“The anesthesia team provided the alternative with a longer peripherally inserted central catheter (PICC) to be optimally directed till the cavo-atrial junction through the small, middle hepatic vein of the child. The size of the middle hepatic vein was determined with ultrasound by the radiologists. Accordingly, a 32-cm long, 20 G PICC line with a 4-cm 18G introducer needle (B. Braun, Melsungen, Germany) was chosen. The middle hepatic vein was punctured under ultrasound guidance and the catheter was threaded over its in-built guidewire through the inferior vena cava and right heart chambers upwards till it reached the superior vena cavo-atrial junction (as described in literature) as confirmed by fluoroscopy.”

Nath S, Naranje P, Kandasamy D, Singh AK. Fluoroscopy-guided transhepatic vena cava cannulation with a peripherally inserted central venous catheter in a pediatric patient with difficult central venous access. J Anaesthesiol Clin Pharmacol. 2023 Apr-Jun;39(2):322-323. doi: 10.4103/joacp.joacp_329_21. Epub 2022 Feb 21. PMID: 37564854; PMCID: PMC10410021.