A 15-year-old child with cerebral palsy, ventriculoperitoneal shunt infection, and bowel obstruction required central venous access. Peripherally inserted central catheter placement was unsuccessful. An internal jugular catheter was requested; however, ultrasound (not shown) revealed absence of the internal jugular veins with extensive collateral veins, one of which was accessed for a subsequent venogram. The venogram showed a lack of opacification of the internal jugular, subclavian, and brachiocephalic veins, as well as the superior vena cava; multiple collateral were present (A). MR angiogram confirmed the lack of central venous patency in the chest (B).
When traditional methods of venous access have been exhausted, there are a few non-traditional options for central catheters. The first is the inferior vena cava (IVC) via translumbar approach.1 A small caliber IVC and severe scoliosis in this case made the translumbar approach implausible. Another option is to utilize a collateral vessel to gain access to the central venous system. This patient had no patent central veins in the chest; therefore, the decision was made to place a transhepatic catheter. Using image guidance, the middle hepatic vein was accessed. A wire and catheter were advanced into the right atrium, a surgical port pocket was created, and the tip of the catheter was positioned in the right atrium (C). Transhepatic central venous access is a feasible option in pediatric patients when the usual venous access sites are not available.2
McDaniel JD, Pittinger TP. At the Viewbox: Transhepatic Port Placement. J Am Osteopath Coll Radiol. 2016;5(1):29.