# Thrombosis — GCMD Library living collection

Everything in the library about thrombosis — built automatically from dossiers that name it.

Updated: n/a · 4 episodes · 85 cited statements

## Episodes
### Medical Management
- [How do we manage thrombogenicity and thrombosis in the Fontan? New Horizons...](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886) — video · 16:51 · [machine version](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886.md)

### Surgical Management
- [Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870) — video · 13:54 · [machine version](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870.md)
- [Pediatric Vascular Access](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112) — podcast · 35:43 · [machine version](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112.md)
- [Update Course Rewind 2025: New Technologies for Central Line Management](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558) — video · 3:48 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=0) Introduction and thrombotic burden in Fontan circulation (Ep 1)
- [3:19](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=199) Case 1: Young adult with superficial thrombophlebitis and abnormal labs (Ep 1)
- [4:40](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=280) Pathophysiology: Virchow's triad in Fontan circulation (Ep 1)
- [5:48](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=348) Aspirin versus warfarin and time-in-therapeutic-range data (Ep 1)
- [7:41](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=461) Case 2: Active 10-year-old with factor V Leiden and challenges of universal anticoagulation (Ep 1)
- [9:16](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=556) Biomarkers for risk stratification and the honeymoon phase (Ep 1)
- [12:13](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=733) Proposed personalized monitoring approach and case management (Ep 1)
- [15:20](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=920) Direct oral anticoagulants: need for data and monitoring (Ep 1)
- [0:13](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=13) Types of Central Venous Access Devices (Ep 2)
- [1:54](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=114) Site Selection and Contraindications (Ep 2)
- [2:57](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=177) Preoperative Workup and Imaging (Ep 2)
- [3:59](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=239) Patient Positioning and Equipment Selection (Ep 2)
- [5:12](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=312) Internal Jugular Access Technique (Ep 2)
- [6:42](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=402) Subclavian Access Technique (Ep 2)
- [7:46](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=466) Catheter Tip Positioning and Confirmation (Ep 2)
- [9:03](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=543) Complications and Line Infection Management (Ep 2)
- [10:20](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=620) Antimicrobial Lock Solutions (Ep 2)
- [12:08](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=728) Salvage Access Techniques (Ep 2)
- [0:00](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=0) Introduction and catheter sizing principles (Ep 3)
- [1:30](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=90) Neonatal IJ access: needle-hole venotomy technique (Ep 3)
- [7:20](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=440) Catheter tip positioning and measurement (Ep 3)
- [10:22](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=622) Percutaneous access and ultrasound guidance (Ep 3)
- [14:57](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=897) Site selection hierarchy and vascular imaging (Ep 3)
- [18:17](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1097) Catheter tunneling and kinking prevention (Ep 3)
- [21:31](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1291) Femoral access and alternative sites (Ep 3)
- [23:58](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1438) Heparin lock protocols and ethanol lock therapy (Ep 3)
- [27:38](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1658) Infected catheter management (Ep 3)
- [31:17](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1877) Thoracoscopic SVC access for exhausted sites (Ep 3)
- [34:48](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=2088) Catheter removal and cuff management (Ep 3)
- [0:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=0) Surfacer System for SVC Recanalization (Ep 4)
- [1:32](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=92) 4D Intracardiac Echo for Radiation-Free Guidance (Ep 4)
- [2:33](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=153) Last-Resort Access: Transhepatic vs Translumbar (Ep 4)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Fontan circulation is a profoundly prothrombotic state and thrombosis is a major cause of death in patients with Fontan circulation. — Joe (clinical) [Ep 1 · 1:01](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=61)
