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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 8
| Issue : 2 | Page : 74-78 |
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Complications of femoral arterial lines in infants under 12 months
Benjamin David Carr, Sumer D Sebik, Clinton J Poling, Lindsay S Holland, Haley R Divis, Irene C St Charles, Anne E Baetzel, Samir K Gadepalli
Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, Michigan, USA
| Date of Submission | 21-Oct-2020 |
| Date of Decision | 01-Dec-2020 |
| Date of Acceptance | 31-Dec-2020 |
| Date of Web Publication | 10-Mar-2021 |
Correspondence Address:
Dr. Benjamin David Carr
Department of Surgery, Section of Pediatric Surgery, University of Michigan, 1540 E Hospital Dr. Ann Arbor, Michigan 48109
USA
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jpcc.jpcc_165_20
Background: The risks of femoral arterial line placement in young children have been incompletely defined. We hypothesized that a low complication rate would be associated with ultrasound use.
Subjects and Methods: Infants aged 0–12 months undergoing placement of a femoral arterial line at our institution over a 3.5-year period were identified through billing data, and their records were reviewed. Events concerning each line were recorded individually. Patients were excluded if there was incomplete documentation or if the line was in place for under 24 h. Demographics, information about line placement, and complications were recorded.
Results: Three hundred and sixty-four femoral arterial lines were included. Eighty percent of lines were placed in the operating room, with the rest placed in the cardiac intensive care unit (ICU) (11%), the cardiac catheterization lab (6%), or the pediatric ICU (3%). Femoral artery occlusion occurred with 16% of lines placed, and limb ischemia in 6%. One patient had tissue loss. Occlusion was associated with lower gestational age at birth (44 [40–57] vs. 50 [41–60], P = 0.04), lower weight (3.7 [3.1–5.7] vs. 4.3 kg [3.3–6.2], P = 0.05), left-sided lines (52% vs. 66%, P = 0.05), placement in interventional catheterization lab (odds ratio [OR]: 3.28, confidence interval [CI]: 1.24–8.67, P = 0.02), >2 attempts (27% vs. 13%, P < 0.01), and catheter diameter (OR: 2.86, CI: 1.18–6.92, P = 0.02).
Conclusion: Femoral arterial catheter placement in infants younger than 12 months resulted in a 16% rate of arterial occlusion at our institution, which was associated with low gestational age, larger catheter size, and left-sided lines but not ultrasound use, line duration, catheter length, use of anticoagulation, physician specialty, or physician training level.
Keywords: Arterial lines, complications, femoral, occlusion, pediatric, ultrasound
How to cite this article:
Carr BD, Sebik SD, Poling CJ, Holland LS, Divis HR, St Charles IC, Baetzel AE, Gadepalli SK. Complications of femoral arterial lines in infants under 12 months. J Pediatr Crit Care 2021;8:74-8 |
How to cite this URL:
Carr BD, Sebik SD, Poling CJ, Holland LS, Divis HR, St Charles IC, Baetzel AE, Gadepalli SK. Complications of femoral arterial lines in infants under 12 months. J Pediatr Crit Care [serial online] 2021 [cited 2021 Apr 20];8:74-8. Available from: http://www.jpcc.org.in/text.asp?2021/8/2/74/311056 |
| Introduction | |  |
Arterial catheters are commonly used to monitor hemodynamics and facilitate frequent blood sampling in children during critical illness or major surgery. Although the preferred site of arterial cannulation is the radial artery, the femoral artery is often used when radial access is not practicable. Unlike the radial artery, the femoral artery has no collateral vessel to provide distal perfusion if thrombus, dissection, or spasm occurs.
Previous studies have shown that arterial occlusion can occur in 3%–20% of pediatric femoral arterial lines and suggest that the most vulnerable patients are those who are youngest, smallest, and undergoing cardiac surgery.[1],[2],[3],[4],[5] However, patient demographics and arterial occlusion rates vary widely in small retrospective series, and large database studies lack the ability to extract detailed, meaningful data on complications and risk factors.
Overall, the current literature does not provide a clear picture of the common complications of femoral line placement in small children and their risk factors. To inform prevention, screening, and management of complications, we sought to define the risk profile of femoral arterial catheters (FACs) specifically in infants under 12 months of age and to determine predictors of arterial occlusion using a large sample of detailed single-institution data.
| Subjects and Methods | | |
As part of an IRB-exempt quality improvement initiative, billing data were used to identify infants aged 0–12 months who underwent arterial line placement from 7/2014 to 2/2018, and their medical records were reviewed. Infants were included if they underwent placement of a femoral catheter or sheath that remained in place over 24 h. Patients were excluded if there was incomplete documentation, or if the FAC was in place under 24 h. Each FAC was analyzed individually including those placed in the same patient, and placement of a previous line in the same vessel within 30 days was noted. Patient demographic information, details of line placement, and complications were recorded.
