Techniques for difficult venous and arterial access

The maintenance of central venous access is critical to the management of pediatric patients in various clinical scenarios, and the establishment of vascular access is one of the most common procedures performed by pediatric surgeons. This is of utmost importance particularly in those who are dependent on parenteral nutrition. Although the internal jugular or subclavian vein is an adequate route of access in most patients, a common pitfall associated with long-term venous access is the eventual exhaustion of traditional sites of peripheral or central catheterization over time. This is caused by multiple complications, including catheter sepsis, venous stenosis and/or thrombosis, or catheter malfunction. It is therefore critical to understand the various options for long-term central venous access in these patients. In this chapter, we provide a comprehensive and multidisciplinary approach to the management of reoperative venous access with particular attention to preoperative planning and imaging, as well as specific techniques in interventional radiology and surgery.