- Many thrombotic events in Fontan patients are subclinical but clinically significant. — Joe (clinical) [Ep 1 · 1:10](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=70)
- The cumulative hazard risk of thrombotic events in Fontan patients increases over time, with Fontan circulation becoming essentially a freight train of thrombogenicity. — Joe (clinical) [Ep 1 · 2:19](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=139)
- Fontan circulation's thrombotic risk is comparable to paroxysmal nocturnal hemoglobinuria (30-40% risk over 5 years), antiphospholipid antibody syndrome, and unprovoked venous thromboembolism (20-30% recurrence rate). — Joe (clinical) [Ep 1 · 2:41](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=161)
- Relative hypoxia and loss of pulsatile flow in the venous system is very thrombogenic for endothelial cells. — Joe (clinical) [Ep 1 · 4:52](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=292)
- Hypoxia and loss of pulsatile flow result in upregulation of tissue factor expression (the primary initiator of the clotting cascade), upregulation of adhesion molecules that activate inflammatory cells, and increased secretion of factor VIII and von Willebrand factor. — Joe (clinical) [Ep 1 · 5:01](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=301)
- Protein-losing enteropathy (PLE) results in increased inflammatory system activation in Fontan patients. — Joe (clinical) [Ep 1 · 5:17](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=317)
- Liver synthetic dysfunction can develop over time in Fontan patients and worsen hemostatic system activation. — Joe (clinical) [Ep 1 · 5:22](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=322)
- Overall data supports that warfarin is better thromboprophylaxis than aspirin in Fontan patients. — Joe (clinical) [Ep 1 · 6:05](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=365)
- Excellent time-in-therapeutic-range above 80% with warfarin is achievable using a paternalistic approach with aggressive monitoring and phone follow-up. — Joe (clinical) [Ep 1 · 7:05](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=425)
- Even with well-managed anticoagulation, the bleeding risk is around 2% per year. — Joe (epidemiological) [Ep 1 · 8:33](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=513)
- Warfarin is very problematic from a pharmacokinetic standpoint and poorly managed warfarin may actually increase thrombotic risk. — Joe (clinical) [Ep 1 · 8:43](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=523)
- Direct oral anticoagulants (DOACs) such as rivaroxaban and apixaban seem superior to warfarin in many ways but are completely unproven in Fontan patients. — Joe (clinical) [Ep 1 · 8:52](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=532)
- The honeymoon phase duration can vary and may be predictable using biomarkers. — Joe (opinion) [Ep 1 · 9:40](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=580)
- Elevated factor VIII is a strong marker of increased thrombotic risk and can be elevated due to genetic factors, endothelial cell activation, or as an acute phase reactant indicating inflammation. — Joe (clinical) [Ep 1 · 10:17](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=617)
- Fontan circulation, even in the context of liver dysfunction, shifts the hemostatic balance toward a thrombophilic state. — Joe (clinical) [Ep 1 · 12:13](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=733)
- Monitoring D-dimer, factor VIII, liver function tests, and albumin every 6 months can predict when the honeymoon period of relatively low thrombotic risk is ending. — Joe (opinion) [Ep 1 · 13:00](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=780)
- Aspirin VerifyNow is an extremely reliable and reproducible test that confirms patients are taking aspirin and having an antiplatelet response. — Joe (clinical) [Ep 1 · 14:40](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=880)
- DOACs need to be studied in the Fontan population before determining how good or bad they are. — Joe (opinion) [Ep 1 · 15:26](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=926)
- To use DOACs routinely in Fontan patients, reliable monitoring methods are needed because organ function can change rapidly in these patients. — Joe (clinical) [Ep 1 · 15:36](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=936)
- DOACs are most likely better than poorly controlled warfarin, but high time-in-therapeutic-range is achievable with warfarin in most patients. — Joe (opinion) [Ep 1 · 16:21](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=981)
- At Cincinnati Children's Hospital, the transplant surgery team manages complex vascular access and catheter-based dialysis access. — Alex Bondoc (clinical) [Ep 2 · 0:26](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=26)
