Anterior Puncture Research Articles

Prevention and treatment of pericardial tamponade in the electrophysiology laboratory: a European Heart Rhythm Association survey.

Pericardial tamponade (PT) is the most frequent severe complication during electrophysiology (EP) procedures and requires immediate, co-ordinated, and effective treatment. However, multiple aspects of PT treatment are either not standardized or are under ongoing debate. An online questionnaire consisting of 26 multiple-choice questions was sent out to the European Heart Rhythm (EHRA) Research Network and also distributed via social media outputs. The EHRA survey was conducted between May and June 2023. A total of 213 replies were received from European (87%) and non-European countries. Ninety per cent of all participants perform interventions in dedicated EP labs equipped with different ablation platforms. In case of PT, most participants use X-ray as the main imaging modality guiding pericardial puncture, predominantly aiming for an anterior puncture site. Sheaths of different sizes are introduced into the pericardial space (84.3%), followed by a pigtail catheter. Application of protamine is an established but variable step in the majority (84.6%). Novel oral anticoagulants (NOAC) antidotes are not used by 73.3% of participants, while 15.2% routinely apply them. Re-transfusion of aspirated blood is performed by 72.1% [before protamine administration (18.2%), after protamine administration (13.5%), if pericardial effusion cannot be controlled (40.4%)]. A total of 72.4% re-transfuse without blood filter systems. A decision for surgical intervention is mostly taken if bleeding continues despite all interventional measures. The current survey demonstrates that the management of PT is heterogeneous among centres. The findings of this survey may help to guide operators in their treatment and decisions in the setting of PT.

Pain behavior and phenotype in a modified anterior lumbar disc puncture mouse model.

An experimental study was performed to improve the anterior approach model of intervertebral disc degeneration (IVDD). The aims of this study were to investigate the anterior approach model of IVDD for the cause of death, phenotypes, and underlying mechanisms of low back pain in mice. In this study, we conducted an anterior puncture procedure on a cohort of 300 C57BL/6J mice that were 8 weeks old. Our investigation focused on exploring the causes of death in the study population (n = 300) and assessing the time-course changes in various parameters, including radiographical, histological, immunofluorescence, and immunohistochemistry analyses (n = 10). Additionally, we conducted behavioral assessments on a subset of the animals (n = 30). Transverse vertebral artery rupture is a major factor in surgical death. Radiographical analyses showed that the hydration of the nucleus pulposus began to decrease at 2 weeks after puncture and obviously disappeared over 4 weeks. 3D-CT showed that disc height was significantly decreased at 4 weeks. Osteophyte at the anterior vertebral rims was observed at 2 weeks after the puncture. As the time course increased, histological analyses showed progressive disruption of the destruction of the extracellular matrix and increased secretion of inflammatory cytokines and apoptosis. Behavioral signs of low back pain were increased between the puncture and sham groups at 4 weeks. The improvement of anterior intervertebral disc approach model in mice will be useful to investigate underlying mechanisms and potential therapeutic strategies for behavior and phenotypes. Furthermore, the application of vibrational pre-treatment can be used to increase the sensitivity of axial back pain in the model, thereby providing researchers with a reliable method for measuring this critical phenotype.

Acetylshikonin promoting PI3K/Akt pathway and inhibiting SOX4 expression to delay intervertebral disc degeneration and low back pain.

This study investigated the molecular mechanism by which acetylshikonin inhibits SOX4 expression via the PI3K/Akt pathway to delay intervertebral disc degeneration (IVDD) and low back pain (LBP).Bulk RNA-seq, RT-qPCR, Western blot analysis, immunohistochemical staining, small interfering RNA (siSOX4), lentivirus (lentiv-SOX4hi ), and imaging techniques were used to assess SOX4 expression and validate its upstream regulatory pathway. Acetylshikonin and siSOX4 were injected into the IVD to measure IVDD.SOX4 expression significantly increased in degenerated IVD tissues. TNF-α increased SOX4 expression and apoptosis-related proteins in nucleus pulposus cells (NPCs). siSOX4 reduced TNF-α-induced NPCs apoptosis, while Lentiv-SOX4hi increased it. The PI3K/Akt pathway was significantly correlated with SOX4, and acetylshikonin upregulated PI3K/Akt pathway while inhibiting SOX4 expression. In the anterior puncture IVDD mouse model, SOX4 expression was upregulated, and acetylshikonin and siSOX4 delayed IVDD-induced LBP.Acetylshikonin delays IVDD-induced LBP by inhibiting SOX4 expression through the PI3K/Akt pathway. These findings offer potential therapeutic targets for future treatments.

