Ultrasound-Guided Percutaneous Vein Access for Placement of Broviac Catheters in Extremely Low Birth Weight Neonates: A Series of 3 Successful Cases

Introduction

Advances in neonatal intensive care techniques have enhanced the ability to support micro-premature infants born weighing less than 1500 g. ¹ This has led to an increasing need for central venous access in very small neonates. Open surgical cutdown (OSC) has been used traditionally to obtain access, especially long-term access, in low birth weight and premature infants.^2,3 In previous studies, however, OSC has been associated with rates of catheter-associated sepsis and mechanical complications of 26% and 27%, respectively.^4,5 Thrombosis and loss of patency of the catheter after OSC have also been shown to occur at rates of up to 25%.^6,7

More recently, percutaneous approaches, both landmark techniques and ultrasound-guided techniques (UGTs), have been shown to be safe and effective methods for placement of a variety of catheter types in infants and young children.^8–14 Recent studies have shown that UGT can decrease the number of cannulation attempts, increase the overall success rate, and decrease complications of central line placement compared with a landmark technique.^{10,11,14–16} In light of this evidence, UGT is being used with increasing frequency to obtain central venous access in infants and young children. With premature and low birth weight infants, use of UGT is preferred over a landmark technique as the latter is an unreliable method in small, underdeveloped neonates.

As ultrasound-guided approaches to percutaneous central line placement have become more prevalent, a subset of studies^9–11 has included extremely low birth weight (ELBW) (weighing<1000 g) infants in their study population. Machotta et al. ⁹ were the first to report successful central venous cannulation in an ELBW infant using UGT. In this case report, Machotta et al. ⁹ placed a central venous catheter successfully in an 850-g infant with ultrasound assistance. Examining placement of tunneled catheters with UGT, Arul et al. ¹⁰ studied tunneled line placement in children. This series included infants weighing as little as 600 g, although the study did not specifically state how many were ELBW. The same group ¹¹ successfully placed 36 Broviac^® (C.R. Bard, Covington, GA) lines in 34 neonates, including 5 ELBW infants (weighing between 630 and 999 g), under ultrasound guidance without complications.

The present case series adds to the fewer than 10 reported cases of percutaneous central placement of long-term vascular access in ELBW neonates weighing 850 g and less.

Subjects and Methods

A retrospective chart review was performed on three infants weighing 850 g or less who had Broviac lines placed using ultrasound guidance by a single surgeon between June 2014 and December 2014 at a single institution. An exemption from Institutional Review Board review was granted by Good Samaritan Hospital (San Jose, CA) on February 12, 2015 in accordance with exemption regulation 45 CFR 46.101(b)(4). Data were collected from the medical histories and operative reports contained in the medical records and included age, weight, admitting diagnoses, procedure details, duration of catheter use, and complications.

Results

Three infants were included in this series, weighing less than 850 g and born between 23 weeks 5 days of gestation and 26 weeks 3 days of gestation. Patients were admitted to the neonatal intensive care unit for a variety of conditions, including extreme prematurity, spontaneous intestinal perforation, respiratory distress, and total parenteral nutrition dependence. Demographic information describing patients is summarized in Table 1.

Broviac line placement was only attempted after a peripherally inserted central catheter (PICC) could not be obtained and the neonatal intensive care unit physicians agreed with the need for central venous access. Broviac line placement occurred between 8 and 16 days after birth. All infants had previous routes of access before Broviac line placement was attempted; two had umbilical catheters, and one had a PICC line. Placement of 2.7-French Broviac lines under ultrasound guidance was successful in all three infants. Right internal jugular vein access was obtained in an average of 2.3 attempts (range, one to four attempts). Total procedure length, inclusive of anesthesia time and time for a chest x-ray to confirm line placement, ranged from 30 to 52 minutes with an average procedure time of 38 minutes.

There were no perioperative complications, including no pneumothorax or hemothorax. All lines were in a central position at the atriocaval junction on immediate postoperative chest x-ray, and no line required repositioning for the duration of use. Broviac lines remained in place for 19–94 days. One infant died of underlying medical causes, and the other two infants were discharged home (length of stay ranged from 162 to 213 days). Procedural data and patient outcomes are summarized in Table 2.

Discussion

With advances in technology as well as both medical and surgical interventions, survival of micro-premature infants has increased. ¹ The need for reliable, long-term access has grown in conjunction with the increase in survival of ELBW infants. Although PICC lines are considered the standard of care for long-term access, PICCs can be technically challenging to insert in ELBW infants, and some hospitals lack the resources and trained staff to consistently obtain PICC access in this population. These situations often require reliable access with lines placed via OSC. Ultrasound-guided percutaneous access for Broviac line placement in ELBW infants offers the ability to successfully obtain long-term access along with the potential of a lower complication rate than lines obtained with an OSC technique.

To date, the largest series examining the use of ultrasound guidance to place Broviac lines in neonates was performed by Arul et al., ¹¹ who examined a total of 34 patients weighing between 630 and 4100 g. Broviac line insertion occurred only after there were no remaining possible sites for insertion of a PICC. This series showed no perioperative complications using UGT. It is notable that the population included in the series included five infants weighing between 630 and 999 g; however, a detailed description of these subjects was not included. The current case series adds a detailed account of UGT for Broviac line placement in ELBW neonates and further supports the feasibility of this technique in a challenging patient population.

In the neonates in this case series, Broviac line placement was attempted after PICC line placement was either unsuccessful or the hospital did not have the resources or expertise to complete PICC placement in an ELBW infant. Broviac line placement was successful in all 3 cases with UGT. In the three ELBW neonates in the current series, cannulation was successful each time with a maximum of four attempts made before cannulation of the vein.

Furthermore, no infant had an intraprocedural or perioperative complication. Most notable is that there were no cases of arterial puncture, pneumothorax, or hemothorax. Multiple studies^4–7 have demonstrated high rates of complications when using OSC in neonates. Previously, no percutaneous technique had demonstrated feasibility in ELBW neonates. Although this series was designed only to demonstrate the feasibility of UGT for percutaneous Broviac line placement in ELBW neonates, the lack of complications is encouraging for future use, although a full-scale study would need to be performed in order to examine the complication rate of UGT versus OSC in depth.

Conclusions

The use of ultrasound-guided percutaneous vein access to assist in the placement of Brovaic catheters in ELBW neonates is feasible, even in infants weighing less than 850 g. A larger experience with such lines is needed to determine the risks and benefits of percutaneous access over OSC.