the cavo-atrial juncton. pediatric patents. In neonates and infants, ultrasound is also useful to guide the “Blind” puncture of central veins is associated with the wire into the superior vena cava toward the right atrium; the risk of failure, repeated punctures, accidental arterial in- fnal positon of the tp can be verifed by echocardiography. jury and pneumothorax due to accidental pleural damage. The guidewire should never be inserted to a length superior Accidental damage to the pleura is signifcantly more fre- than the distance between puncture site and right atrium, quent afer subclavian than afer jugular venipuncture (27). since even the sofest guidewire may damage the heart A peculiar complicaton is the so-called pinch-of syndrome, wall or provoke dangerous arrhythmias. A guidewire can be a compression of the catheter between the frst rib and the advanced to the inferior vena cava only if the maneuver is clavicle, resultng in malfuncton, obstructon, fssure and/or performed under fuoroscopic guidance, but this is not rou- fracture and embolizaton of a catheter fragment: this syn- tnely recommended and it might be risky, especially in neo- drome is exclusively associated with “blind” infraclavicular nates and infants. Afer the inserton of the guidewire—as all cannulaton of the subclavian vein (12, 22, 23). MTVAs and LTVAs are currently inserted by the modifed The use of the surgical technique for the isolaton and Seldinger technique—a peel-away introducer is advanced cannulaton of the vein (venous cutdown) is associated with a over the guidewire untl the lower porton of the superior relevant incidence of tssue trauma, failure and local compli- vena cava. The guidewire is removed and the catheter is catons even in experienced hands. Vessel thrombosis occurs threaded through the introducer. more frequently, because of the dissecton of tssues and the The optmal positon of the catheter tp is at the juncton direct secton and ligaton of the vessel. Also, the surgical iso- between the right atrium and the superior vena cava (1, 2). laton of the vein entails a higher risk of infecton at the site The tp locaton should be ideally verifed in real tme dur- of entry of the catheter (2, 28, 29). ing the procedure (by fuoroscopy, by intracavitary electro-

© 2014 Wichtg Publishing Crocoli et al 5 cardiogram (ECG) or by echocardiography) or—as a second Catheter fxaton to the muscular fascia with nonabsorb- opton—soon afer the procedure (by chest x-ray or by echo- able braided sutures has also been used for reducing the risk cardiography). In the case of femoral access, the recommend- of dislocaton in cases where a delay of the healing process ed level of the catheter tp is in the inferior vena cava below and cuf anchoring is expected (prolonged use of cortcoste- the renal veins. Before startng to use an LTVA or MTVA, the roids, Omenn syndrome, epidermolysis bullosa) (13). The correct positon of the tp must be verifed and documented new sutureless device anchoring the catheter to the subcu- in the medical record (2, 21, 33, 34). Intracavitary ECG and/ taneous tssue (42, 43) will most likely make these surgical or echocardiography is safer and more accurate than fuoros- securement obsolete. copy for verifying tp locaton and is becoming increasingly The reservoir of venous ports is sometmes secured to the used in clinical practce, although the experience in pediatric underlying muscle fascia (10), although this is not considered patents is stll limited (38, 39). to be mandatory in all cases (26). In the case of subclavian vein access, ultrasound examina- The migraton of the tp is another common mechanical ton of the intercostal spaces is a suitable examinaton for the complicaton that can occur even without external disloca- early diagnosis of a pneumothorax secondary to the proce- ton of the catheter and is more frequent with silicon cathe- dure. Immediate ultrasound scan of the pleural space for de- ters, due to the sofness of the material. It is ofen associated tectng the “sliding sign” is needed in any difcult puncture of with inappropriately “high” positon of the tp (i.e., when the the subclavian or axillary vein, and partcularly if the patent tp does not enter the lower third of the superior vena cava). complains of shortness of breath, discomfort or pain worsen- The occlusion of the lumen is more frequent with smaller ing afer catheter placement; chest x-ray is less accurate and caliber catheters and/or when proper protocols of fushing less immediately available in this regard (21, 40). and locking are not adopted. Valved catheters are available Proper training of the vascular team (41) and proper for both MTVA and LTVA, although there is no evidence that choice of methods and materials (13) are the key factors in valved catheters (either with distal or with proximal valves) reducing operatve tme and risk of intra- and postprocedural may be associated with a lower risk of occlusion (or of any complicatons. When the same team is also responsible for other complicaton) (45-48). Lumen occlusion is basically the management of the venous access, late complicatons are related to the local policies of fushing and locking the VAD, also reduced (37). rather than to the technique of inserton (2, 15). Mechanical lesions, breakage and fracture of the device— Preventon of late mechanical complicatons of CVC partcularly of