Endoscopically-Assisted Percutaneous Trigeminal Rhizotomy for Trigeminal Neuralgia: A Cadaveric Feasibility Study.

Objective Trigeminal neuralgia (TN) is a debilitating syndrome characterized by paroxysmal facial pain in one or more divisions of the trigeminal nerve. The etiology and treatment paradigms are still controversial. The endoscopically-assisted procedure has not yet been described in percutaneous procedures for TN. The aim of this study was to assess the utility and feasibility of endoscopic-assisted percutaneous approaches for trigeminal rhizotomy in TN. Methods This study comprised eight cadaveric sides heads that underwent an endoscopically assisted percutaneous approach using Hakanson's anterior puncture method for targeting the foramen ovale. Results V3 exiting the foramen ovale was easily visualized with the endoscope on all sides. While approaching the foramen ovale, distal branches of V3 such as the lingual and inferior alveolar nerves were first identified as they traveled between the medial and lateral pterygoid muscles. These branches were then traced proximally to the V3 trunk deep to the lateral pterygoid. Large arteries and veins were easily visualized and avoided in the trajectory to the foramen ovale. No gross injury to any neurovascular structure along the course of the needle insertion was identified. Conclusion We found that endoscopic-assisted percutaneous approach to the foramen ovale is feasible and allows for accurate canalization and anatomical identification of the precise location for rhizotomy under direct visualization. Such a procedure, after it is confirmed in patients, could offer a new technique for reducing unsuccessful canalization and could improve outcomes.

Cytomegalovirus Immune Recovery Retinitis with Similarity to Acute Retinal Necrosis

Purpose: To describe successful treatment of cytomegalovirus immune recovery retinitis, with similarity to acute retinal necrosis, in patients with acquired immunodeficiency syndrome (AIDS) in the immune recovery stage.Case summary: A 37-year-old man, diagnosed with AIDS 5 years prior, visited our clinic with a chief complaint of visual disturbance in his right eye for 1 week. Slit lamp examination revealed severe inflammation; a light gray retinal lesion with a clear border was present in the inferotemporal area of the peripheral retina. Antiviral (ganciclovir) and oral steroid treatments were initiated. Blood test results indicated that the CD4+ T-cell count was 222/μL. Polymerase chain reaction analysis of anterior puncture findings showed a positive result for cytomegalovirus. Clinical findings were suggestive of acute retinal necrosis, but the patient's condition and examination were also suggestive of cytomegalovirus retinitis in the immune recovery stage. One month after treatment, retinal detachment was observed; surgery was performed. There was no recurrence for 3 years after the second operation and the patient remained in stable condition.Conclusions: In the immune recovery stage, non-specific cytomegalovirus retinitis accompanied by inflammation may exhibit fundus findings similar to acute retinal necrosis. We report a rare case of cytomegalovirus immune recovery retinitis where normal vision was restored via systemic drug treatment and surgery.

Heterogeneous macrophages contribute to the pathology of disc herniation induced radiculopathy

