Vascular Access

Safe, painless, and long-term central venous access is an essential component of modern pediatric oncological care. Modern catheters and devices and sophisticated, minimally invasive access techniques make vascular access possible even in patients with very small vessels and allow for repeated blood sampling and administration of chemotherapeutic and vasoactive drugs and other drugs without the trauma and other problems associated with repeated needling. There are numerous device options, access sites, and placement techniques available to treatment teams, and the most appropriate plan for each patient should be formulated based on individual patient need, local facilities and device availability, and physician skill-set. Central venous access devices (CVADs) may be broadly categorized into non-tunneled, tunneled, and totally implantable devices, each having their own relative advantages and disadvantages. All are designed to provide safe, long-term access. Typically, CVADs are placed using radiologically assisted minimally invasive techniques, but in certain patients and certain circumstances, surgeons or interventionists may opt for open cut-down techniques or percutaneous placement using landmark techniques. The placement and care of long-term CVADs relies on an understanding of the associated complications which may occur at time of insertion or in the following weeks and months. Robust line care bundles, hospital infection control policies, and staff, patient, and caregiver training and education are essential to the successful use of these devices. This chapter discusses indications for central venous access in the oncology patient, patient and device selection, insertion techniques, complications, and their prevention and highlights adaptations required in resource-constrained environments.