Reply: Blocked drain switch-hepatic venous outflow obstruction.

BackgroundThe current research focused on studying the pattern of catheter-related bloodstream infections (CRBSI) with femoral central access versus internal jugular access in patients admitted to the medical intensive care unit (ICU).MethodsA cross-sectional study was conducted at the Department of Emergency Medicine, Shifa International Hospital, between March 4, 2022, and August 4, 2022. All individuals who presented to the ICU who needed a central venous catheter (CVC) for more than 48 hours were included. Catheter insertion was not permitted if the patient had a history of dermatitis or burns at the site of insertion or if the hemodialysis procedure necessitated the insertion of the catheter into a blood vessel. Three groups of patients were created: group A patients had been diagnosed with CRBSI; group B patients had catheter colonization (CC); and group C did not have CRBSI or CC. Standard microbiological methods were used to identify all of the bacteria collected from the cultures. All data was documented in a predefined pro forma.ResultsOverall, 20 (12.12%) patients had positive CRBSI, 68 (41.5%) had CC, and the remaining 46.3% of cultures were negative. Elderly populations were more prone to acquiring CRBSI showing a significant correlation between older age and CRBSI (p < 0.0001). CC was significantly associated with a longer duration of ICU stay, i.e., 30.3 ± 3.7 (p = 0.003). The absence of both CRBSI and CC was significantly associated with a lower duration of catheterization (11 ± 8.5 days in group C versus 22.1 ± 6.9 and 18.7 ± 7 days in groups A and B, respectively; p < 0.0001). Our study revealed a higher risk of CRBSI when the femoral access was compared to the internal jugular access (58.3% vs. 41.7%; p = 0.0008). The study did not find any significant association of CC with femoral or internal jugular access. Furthermore, a significantly higher rate of negative cultures was reported in patients with internal jugular access as compared to femoral vein access (85.8% vs. 14.2%; p = 0.007).ConclusionThe need for routinely monitoring and observing the microbiological spectrum in patients receiving care in intensive care units is highlighted by the current investigation. The patients with internal jugular vein access had a decreased incidence of CRBSI and CC, while those with femoral access experienced CRBSI more frequently. Escherichia coli and Pseudomonas aeruginosa were the most frequently isolated germs, and both were resistant to various drugs that are used today. It is essential to regularly monitor the epidemiology of CRBSI in order to adopt preventative measures for infection prevention and control, such as staff education, strict hygiene standards, and a higher nurse-to-patient ratio.

BackgroundIn children in the ICU, catheter-related bloodstream infections (CRBSI) have also been linked to mortality, morbidity, and healthcare costs. Although CRBSI poses many potential risks, including the need to avoid femoral access, there is debate regarding whether jugular access is preferable to femoral access in adults. Study reports support both perspectives. There is no consensus in meta-analyses. Children have yet to be examined in depth. Based on compliance with the central line bundle check lists, we aim to determine CRBSI risk in pediatric intensive care units for patients with non-tunneled femoral and internal jugular venous access.MethodsA retrospective cohort study was conducted on patients with central venous catheters in the pediatric ICU of King Abdulaziz University Hospital between January 1st, 2017 and January 30th, 2018. For the post-match balance, we use a standardized mean difference of less than 0.1 after inverse probability treatment weighting for all baseline covariates, and then we draw causal conclusions. As a final step, the Rosenbaum sensitivity test was applied to see if any bias influenced the results.ResultsWe recorded 145 central lines and 1463 central line days with 49 femoral accesses (33.79%) and 96 internal jugular accesses (66.21%). CRBSI per 1000 central line days are 4.10, along with standardized infections of 3.16. CRBSI risk differed between non-tunneled femoral vein access and internal jugular vein access by 0.074 (− 0.021, 0.167), P-value 0.06, and relative risk was 4.67 (0.87–25.05). Using our model, the actual probability was 4.14% (0.01–0.074) and the counterfactual probability was 2.79% (− 0.006, 0.062). An unobserved confounding factor was not identified in the sensitivity analysis.ConclusionsSo long as the central line bundle is maintained, a femoral line does not increase the risk of CRBSI. Causation can be determined through propensity score weighting, as this is a trustworthy method of estimating causality. There is no better way to gain further insight in this regard than through the use of randomized, double-blinded, multicenter studies.