- From a logistical standpoint, chest and neck central venous access is preferred over femoral access. — Alex Bondoc (clinical) [Ep 2 · 2:09](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=129)
- Contraindications for central venous access include thrombosis, collateralization, and central stenosis of the SVC, which may require exotic concurrent procedures or alternative access sites. — Alex Bondoc (clinical) [Ep 2 · 2:39](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=159)
- Unless patients have congenital anomalies (usually cardiovascular), routine pre-procedural ultrasound is not necessary for first-time line placement. — Alex Bondoc (clinical) [Ep 2 · 3:09](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=189)
- For patients requiring multiple lines (line number 4, 5, or 6), Doppler venous ultrasound of the jugulars is recommended, and in small children the SVC and subclavians can sometimes be visualized. — Alex Bondoc (clinical) [Ep 2 · 3:20](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=200)
- Pre-procedural imaging may be escalated to contrast-enhanced MR or CT venography, and sometimes intraoperative venography with fluoroscopy is performed. — Alex Bondoc (clinical) [Ep 2 · 3:37](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=217)
- For small children, neonates, and infants, positioning over a vertically oriented shoulder roll (parallel with the spine) provides hyperextension of the neck and allows shoulder weight to drop posteriorly, giving access to bilateral subclavians and jugulars. — Alex Bondoc (clinical) [Ep 2 · 3:59](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=239)
- Dr. Bonddo prefers using a micropuncture kit with a 21-gauge finder needle for small babies, which is smaller than the 18-gauge needle in standard tunnel line kits. — Alex Bondoc (clinical) [Ep 2 · 4:55](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=295)
- Using ultrasound for internal jugular central line placement is the number one preferred method, with the lowest risk of pneumothorax and carotid artery injury. — Alex Bondoc (clinical) [Ep 2 · 5:25](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=325)
- For large-bore access like dialysis catheters, the patient should be stuck as low as possible on the neck, using the ultrasound probe (approximately 12mm diameter) levered against the clavicle as a landmark. — Alex Bondoc (clinical) [Ep 2 · 5:52](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=352)
- Low neck puncture leaves more catheter to curve in the neck; mid-neck puncture creates lax catheter that can lead to problems with neck turning and catheter displacement from the SVC. — Alex Bondoc (clinical) [Ep 2 · 6:22](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=382)
- For subclavian access, the insertion point is at the junction of the median and medial aspects of the clavicle, at least one finger breadth (approximately 1cm) inferiorly and laterally, to allow levering under the bone. — Alex Bondoc (clinical) [Ep 2 · 6:56](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=416)
- When approaching the clavicle during subclavian access, the needle should be kept flat with downward pressure on the skin rather than angling at 30 degrees. — Alex Bondoc (clinical) [Ep 2 · 7:14](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=434)
- For subclavian access, the needle should be aimed directly at the sternal notch initially, then angled wider toward the angle of the mandible in a radial motion if unsuccessful. — Alex Bondoc (clinical) [Ep 2 · 7:34](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=454)
- The right triangle technique for catheter tip positioning uses the trachea as the theoretical midline continued from the carina, with the right main stem bronchus as the hypotenuse; the catheter tip should be within this triangle to ensure atriocaval junction placement. — Alex Bondoc (clinical) [Ep 2 · 8:04](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=484)
- Post-procedural chest X-ray is not routinely ordered for single-stick, uncomplicated line placement using fluoroscopy, based on data from Children's Mercy Hospital Kansas City. — Alex Bondoc (clinical) [Ep 2 · 8:38](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=518)
- Post-procedural complications include pneumothorax, hemothorax, arterial injury (subclavian or carotid), and rare complications like chylothorax or thoracic duct injury. — Alex Bondoc (clinical) [Ep 2 · 9:06](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=546)
- For line infection management, the first clinical decision is whether the patient is septic from the line; if septic and in the ICU, source control requires bedside line removal under light sedation. — Alex Bondoc (clinical) [Ep 2 · 9:41](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=581)
