![]() ![]() (a) Ultrasonogram of the right side of the neck showing a patent carotid artery (medial) but a thrombosed right internal jugular vein (arrow) (b) inflamed chest wall at the site of the Hickman line anchorage (c) fluoroscope image of the Hickman line via the left internal jugular vein (before removal) We came up with an innovative solution to this challenge.ĭepicting the condition before the surgery. Open technique for the right subclavian vein cannulation was not considered because of low platelet count and existing chest wall infection. While her RIJV was thrombosed, right subclavian was difficult to access and LIJV already cannulated, the only option was to cannulate one of the femoral veins, but that would last not more than a few days because of infection. Removal of her Hickman line posed a unique challenge as the child would need a central venous access for continuation of her treatment. She was taken to OR with platelet transfusion. Suspecting chest wall infection, she was posted for urgent removal of the Hickman line under GA, with white blood cell count = 300/cumm, platelet count of 32,000/cumm, and hemoglobin of 9.2 g/dl. On examination, there was erythema with tenderness and induration up to T3 level. She complained of pain at the Hickman line anchorage site. She was started on chemotherapy alongside higher antibiotics. A double-lumen Hickman line (Vygon) was inserted via LIJV under all aseptic measures. The right subclavian vein was difficult to image, and after failed attempts at right subclavian cannulation, LIJV was accessed under ultrasound guidance. After induction of GA, an ultrasound scan of right neck revealed a thrombosed RIJV. She was taken to the operating room (OR) under platelet infusion cover. She had relapse of ALL and was advised a Hickman line insertion. Upon remission, the chemo port was removed on day-care basis. Prior consent for case report publication was obtained from the parents after thorough explanation of the procedure.Ī 4-year-old girl diagnosed with precursor-B cell acute lymphoblastic leukemia (ALL) was posted for chemo port insertion via her RIJV under general anesthesia (GA). This case posed a unique challenge for CVC replacement that was meted with innovative solution. The left subclavian vein is avoided due to high procedure-related risk and the femoral veins because of their high risk of contamination. After RIJV, the next choices are right subclavian vein and left internal jugular vein (LIJV). The commonly preferred location of insertion of a Hickman's line or a chemo port is right internal jugular vein (RIJV), but one has to look for other options once the line gets infected or occluded. It is common for the indwelling CVCs to get infected in spite of best possible care. While PICC and CVC are less expensive, usable up to a few weeks and can be inserted in the chemotherapy unit itself, Hickman line and chemo port are costlier, can be used from months to a year, and need the assistance of a surgical unit. For this purpose, various devices such as peripherally inserted central catheter (PICC), central venous catheter (CVC), Hickman line, and chemo port (Port-a-Cath) are employed. Wider bore veins, especially the central veins, can receive chemotherapy better as the drug becomes diluted before coming in contact with the vascular endothelium. Chemotherapy drugs are known to cause damage to the veins through which they are administered. ![]()
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