Central venous catheterization is a routine procedure in intensive care, and internal jugular access (IJA) is often used due to its high success rates. However, complications can happen in up to 4.2% of internal jugular punctures and it is contraindicated in the presence of coagulopathy. The external jugular access (EJA) is underused, has low complications rates and is successful in up to 90% of cases. So far, there has been no randomized, controlled trial comparing both accesses. The objective of this study was to determine the success and early complication rates of internal and external jugular vein access [1].

Non-invasive imaging advocates may have foretold the demise of invasive right heart catheterization (RHC), but it retains a clear role in the diagnosis and management of disorders such as pulmonary arterial hypertension, intracardiac shunts and chronic thromboembolic disease. Indeed as more drugs and interventional therapies targeting these diseases reach the market, we predict a resurgence of RHC. This is supported by current guidelines, which mandate RHC for confirmation of diagnosis and vasoreactivity testing in all patients with pulmonary hypertension prior to initiation of therapy[1]. In this issue of the journal, Shah et al. present their single center experience comparing RHC performed via antecubital vein with proximal (i.e. internal jugular, femoral or subclavian) vein access[2]. In this retrospective analysis of 272 diagnostic RHC procedures performed over a 5-year period, the authors documented a swift uptake of antecubital vein access amongst operators, with comparable success rates (91% vs. 96% for antecubital and proximal venous access respectively) and low crossover from antecubital to proximal venous access. After 5 years, 85% of all cases were performed from the arm. This high take up almost certainly reflects an institutional propensity towards trans-radial access, but interestingly there was no evidence of a learning curve with similar success rates in the first and last quartiles. There was a significant reduction in fluoroscopy time compared with proximal vein access. This may reflect the relative ease of navigating through the cardiac chambers when approached from above compared with from below via femoral access, although a breakdown by choice of proximal venous access route was not included. Though lagging behind Europe, adoption of trans-radial access for left heart catheterization (LHC) has risen steadily in the US[3]. While debate continues regarding relative bleeding and mortality benefits compared with trans-femoral access, advantages such as early patient mobilization post-procedure, facilitation of same-day discharge and uninterrupted anticoagulation are clear. These same advantages apply to RHC performed from the arm. Certainly from a logistical perspective, if the operator selects trans-radial access for LHC then it makes little sense to perform simultaneous RHC from the groin. Freeing up the groin also enables lower limb exercise hemodynamic assessment in the cath lab, which may unmask findings not apparent at rest[4]. RHC from the arm is a simple technique and is achievable through most forearm or antecubital veins. Indeed the first cardiac catheterization was performed from the arm in 1929. Veins on the medial (ulnar) side of the forearm are preferred because the route to the heart is more direct through the basilic, axillary and subclavian veins. Access via veins on the lateral (radial) side of the forearm can be more challenging because the cephalic vein typically enters the axillary vein at a sharp angle which can be difficult to navigate. Initial access can be obtained using aseptic technique outside the catheterization laboratory using a tourniquet on the upper arm and a standard peripheral IV cannula. The cannula should be covered with a dressing to maintain sterility. In the lab the field is cleaned again, local anesthesia is given and the cannula exchanged over a 0.018” guidewire for a larger (preferably hydrophilic-coated radial) sheath. Antispasmodics are not usually needed, but if so then nitroglycerine is the agent of choice. In most cases, balloon-tipped catheters can be advanced even without a guidewire. The balloon is inflated once the catheter enters the subclavian vein. It is important not to push if resistance is felt. The most common challenge is venous occlusion from previous trauma or prior instrumentation, which may not be apparent on physical examination because of the rich collateral circulation. A careful history can be a more useful indicator that the contralateral side or alternative access may be preferred. An optional venogram helps to determine the optimal path and a hydrophilic guidewire can be used to navigate tortuosity in case of difficulty advancing the catheter. Once the subclavian vein is reached then RHC is performed using the same maneuvers as for direct subclavian or internal jugular access. After the procedure, hemostasis is achieved with brief manual compression. No adjunctive closure or compression device is needed. The present study by Shah et al. demonstrates that returning to first principles with RHC performed from the arm is practicable in the modern catheterization laboratory and may encourage trans-radial enthusiasts to forgo the groin altogether!