- For non-septic line-dependent patients with complex vascular access, the organism and antibiotic sensitivity are determined, serial blood cultures are obtained, and the line may be salvaged if sustained culture negativity is achieved. — Alex Bondoc (clinical) [Ep 2 · 10:04](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=604)
- Traditional locking solutions are predominantly antibiotic locks, but they lead to development of bacterial resistance. — Paul Wales (clinical) [Ep 2 · 10:35](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=635)
- Ethanol locks are antimicrobial without resistance development and kill both planktonic bacteria (floating in the lumen) and sessile bacteria (embedded in biofilm along the catheter wall). — Paul Wales (clinical) [Ep 2 · 10:56](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=656)
- Kite lock is a 4% tetrasodium EDTA solution that is antimicrobial without resistance, and has antifibrinolytic and antithrombotic properties. — Paul Wales (clinical) [Ep 2 · 11:24](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=684)
- Kite lock is licensed for pediatric use in Canada, Europe, and Australia, but availability varies by region. — Paul Wales (clinical) [Ep 2 · 11:59](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=719)
- For patients with exhausted femoral, IJ, and subclavian access options, translumbar line placement through the back musculature into the intrahepatic IVC is an alternative approach performed with interventional radiology. — Alex Bondoc (clinical) [Ep 2 · 12:19](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=739)
- For emergency vascular access via facial vein cutdown, a horizontal incision is made just lateral to the sternocleidomastoid at the angle of the mandible with the head turned to the patient's left, and the facial vein is typically the first large vein encountered. — Alex Bondoc (clinical) [Ep 2 · 12:48](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=768)
- For facial vein cutdown, the catheter should be beveled hard to allow blind passage without wire guidance, theoretically allowing it to follow a path without bumping against the vessel wall. — Alex Bondoc (clinical) [Ep 2 · 13:04](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=784)
- The Surfacer is made by Merritt Medical and is image guided SVC recannulation using a special piece of equipment. — Nathan Fagan (clinical) [Ep 4 · 0:29](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=29)
- The Surfacer works best when there is at least a remnant of something there that you can get through. — Nathan Fagan (clinical) [Ep 4 · 0:42](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=42)
- The Surfacer might be safer than trying to jab a needle down to the right atrium when there is a remnant lumen. — Nathan Fagan (opinion) [Ep 4 · 0:42](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=42)
- The Surfacer technique involves burying a special catheter where you want your exit site to be and creating a target at 90 degrees where the catheter will exit. — Nathan Fagan (clinical) [Ep 4 · 0:59](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=59)
- The operator drives a special needle through the catheter that has been pulled up to the skin surface. — Nathan Fagan (clinical) [Ep 4 · 1:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=75)
- 4D intracardiac echo catheter is used more in cardiology for ablations or left atrial appendage occlusions. — Nathan Fagan (clinical) [Ep 4 · 1:39](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=99)
- The 4D intracardiac echo probe projects an ultrasound wave in 360 degrees. — Nathan Fagan (clinical) [Ep 4 · 1:48](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=108)
- The 4D echo image can be reconstructed in any plane to guide the needle across an occlusion. — Nathan Fagan (clinical) [Ep 4 · 1:56](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=116)
- The technique involves getting access from above with a normal ultrasound, then using the special 4D catheter to reconstruct and guide the needle across the occlusion. — Nathan Fagan (clinical) [Ep 4 · 2:14](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=134)
- Nobody is using 4D intracardiac echo for central line recanalization yet. — Nathan Fagan (clinical) [Ep 4 · 2:24](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=144)
- 4D intracardiac echo catheters are being used more for TIPS procedures. — Nathan Fagan (clinical) [Ep 4 · 2:26](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=146)
- There is a big debate on whether to use transhepatic or translumbar access. — Nathan Fagan (clinical) [Ep 4 · 2:41](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=161)
- Transhepatic access makes the most sense in pediatric patients because if there is bleeding or if it gets dislodged, it is easier to get to or control. — Nathan Fagan (opinion) [Ep 4 · 2:43](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=163)
