The vessels with their surrounding tissues appear

larger than expected. When elevated, there will be no

caudal bulge, distinguishing them from the urachus. If

a previously attempted catheter was left “in place,” palpation of the area allows more ready identification of

the vessel. Previously unsuccessful attempts, with failure to pass more than a few centimeters, are usually

associated with perivascular hematoma formation from

unrecognized perforation and dissection through a false

tract. Visualization of a hematoma helps distinguish the

vessel from the urachus.

12. Try to avoid entering the peritoneum. In infants with

very little subcutaneous tissue, it may be impossible to

avoid penetrating the peritoneum. Should this occur,

replace any bowel that may protrude and carefully

close the peritoneum with absorbable suture, taking

extreme care not to include any bowel within the

suture. Start antibiotics for peritonitis prophylaxis.

13. Insert the tip of the mosquito forceps under the vessel

and pull a doubled strand of plain absorbable suture

under the vessel. Position sutures 1 cm apart.

14. While elevating the sutures and with suture scissors

directed cephalad, make a V-shaped incision through

three fourths of the diameter of the vessel. Take care not

to transect the vessel, but cut cleanly into the lumen.

If the artery is accidentally transected and if the

catheter insertion is unsuccessful, tie off the caudal end

of the artery to prevent hemorrhage.

15. Use curved tissue forceps or a catheter introducer to

dilate the artery.

16. Pass the catheter through the opening for the predetermined distance, checking for blood return after a few

centimeters. The catheter should advance without

resistance.

17. When the catheter is properly positioned, have an assistant check the perfusion in the lower extremities. If that

is satisfactory, secure the catheter by tying the lower

ligature firmly around the catheter.

18. Using absorbable suture, close the fascia and approximate the subcutaneous tissues.

Hashimoto et al. (29) proposed an alternative technique that allows for catheter reinsertion in case of

catheter thrombosis or occlusion. They use loose ligation around the artery once the catheter is in proper

position. They then fix the artery by using the same

sutures that close the fascia, thus creating an arteriocutaneous fistula, making it easy to find the insertion site

and use it for reinsertion.

19. Close the skin with nonabsorbable suture or with skinclosure tape after cleaning the area.

20. The catheter may be further secured with a tape bridge

(Fig. 38.14).