Effect of access site choice on inferior vena cava filter angulation and outcomes

BACKGROUNDAtrial fibrillation (AF) is the most common cardiac arrhythmia worldwide, hosting numerous serious possible complications such as stroke and heart failure. In the past two decades, managing rhythm control was more successful via pulmonary vein isolation (PVI) ablation, generally performed via transfemoral access. Patients with anatomical variations may necessitate a dose of creativity and evidence-based techniques. To our knowledge, we present the first PVI case in a patient with AF via right internal jugular (IJ) vein access using pulse field ablation.CASE SUMMARYA 76-year-old male with an extensive medical history notable for type 2 diabetes and severe peripheral vascular disease requiring vascular bypass surgery is identified to have paroxysmal AF. Given functional decline and worsening arrhythmia burden refractory to oral antiarrhythmics, an initial PVI ablation was attempted but failed as the catheter could not be advanced secondary to bilateral iliac vein occlusions. This necessitated a novel approach and a subsequent PVI ablation via the right IJ vein was successful without any complications. The success of this case highlights the feasibility of an IJ approach for PVI in patients where traditional access is not possible. This case can be used as a reference for other practitioners who may face similar challenges when attempting to perform PVI for AF or similar procedures requiring access to similar anatomical locations.CONCLUSIONThe success of this case highlights the feasibility of an IJ approach for PVI when traditional access is impossible.

CONTEXTO: Hemocultura positiva associada a cateter venoso central tem sido estudada em unidades de terapia intensiva (UTI), mas ainda é controverso se o acesso jugular tem maior incidência de complicações infecciosas que o acesso na veia subclávia. OBJETIVO: Comparar índice de infecção entre os acessos na jugular interna e os na veia subclávia em pacientes internados nas enfermarias de cirurgia. MÉTODOS: Estudo prospectivo, descritivo e comparativo com 114 cateteres em 96 pacientes admitidos nas enfermarias de cirurgia de um Hospital Quaternário, tendo como variáveis o local de inserção, número de lumens, tempo de uso, comparando-os com o índice de complicações infecciosas. RESULTADOS: O índice de infecção foi de 9,64% (11 cateteres), sem significância estatística quando comparados o número de lumens (mono versus duplo) e infecção (p=0,274); também sem significância estatística a comparação entre o tempo de uso (&gt;14 dias) e infecção (p=0,156). Comparando os acessos jugular e subclávia, encontramos significância estatística tendo infecção em 17,2% na subclávia e 1,8% na jugular, com p=0,005. Índice de Hemocultura positivo associado a cateter venoso central foi maior no acesso subclávia quando comparado com jugular interna, com OR 11,2, IC95% (1,4-90,9; p=0,023). CONCLUSÕES: O acesso venoso central na jugular interna tem menor risco de infecção se comparado com subclávia em enfermarias.

Pediatric Extracorporeal Cardiopulmonary Resuscitation ELSO Guidelines.