- For translumbar access, the operator locates the IVC at the lumbar level using CT, guides a needle down to get access, and then places the line. — Nathan Fagan (clinical) [Ep 4 · 3:07](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=187)
- In micro-preemies (1000g to 2kg), a 3-French soft silastic cuffed catheter is preferred because larger catheters that fill the vessel lumen increase the risk of vessel thrombosis. — Mark Wulkan (clinical) [Ep 3 · 1:30](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=90)
- A needle-hole venotomy technique for neonatal IJ access involves isolating the vein, making a needle puncture without formal venotomy, and advancing a beveled catheter through the puncture site to preserve vein patency for future access. — Mark Wulkan (clinical) [Ep 3 · 2:33](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=153)
- Beveling the catheter tip for needle-hole venotomy was associated with slightly more catheter thrombosis in one study compared to straight-cut catheters, but the technique is justified to preserve the vein. — Mark Wulkan (clinical) [Ep 3 · 3:23](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=203)
- When ultrasound-guided needle placement appears to be in the vein but no blood return is obtained in small infants, the needle may have passed through the collapsed vein and withdrawing it slightly may establish access. — Mark Wulkan (clinical) [Ep 3 · 12:35](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=755)
- For oncology patients receiving vesicant chemotherapy such as Adriamycin that causes tissue necrosis if infiltrated, a cuffed external catheter (Broviac) is preferred over a subcutaneous port. — Mark Wulkan (guideline) [Ep 3 · 13:36](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=816)
- Bone marrow transplant patients at the speaker's institution receive three central line lumens: a double-lumen catheter plus a single-lumen catheter. — Todd Ponsky (clinical) [Ep 3 · 14:32](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=872)
- MRV is the gold standard imaging study for evaluating central venous patency in patients with multiple prior lines or history of thrombosis. — Mark Wulkan (clinical) [Ep 3 · 15:34](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=934)
- A glide wire can sometimes be advanced through a partially occluded superior vena cava when a standard guide wire will not pass. — Mark Wulkan (clinical) [Ep 3 · 17:53](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1073)
- When tunneling from an IJ access site, placing the exit site laterally creates a more gentle curve and reduces catheter kinking compared to medial or sternal exit sites. — Todd Ponsky (clinical) [Ep 3 · 18:17](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1097)
- For infected central lines, if the patient has peripheral IV access, the infected line should be removed and peripheral access used temporarily rather than exchanging over a wire, which risks infecting the new line. — Mark Wulkan (clinical) [Ep 3 · 19:24](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1164)
- Ideally, blood cultures should be negative for 48 hours before placing a new central line after removal of an infected catheter. — Mark Wulkan (guideline) [Ep 3 · 20:00](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1200)
- Femoral venous access in neonates frequently results in leg swelling and should be avoided in this population. — Mark Wulkan (clinical) [Ep 3 · 22:03](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1323)
- Routine preoperative coagulation studies (PT/PTT) are not indicated for central line placement unless the patient is anticoagulated or has liver failure; platelet function assay (PFA) is more useful when coagulopathy is suspected. — Mark Wulkan (clinical) [Ep 3 · 23:24](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1404)
- Standard heparin lock concentrations are 10 units/mL for accessed catheters (ports and cuffed lines), 100 units/mL for non-accessed buried ports, and 1000 units/mL for dialysis catheters. — Mark Wulkan (guideline) [Ep 3 · 24:40](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1480)
- Prophylactic ethanol lock therapy is being used in some bone marrow transplant patients to reduce catheter-related bloodstream infection rates. — Mark Wulkan (clinical) [Ep 3 · 25:31](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1531)
- For catheter-related infections with gram-positive organisms, treatment with antibiotics through the catheter plus ethanol lock can successfully clear the infection approximately 50% of the time; for gram-negative infections, clearance rate is lower. — Mark Wulkan (clinical) [Ep 3 · 26:16](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1576)
- Catheter-related fungal infections (Candida) require line removal; salvage attempts are not appropriate. — Mark Wulkan (guideline) [Ep 3 · 26:54](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1614)
