Computed Tomography-Guided Paravertebral Venous Access: An Unconventional Approach for Percutaneous Embolisation of Collaterals in Children

Abstract

This study presents the case of a 9-year-old boy with hypoplastic left heart syndrome with troublesome venovenous collaterals. He underwent staged Norwood palliation, culminating in a fenestrated extracardiac total cavopulmonary connection at 5 years of age. He had transcatheter device closure of the fenestration at 6 years of age. He presented with new-onset effort intolerance and cyanosis (transcutaneous oxygen saturation 83% at rest). Cardiac catheterisation revealed a large venous collateral vessel originating from the distal innominate vein and draining into the left upper pulmonary vein, which was successfully embolised with an Amplatzer vascular plug. An additional large venous collateral was identified originating from the left renal vein, draining upward, seemingly continuing as the levo-cardinal vein, and terminating at the coronary sinus. Due to its tortuous nature and acute angulations, repeated attempts at standard transfemoral percutaneous embolisation were unsuccessful. Following review and discussion, a multidisciplinary interventional approach via paravertebral venous access was performed. Computed tomography and ultrasound-guided percutaneous paravertebral puncture of the venous collateral were performed. An 8-F sheath was placed, and the collateral vessel was successfully embolised cranially using a 14-mm AVP II device. To ensure haemostasis, two Nester coils (14 × 10) and a small volume of gel foam were deployed in the tract at the time of sheath removal. There was no residual flow seen in the collateral, with immediate improvement in the arterial oxygen saturation (SpO2 98%). This case illustrates the successful application of an alternative approach to venous access in cases where standard femoral venous approach proves impossible.