Occlusion was defined as any documented arterial occlusion on Doppler ultrasound imaging or cross-sectional imaging within 90 days of FAC placement. Ischemia was defined as any documented finding suggesting decreased perfusion to the leg (mottling, decreased pulses, discoloration, and cool extremity in a normothermic patient). Cardiac surgery was defined as any patient undergoing a cardiac procedure during the same admission as FAC placement including both open cardiac surgery and catheter-based procedures. Documented attempts were recorded as 1–4 attempts because the documentation system used by our anesthesia department records a maximum of four attempts.
The Shapiro–Wilks test for parametricity, Kruskal–Wallis comparison of means, Student's t-test, and Fisher's exact test were used as appropriate. Multivariate logistic regression analysis was used to evaluate factors having P < 0.25 on comparison between occlusion and no occlusion groups. Multivariable logistic regression with cluster-robust standard errors was used to adjust for possible correlation within patients and identify which variables remained significantly associated with occlusion. Statistical analysis was conducted using STATA v. 15 (College Station, TX), and P < 0.05 was considered statistically significant.
| Results | | |
In total, 364 femoral arterial lines met inclusion criteria. Patient demographic data are shown in [Table 1] and are notable for a preponderance of term infants undergoing cardiac surgery (85%). Details of line placement are shown in [Table 2]. The majority of FACs were placed in the operating room (OR) by the anesthesia team under ultrasound guidance, using one or two attempts. Complications are summarized in [Table 3]. There was an overall occlusion rate of 16% but a low rate of tissue loss or subsequent intervention. | Table 1: Patient characteristics for 364 femoral arterial lines analyzed
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[Table 4] compares characteristics of lines associated with vessel occlusion versus those without occlusion. Corrected gestational age was significantly lower for those with occlusion (median [interquartile range] 44 [40–57] vs. 50 weeks [41–60], P = 0.04). Weight was also significantly lower in the occlusion group (3.7 [3.1–5.7] vs. 4.3 kg [3.3–6.2], P = 0.05). A higher proportion of occlusions were associated with previous cannulation of that vessel within 30 days, though this did not reach statistical significance (17% vs. 9%, P = 0.06). There was a significant increase in occlusion rate if 3 or more cannulation attempts were made (27% vs. 13%, P < 0.01). Unexpectedly, there was a significant association between occlusion and left-sided line placement (76% vs. 52%, P = 0.05). There was no significant association of occlusion with ultrasound use, line duration, cardiac surgery, or specialty or training level of placing physician.
Univariate logistic regression analysis of nondichotomous line characteristics associated with arterial occlusion is shown in [Table 5]. Occlusion was significantly associated with lines placed in the cardiac catheterization lab (odds ratio [OR] 3.28, confidence interval [CI]: 1.24–8.67, P = 0.02). Diameter of the arterial cannula was also significantly associated with occlusion (OR: 2.99, CI: 1.23–7.32, P = 0.02). On multivariate regression analysis, occlusion was significantly associated with lower corrected gestational age (OR: 0.96, CI: 0.94–0.99, P = 0.01), side of the line (OR: 1.98, CI: 1.01–3.89, P = 0.05), and cannula diameter (OR: 2.86, CI: 1.18–6.92, P = 0.02). Number of attempts contributed to the best-fit model but did not reach statistical significance (OR: 1.36, CI: 0.99–1.87) [Table 6]. | Table 5: Univariate logistic regression analysis of nondichotomous line characteristics associated with occlusion
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 | Table 6: Multivariate logistic regression analysis of line characteristics associated with occlusion
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| Discussion | | |
In a detailed single-institution review of 364 femoral arterial lines placed in children 0–12 months, a high association was found between FAC use and cardiac surgery. Overall arterial occlusion rate was 16%, although major sequelae appeared to be rare. Occlusion was associated with lower corrected gestational age, lower weight, left-sided lines, placement in cardiac catheterization lab, cannula diameter, and number of cannulation attempts. We found that ultrasound use, line duration, physician specialty, and physician training level were not significantly associated with arterial occlusion. Given these findings, we recommend that cannulation of the femoral artery is best avoided in infants whenever possible. When FAC use is unavoidable, patients should be closely monitored for signs of vascular insufficiency and screened with ultrasound if ischemic signs are present.
It is unclear why we observed an association between the side of FAC placement and occlusion. Overall, there was a slight predominance of left-sided lines in our study (55% of all lines placed were left sided), but we found that 76% of occlusions were left sided, while cases of nonocclusion were evenly distributed left versus right. It is possible that a hidden variable is at play (e.g., preferential right-sided femoral cannulation for cardiac bypass), but we found no statistical evidence for codependent variables in our dataset, and we hypothesize that a mechanistic explanation exists but was not captured by the variables we collected.