- Implementation of ethanol lock therapy substantially reduced the number of line removals for infection at the speaker's institution. — Todd Ponsky (epidemiological) [Ep 3 · 27:38](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1658)
- For patients with complete central venous occlusion, thoracoscopic-assisted needle puncture of the SVC can be performed by advancing a needle through the thrombosed IJ tract under direct visualization; the SVC almost always recanalizes at the azygous vein junction. — Mark Wulkan (clinical) [Ep 3 · 28:26](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1706)
- For thoracoscopic SVC access in larger adolescents, the standard line kit needle may not be long enough and an extra-long spinal needle may be required. — Mark Wulkan (clinical) [Ep 3 · 30:40](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1840)
- Some older silicone catheters become chalky and friable over time, possibly due to betadine exposure, making removal difficult. — Mark Wulkan (clinical) [Ep 3 · 31:17](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1877)
- Cuffed catheters (Broviacs) can be removed at the bedside by applying slow, steady traction until the cuff breaks away from the catheter; the cuff is left in situ and does not require surgical removal. — Todd Ponsky (clinical) [Ep 3 · 32:46](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1966)
- In 18 years of practice using bedside cuffed catheter removal with retained cuff, the speaker encountered only one cuff that developed infection requiring surgical removal. — Todd Ponsky (epidemiological) [Ep 3 · 33:14](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1994)
- If a cuffed catheter breaks during bedside removal, the retained segment with cuff will not migrate because tension is only on the exit side; the segment can be retrieved by local exploration. — Todd Ponsky (clinical) [Ep 3 · 33:58](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=2038)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- The prevalence of silent pulmonary embolism in adults with Fontan circulation may be as high as 1 in 5 (20%). — Joe summarizing the discussion [Ep 1 · 1:23](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=83)
- In Paul Monagle's study comparing aspirin and warfarin in newer style Fontans, patients had an overall cumulative risk of 22% for thrombotic events. — Joe summarizing the discussion [Ep 1 · 1:39](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=99)
- Reanalysis of Monagle's data showed that warfarin with time-in-therapeutic-range of 60% or better edged out aspirin over time. — Joe summarizing the discussion [Ep 1 · 6:14](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=374)
- Retrospective data from Cedric Manliot's group showed warfarin was clearly better than aspirin, though both were significantly better than no thromboprophylaxis. — Joe summarizing the discussion [Ep 1 · 6:39](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=399)
- In patients with excellent time-in-therapeutic-range (>80%), Grushin's group observed only one thrombotic event over 53 patient-years. — Joe summarizing the discussion [Ep 1 · 7:14](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=434)
- Thrombotic risk in Fontan patients follows a bimodal incidence: initial post-surgical risk, then a honeymoon phase of variable duration, followed by inexorable increase in thrombotic risk. — Joe summarizing the discussion [Ep 1 · 9:16](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=556)
- Elevated D-dimer is a strong marker of increased thrombotic risk in adults with unprovoked venous thromboembolism. — Joe summarizing the discussion [Ep 1 · 10:08](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=608)
- Factor VIII activity increases significantly post-Fontan, and in one study the four patients with the highest factor VIII levels were the ones who developed thrombotic complications. — Joe summarizing the discussion [Ep 1 · 10:49](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=649)
- In Fontan patients, natural anticoagulants (antithrombin, protein C) are often lower, consistent with liver synthetic dysfunction developing over time. — Joe summarizing the discussion [Ep 1 · 11:10](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=670)
- Despite lower procoagulants from liver dysfunction, Fontan patients have elevated prothrombin fragment 1.2, indicating they are at thrombotic risk rather than bleeding risk. — Joe summarizing the discussion [Ep 1 · 11:46](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=706)
- In the United States, approximately 5 million central venous catheter lines are placed annually, with several thousand in pediatric surgical patients. — Rod Gerardo summarizing the discussion [Ep 2 · 0:13](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=13)
- Central venous catheters are non-tunneled, typically for temporary hospital use, and can have 1 to 3 lumens. — Rod Gerardo summarizing the discussion [Ep 2 · 1:00](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=60)
