Systematic approach to obtain axillary arterial access for pediatric heart catheterizations

Abstract

BackgroundAxillary arterial access (AAA) in pediatric heart catheterizations is undervalued.MethodsWe retrospectively reviewed children with congenital heart diseases (CHDs) who received trans-axillary arterial catheterizations between January 2019 and February 2023. We aimed ultrasound-guided punctures in the proximal two-thirds of axillary arteries with diameters ≥2 mm to insert 7 cm/4 Fr short introducers. We administrated intra-arterial verapamil (1.25 mg) and heparin (100 UI/kg). We infiltrated per-operatively 2% lignocaine (10 mg) for arterial spasms, long sheaths use (≥5 Fr), and ≥60 min procedures in <3 kg patients.ResultsWe identified 30 patients (66.7% males) with a median age of 1.1 months (IQR, 0.3–5.4), and a median weight of 3.1 kg (IQR, 2.7–3.7). 5/30 patients had six redo interventions after a median of 3.9 months (IQR, 1.7–5.1). Overall, 27/36 procedures were interventional, including 6 aortic valvuloplasties, 6 balloon angioplasties, and 15 stenting procedures. The median arterial axillary angiographic diameter was 2.6 mm (IQR, 2.4–3). Access was right-sided in 23/36 (63.9%) procedures and obtained using 21G/2.5 cm bevel needles in 25/36 (69.4%) procedures. No hemodynamical change occurred after introducing spasmolytic drugs. The median fluoroscopy time was 26.1 min (IQR, 19.2–34.8). There were two self-resolving arterial dissections, one sub-occlusive arterial thrombosis (resolved with 6 weeks of enoxaparin), and one occlusive arterial thrombosis (resolved with alteplase thrombolysis and 6 weeks of enoxaparin). Median follow-up was 11.7 months (IQR, 8–17.5). Four patients with complex univentricular hearts died from non-procedural causes at a median of 40 days (IQR, 31–161) postoperative.ConclusionSystematic approach for AAA is the key to success and unlocks the many potentials of trans-axillary pediatric cardiology interventions.