It is also interesting to note the 3-fold increase in occlusion observed for FACs placed in the cardiac catheterization laboratory. Several studies from the pediatric vascular surgery and interventional cardiology literature may shed light on this. Franken et al. emphasize that thrombosis is frequently caused by arterial spasm, which is related both to patient age and the diameter of the catheter relative to the artery.[6] Ding et al. found that catheter length also influences thrombosis risk, in addition to patient weight.[7] There may be an association, since interventional procedures typically require a larger sheath than an FAC placed purely for hemodynamic monitoring. Interestingly, Lin et al. not only observed increased thrombosis risk with younger age and larger catheters but also with increased manipulation of the catheter with therapeutic interventions.[8] Kou et al. noted in a large observational study that increased procedural time (implying increased transarterial manipulation) and increased sheath size: age ratio were both independent predictors of arterial occlusion.[9] Taken together, these studies support that a larger catheter relative to the accessed artery (either because of large catheter size or small patient size), especially if the catheter is extensively manipulated (e.g., during an interventional procedure), can lead to significant vasospasm and increased thrombotic risk, compatible with our observations. The number of cannulation attempts, associated in our study with increased complication risk, is another factor that implies either repeated trauma to the tissue around the artery, or repeated puncture of the vessel itself, both of which would tend to provoke arterial spasm.
Existing literature on FAC in children is sparse. Occlusion rates between 3% and 32% have been observed, with multiple series reporting outcomes for children up to 18 years.[1],[2],[3],[4],[5],[10],[11] Only a minority of series used imaging to diagnose thromboses.[2],[4] Younger age is associated with higher arterial occlusion rates.[1],[4],[5] However, the rate of clinically evident arterial insufficiency seems to be lower than the rate of image-proven arterial occlusion[2] and tends to resolve after catheter removal.[1],[5],[11] These findings appear congruent with our results.
The strengths of our study include a large sample size in a specific and clinically important age range, detailed outcomes and risk factor data, the use of imaging to confirm arterial occlusion, and investigation of multiple variables not previously reported in the literature. Limitations include population heterogeneity (cardiac vs. noncardiac patients), short follow-up interval, and limitations inherent to a single-institution retrospective study including generalizability relative to local practice patterns and dependence on the accuracy of the medical record.
| Conclusion | | |
FAC placement in infants younger than 12 months resulted in a 16% rate of arterial occlusion at our institution, which was associated with low gestational age and weight, number of cannulation attempts, catheter size, left-sided lines, and placement for an interventional catheterization procedure but not ultrasound use, line duration, catheter length, use of anticoagulation, physician specialty, or physician training level.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Graves PW, Davis AL, Maggi JC, Nussbaum E. Femoral artery cannulation for monitoring in critically ill children: Prospective study. Crit Care Med 1990;18:1363-6.  |
| 2. | Kocis KC, Vermilion RP, Callow LB, Kulik TJ, Ludomirsky A, Bove EL. Complications of femoral artery cannulation for perioperative monitoring in children. J Thorac Cardiovasc Surg 1996;112:1399-400. |
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| 4. | Brotschi B, Hug MI, Latal B, Neuhaus D, Buerki C, Kroiss S, et al. Incidence and predictors of indwelling arterial catheter-related thrombosis in children. J Thromb Haemost 2011;9:1157-62. |
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| 6. | Franken EA Jr., Girod D, Sequeira FW, Smith WL, Hurwitz R, Smith JA. Femoral artery spasm in children: Catheter size is the principal cause. AJR Am J Roentgenol 1982;138:295-8. |
| 7. | Ding L, Pockett C, Moore J, El-Said H. Long sheath use in femoral artery catheterizations in infants <15 kg is associated with a higher thrombosis rate: Proposed protocol for detection and management. Catheter Cardiovasc Interv 2016;88:1108-12. |
| 8. | Lin PH, Dodson TF, Bush RL, Weiss VJ, Conklin BS, Chen C, et al. Surgical intervention for complications caused by femoral artery catheterization in pediatric patients. J Vasc Surg 2001;34:1071-8. |
| 9. | Kou L, Wang Q, Long WA, Tang F, Li L. Emerging predictors of femoral artery occlusion after pediatric cardiac catheterization. Sci Rep 2020;10:14001. |
| 10. | Venkataraman ST, Thompson AE, Orr RA. Femoral vascular catheterization in critically ill infants and children. Clin Pediatr (Phila) 1997;36:311-9. |
| 11. | Wardle SP, Kelsall AW, Yoxall CW, Subhedar NV. Percutaneous femoral arterial and venous catheterisation during neonatal intensive care. Arch Dis Child Fetal Neonatal Ed 2001;85:119F-22. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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