- Ports are for long-term access (months to years), have tunneled catheters with totally implantable reservoirs, are often used for chemotherapy, and can have 1 or 2 lumens. — The host summarizing the discussion [Ep 2 · 1:10](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=70)
- Broviac catheters are tunneled lines with cuffs, used for months to years for chemotherapy, parenteral nutrition, or frequent blood transfusions, and can have 1 or 2 lumens. — Rod Gerardo summarizing the discussion [Ep 2 · 1:25](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=85)
- Hemodialysis or pheresis catheters can be temporary (uncuffed) or permanent (cuffed), and can have 1 to 3 lumens. — The host summarizing the discussion [Ep 2 · 1:40](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=100)
- There is evidence suggesting an increased rate of complications and infection with femoral access compared to chest and neck access. — The host summarizing the discussion [Ep 2 · 2:17](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=137)
- For very small neonates, many surgeons prefer a cut-down approach over percutaneous access. — Rod Gerardo summarizing the discussion [Ep 2 · 4:43](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=283)
- Subclavian line placement should be considered when both IJ access sites are lost or the patient is in a cervical collar. — The host summarizing the discussion [Ep 2 · 6:42](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=402)
- The catheter tip should typically be positioned at the junction between the right atrium and superior vena cava. — The host summarizing the discussion [Ep 2 · 7:46](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=466)
- Long-term complications include thrombosis, catheter displacement, kinking, and eventual line degradation over extended periods. — Rod Gerardo summarizing the discussion [Ep 2 · 9:21](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-cons-5870?t=561)
- The Surfacer requires an open femoral vein, preferably on the right side, to be effective. — Jill Knepprath summarizes what Dr. Nathan Fagan said [Ep 4 · 0:36](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=36)
- The Surfacer technique is suitable for acute pediatric cases as opposed to the chronic scarring seen in adult cases. — Jill Knepprath summarizes what Dr. Nathan Fagan said [Ep 4 · 1:25](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=85)
- Transhepatic and translumbar access are last resorts when all traditional central access is lost. — Jill Knepprath summarizes what Dr. Nathan Fagan said [Ep 4 · 2:33](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=153)
- Transhepatic access involves a catheter being directly placed through the liver into the inferior vena cava. — Jill Knepprath summarizes what Dr. Nathan Fagan said [Ep 4 · 2:52](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=172)
- Transhepatic access is a more complicated procedure and has higher risk for thrombosis. — Jill Knepprath summarizes what Dr. Nathan Fagan said [Ep 4 · 2:59](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=179)
- Translumbar access involves accessing the inferior vena cava from the back. — Jill Knepprath summarizes what Dr. Nathan Fagan said [Ep 4 · 3:13](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-new-technologies-for-central-line-management-13558?t=193)
- The atrial-caval junction is located deeper on chest radiograph than many surgeons estimate, often at a level that appears to be within the superior atrium. — Mark Wulkan summarizing a resource [Ep 3 · 9:13](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=553)
- A 2013 JACS study by Dutta, St. Peter and others showed that ultrasound-guided IJ access achieved first-pass success in 65% of cases versus 45% with landmark technique, and 95% success by three attempts versus 74% with landmark technique. — Mark Wulkan summarizing a resource [Ep 3 · 10:25](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=625)
- In adult literature, the number of needle passes is a validated proxy marker for complication risk in central line placement. — Mark Wulkan summarizing a resource [Ep 3 · 11:25](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=685)
- Antibiotic-coated and heparin-coated temporary central venous catheters have been shown to decrease catheter-related bloodstream infection rates. — Mark Wulkan summarizing a resource [Ep 3 · 27:41](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1661)
- The ASBS Outcomes Committee meta-analysis in 2011 found Class A or B evidence that chlorhexidine-alcohol skin preparation decreases catheter-related bloodstream infections compared to betadine-based preparations. — Mark Wulkan summarizing a resource [Ep 3 · 31:17](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-6112?t=1877)

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