Surgical techniques for vascular access for chemotherapy in infants and children

Abstract

Three major factors that have contributed to recent major improvements in survival figures in childhood cancers are a better understanding of the mode of action of chemotherapeutic agents, their more intensive and prolonged use, and the steady introduction of new drugs and protocols. The long-term administration of such medicines can become increasingly difficult as the limited supply of veins is exhausted by repeated injections of corrosive thrombogenic substances causing progressive discomfort to the patient, family, and physician and increasing the risk of either termination of therapy or tissue-threatening extravasations. To minimize or obviate these hazards, we have performed vascular access procedures in 74 children and in infants weighing less than 10 kg. These techniques have been borrowed from the repertoire of the transplant surgeon and have been upgraded to meet the special needs of patients who require repeated venipuncture for blood drawing, drug injection, and blood products administration, especially during periods of profound aplasia when infection is an everpresent threat. The operation of choice is a loop fistula from saphenous vein to superficial femoral artery. Bovine carotid artery and umbilical vein loops have been employed when the first procedure cannot be performed. When immediate access has been required, femoral-femoral shunts have been constructed and have proved entirely serviceable for periods of over 1 yr. Saphenous fistulas have the advantages of not requiring external connections, of using solely autogenous material, of high flow rates to rapidly dilute chemicals, and of lasting for at least as long as 3 yr. No infections and only two faifures have occurred in the series; in both instances a synthetic material was employed. Such accesses provide another surgical modality to help make easier and more successful the care and life of the child with malignancy. The particular choice of operation is mandated by the individual case.