No. 527 High incidence of large-bore temporary hemodialysis catheter thrombosis in patient with COVID-19–related kidney injury

To evaluate the incidence of large bore hemodialysis catheter malfunction in the setting of COVID-19. A retrospective review was performed of all patients who underwent placement of a temporary hemodialysis catheter after developing kidney injury after COVID-19 infection at our institution. Data collected included demographic information, procedure related information, and incidence of replacement due to lumen thrombosis. Groups were compared using students t-test for continuous variables and Fisher's exact test for nominal variables. Sixty-four patients (43M, mean age 63.2 ± 13.3) underwent placement of temporary hemodialysis catheter placement for kidney injury related to COVID 19 infection. Thirty-one (48.4%) of catheters were placed via an internal jugular vein (IJV) access and 33 (52.6%) of catheters were placed via a common femoral vein (CFV) access. Overall, 15 (23.4%) catheters required replacement due to catheter dysfunction. There were no differences in demographics in patients who required replacement to those who did not (p > 0.05). Of the replacements, 5/31 (16%) were placed via an IJV access and 10/33 (30.3%) were placed via a CFV access (p = 0.18). The average time to malfunction/replacement was 7.8 ± 4.8 days for catheters placed via an IJ access versus 3.4 ± 3.3 days for catheters placed via a CFV access (p = 0.055). A high incidence of temporary dialysis catheter lumen dysfunction was present in patients with COVID-19 infection. Catheters placed via a femoral vein access had more frequent dysfunction with shorter indwelling time.

Successful transseptal puncture and cryoballoon ablation of symptomatic paroxysmal atrial fibrillation via jugular access in a patient with bilateral thrombotic femoral vein occlusion

Totally implantable venous access devices are used extensively worldwide in cancer patients for administration of venotoxic agents, blood sampling, and nutrition. Their tip is usually positioned at the junction of superior vena cava and right atrium. Inferior vena cava filters are usually used for deep venous thrombosis in cases where anticoagulation is contraindicated; they can be inserted either via internal jugular or femoral access depending on patient conditions and preference. We are describing here a case of totally implantable venous access device fracture following a right internal jugular approach for inferior vena cava filter placement as the patient had inferior vena cava thrombus below the renal veins, extending into the right common iliac vein prohibiting femoral approach. Iatrogenic fracture of totally implantable venous access device is a potential complication of accessing the internal jugular vein for other procedures such as insertion of inferior vena cava filter.

The femoral and internal jugular veins are the most commonly used access routes for TTVPM placement. Femoral access is associated with higher rates of infection and bleeding due to groin proximity, whereas jugular access may increase the risk of vascular injury or pneumothorax when performed without imaging guidance. Despite numerous observational studies comparing these access sites, the evidence remains inconclusive due to heterogeneous methodologies, small sample sizes, and varying definitions of complications. To address these limitations, we conducted a meta-analysis to compare the relative safety and effectiveness of jugular versus femoral access for TTVPM placement. A comprehensive search of PubMed, Embase, and Cochrane was performed from June 28, 2025, without language restrictions. Eligible studies included adult patients (≥18 years) undergoing TTVPM placement and directly comparing femoral and jugular venous access. Trials were considered if they reported at least one of the following outcomes: bleeding, infection, lead repositioning, cardiac perforation, or other major procedural complications. Six observational studies published between 2013 and 2024 met the inclusion criteria and encompassed 2,267 patients from diverse clinical settings. Bleeding complications were reported in five studies (n = 1,457), showing no statistically significant difference between access sites (RR 0.54; 95% CI 0.18-1.60; p = 0.27). Four studies (n = 528) reported catheter-related infections, demonstrating a significantly lower risk with jugular access (RR 0.25; 95% CI 0.11-0.53; p = 0.0003). Lead repositioning (RR 0.73; p = 0.46) and cardiac perforation (RR 0.50; p = 0.33) showed no significant differences. Jugular venous access for TTVPM placement is associated with a significantly lower risk of catheter-related infections compared with femoral access, while rates of bleeding, lead repositioning, and cardiac perforation do not significantly differ between approaches. Jugular access may be preferred for patients expected to require prolonged pacing or those at high infection risk, whereas femoral access remains reasonable for short-term or emergent indications.