PICCs—are signifcantly more frequent with silicon than polyurethane catheters. The “pinch-of” syndrome The more frequent late mechanical complicatons are has been a frequent cause of catheter malfuncton and frac- dislocaton of the catheter, migraton of the tp, lumen oc- ture in the past, although it is bound to disappear in the ul- clusion and catheter rupture. All these complicatons are trasound era, as it was invariably associated with the “blind” clinically associated with a malfuncton of the device, ofen puncture of the subclavian vein by infraclavicular approach. as a failure to draw from and/or to infuse through the device. Dislocaton is the leading cause of premature loss of Removal of the CVC external venous access, especially in younger children (11). Dislocaton can be minimal (less than 1-2 cm), partal (more Removal of MTVA or LTVA must be performed by ex- than 2 cm) or complete (complete removal of the device). perienced personnel, in an appropriate setng. Noncufed All noncufed central catheters—both tunneled and non- catheters such as PICCs may be easily removed at the tunneled—should be permanently secured to the skin by patent’s bedside, whereas the removal of an LTVA requires an adequate sutureless device (29), although securement proper aseptc conditons (operatng or procedure room). by a sutureless device is also needed for cufed tunneled Before removing a tunneled cufed catheter, the cuf should catheters, at least in the frst 3-4 weeks afer placement. be located by palpaton or by ultrasound. If the cuf is placed Management of the exit site should be performed by trained quite distant from the exit site, removal may require a new personnel and in accordance with the characteristcs of the incision of the overlying skin (49, 50). VAD and the type of dressing used. Sutures should be used In pediatric patents, local anesthesia/sedaton is used to only in very selected cases, that is, when atachment of the remove a cufed tunneled device whereas general anesthesia sutureless device to the skin does not appear to be reliable. is usually needed to remove a port (49-51). A new securement device which is apparently more efec- Afer removing the device, the exit site must be com- tve than sutures in preventng dislocaton consists in a de- pressed for at least 5 minutes to reduce local bleeding. The vice which anchors the catheter directly to the subcutaneous exit point or points must be closed with absorbable sutures tssue (42, 43), although clinical studies with this device in and/or glue; an occlusive dressing should be applied for at pediatric patents are not yet available. least 48 hours to avoid the risk of air embolism (49, 50). The tunneled cufed catheters have a Dacron cuf, which The complete removal of the cuf is necessary, since requires 2 to 4 weeks to ensure a proper securement to the retained cufs or cuf fragments may become a source of subcutaneous tssue of the patent (12, 13, 44). The cuf must infecton, create false radiological images or cause unsats- be placed inside the tunnel at least 2 cm far from the exit site, factory cosmetc results (49-51). as recommended by the manufacturer. A cuf inappropriately In the case of catheter embolizaton, the removal of the placed too close to the exit site is a well-recognized cause of fragment usually requires a nonsurgical endovascular proce- dislocaton of tunneled cufed catheters (8). dure by an interventonal radiologist (22, 52).

In case of loss of the catheter due to complete disloca- results of a prospectve study. Support Care Cancer. 2014; Epub ton, the VAD can be repositoned in the same vein. In case of ahead of print. infecton, the procedures of VAD removal and repositoning 10. Cil BE. Radiological placement of chest ports in pediatric oncol- are carried out at diferent tmes to avoid the risk of infectng ogy patents. Eur Radiol. 2004;14(11):2015-2019. the new device, and preferentally using a diferent venous 11. Cesaro S, Corrò R, Pelosin A, et al. A prospectve survey on access (53). incidence and outcome of Broviac/Hickman catheter-related complicatons in pediatric patents afected by hematological and oncological diseases. Ann Hematol. 2004;83(3):183-188. Conclusions 12. Marcy PY. Central venous access: techniques and indicatons in oncology. Eur Radiol. 2008;18(10):2333-2344. As far as we know, this is the frst positon paper review- 13. Pitrut M. Ultrasound guided central vascular access in neo- ing and discussing the issues of choice, placement and re- nates, infants and children. Curr Drug Targets. 2012;13(7): moval of LTVAs from the perspectve of oncologic pediatric 961-969. patents. Despite the referenced literature, there is far less 14. Cohen AB, Dagli M, Stavropoulos SW Jr, et al. Silicone and evidence for children than for adults. The use of ultrasound polyurethane tunneled infusion catheters: a comparison of guidance is an important innovaton to reduce invasiveness durability and breakage rates. J Vasc Interv Radiol. 2011;22(5): and lower the incidence of both early and late complica- 638-641. 15. Cesaro S, Tridello G, Cavaliere M, et al. Prospectve, random- tons. The investment needed for adequate staf training, ized trial of two diferent modalites of fushing central venous and the acquisiton of appropriate materials and appropri- catheters in pediatric patents with cancer. 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