Comparison of global end-diastolic volume index (GEDVI) obtained by femoral and jugular transpulmonary thermodilution (TPTD) indicator injections using the EV1000/VolumnView(®) device (Edwards Lifesciences, Irvine, USA). In an 87-year-old woman with hypovolemic shock and equipped with both jugular and femoral vein access and monitored with the EV1000/VolumeView(®) device, we recorded 10 datasets, each comprising duplicate TPTD via femoral access and duplicate TPTD (20 ml cold saline) via jugular access. Mean femoral GEDVI ((674.6±52.3) ml/m(2)) was significantly higher than jugular GEDVI ((552.3±69.7) ml/m(2)), with P=0.003. Bland-Altman analysis demonstrated a bias of (+122±61) ml/m(2), limits of agreement of -16 and +260 ml/m(2), and a percentage error of 22%. Use of the correction-formula recently suggested for the PiCCO(®) device significantly reduced bias and percentage error. Similarly, mean values of parameters derived from GEDVI such as pulmonary vascular permeability index (PVPI; 1.244±0.101 vs. 1.522±0.139; P<0.001) and global ejection fraction (GEF; (24.7±1.6)% vs. (28.1±1.8)%; P<0.001) were significantly different in the case of femoral compared to jugular indicator injection. Furthermore, the mean cardiac index derived from femoral indicator injection ((4.50±0.36) L/(min·m²)) was significantly higher (P=0.02) than that derived from jugular indicator injection ((4.12±0.44) L/(min·m²)), resulting in a bias of (+0.38±0.37) L/(min·m²) and a percentage error of 19.4%. Femoral access for indicator injection results in markedly altered values provided by the EV1000/VolumeView(®), particularly for GEDVI, PVPI, and GEF.

To compare the accuracy of inferior vena cava (IVC) filter placement using a bedside technique guided by intravascular ultrasound (IVUS) with a concurrent experience of filter deployment with fluoroscopic venogram imaging. From November 2006 to December 2009, 195 consecutive IVC filters were placed to prevent pulmonary embolism in 120 high-risk patients without lower limb deep vein thrombosis (DVT) and 75 patients with DVT and anticoagulation contraindications. Filter insertion techniques included bedside IVUS-guided (n = 97) and fluoroscopic-guided (n = 98) procedures. Before mid-2008, 2 bedside IVUS-guided protocols were used evolving from a single-puncture, pullback technique (n = 48), in which the measured distance from the venous access site to the IVC landing zone then allowed a calibrated reinsertion of a 7F delivery sheath and filter deployment. After mid-2008, a single puncture 8F sheath technique (n = 48) using IVUS to position the delivery sheath tip within the IVC landing zone without catheter or sheath measurement or reinsertion was used. Venous access was via the right femoral (84 IVUS and 56 fluoroscopy), left femoral (10 IVUS and 16 fluoroscopy), or right internal jugular vein (3 IVUS and 26 fluoroscopy). The 3 filter insertion techniques were compared for "optimal" IVC placement defined as the filter positioning between L1 and L4 vertebrae with tilt <15° based on postprocedure abdominal x-rays or venography. Filter malposition occurred with 6% (6 of 97) bedside IVUS-guided procedures with no malpositions during fluoroscopic imaging. Malposition was lower with the evolved sheath (4%, 2 of 48) compared with the earlier pullback (8%, 4 of 48) insertion technique (P = .03). The incidence of the filter malposition during IVUS-guided deployment was highest using left femoral access (4 of 10) compared with right femoral (2 of 84) or internal jugular (0 of 3) vein access (P < .01). Filter tilt occurred more after IVUS-guided procedure (10 of 97) than fluoroscopic procedure (3 of 98; P = .05) and was most frequent for left femoral access (5 of 10 IVUS and 1 of 16 fluoroscopy; P < .01) and was not related to filter type (P = .13). Our current bedside IVUS-guided IVC filter technique using a single venous puncture and single sheath positioning has improved the placement accuracy. Left femoral venous access should be avoided to minimize the occurrence of filter malpositioning and tilt.