Macrophages play important roles in the progression of intervertebral disc herniation and radiculopathy. To better understand the roles of macrophages in this process, we developed a new mouse model that mimics human radiculopathy. A preclinical randomized animal study. Three types of surgeries were performed in randomly assigned Balb/c mice. These were spinal nerve exposure, traditional anterior disc puncture, and lateral disc puncture with nerve exposure (n=16/group). For the nerve exposure group, the left L5 spinal nerve was exposed without disc injury. For the traditional anterior puncture, L5/6 disc was punctured by an anterior approach as previously established. For lateral puncture with nerve exposure, the left L5 spinal nerve was exposed by removing the psoas major muscle fibers, and the L5/6 disc was punctured laterally on the left side with a 30G needle, allowing the nucleus to protrude toward the L5 spinal nerve. Mechanical hyperalgesia (pain sensitivity) of hind paws was assessed with electronic von Frey assay on alternative day for up to 2 weeks. MRI, histology, and immunostaining were performed to confirm disc herniation and inflammation. Ipsilateral pain in the lateral puncture with nerve exposure group was significantly greater than the other groups. Pro-inflammatory cytokines IL-1β and IL-6 were markedly elevated at the hernia sites of both puncture groups and the spinal nerve of lateral puncture with never exposure group on postoperative day 7. Heterogeneous populations of macrophages were detected in the infiltration tissue of this mouse model and in tissue from patients undergone discectomy. We have established a new mouse model that mimics human radiculopathy and demonstrated that a mixed phenotype of macrophages contribute to the pathogenesis of acute discogenic radiculopathy. This study provides a clinically relevant in vivo animal model to elucidate complex interactions of disc herniation and radicular pain, which may present opportunities for the development of macrophage-anchored therapeutics to manage radiculopathy.

RNase reverses segment sequence in the anterior of a beetle egg (Callosobruchus maculatus, Coleoptera).

The genetic regulation of anterior-posterior segment pattern development has been elucidated in detail for Drosophila, but it is not canonical for insects. A surprising diversity of regulatory mechanisms is being uncovered not only between insect orders, but also within the order of the Diptera. The question is whether the same diversity of regulatory mechanisms exists within other insect orders. I show that anterior puncture of the egg of the pea beetle Callosobruchus maculatus submerged in RNase can induce double abdomen development suggesting a role for maternal mRNA. In a double abdomen, anterior segments are replaced by posterior segments oriented in mirror image symmetry to the original posterior segments. This effect is specific for RNase activity, for treatment of the anterior egg pole and for cytoplasmic RNA. Yield depends on developmental stage, enzyme concentration, and temperature. A maximum of 30% of treated eggs reversed segment sequence after submersion and puncture in 10μg/mL RNase S reconstituted from S-protein and S-peptide at 30°C. This result sets the stage for an analysis of the genetic regulation of segment pattern formation in the long germ embryo of the coleopteran Callosobruchus and for comparison with the short germ embryo of the coleopteran Tribolium.

Phrenic nerve block caused by interscalene brachial plexus block: breathing effects of different sites of injection

BackgroundInterscalene brachial plexus (ISB) block is often associated with phrenic nerve block and diaphragmatic paresis. The goal of our study was to test if the anterior or the posterior ultrasound guided approach of the ISB is associated with a lower incidence of phrenic nerve blocks and impaired lung function.MethodsThis was a prospective, randomized and single-blinded study of 84 patients scheduled for elective shoulder surgery who fullfilled the inclusion and exclusion critereria. Patients were randomized in two groups to receive either the anterior (n = 42) or the posterior (n = 42) approach for ISB. Clinical data were recorded. In both groups patients received ISB with a total injection volume of 15 ml of ropivacaine 1 %. Spirometry was conducted at baseline (T0) and 30 min (T30) after accomplishing the block.Changes in spirometrical variables between T0 and T30 were investigated by Wilcoxon signed-rank test for each puncture approach. The temporal difference between the posterior and the anterior puncture approach groups were again analyzed by the Wilcoxon-Mann-Whitney test.ResultsThe spirometric results showed a significant decrease in vital capacity, forced expiratory volume per second, and maximum nasal inspiratory breathing after the Interscalene brachial plexus block; indicating a phrenic nerve block (p <0.001, Wilcoxon signed-rank). A significant difference in the development of the spirometric parameters between the anterior and the posterior group could not be identified (Wilcoxon-Mann-Whitney test). Despite the changes in spirometry, no cases of dyspnea were reported.ConclusionA different site of injection (anterior or posterior) did not show an effect in reducing the cervical block spread of the local anesthetic and the incidence of phrenic nerve blocks during during ultrasound guided Interscalene brachial plexus block. Clinical breathing effects of phrenic nerve blocks are, however, usually well compensated, and subjective dyspnea did not occur in our patients.Trial registrationGerman Clinical Trials Register (DRKS number 00009908, registered 26 January 2016).

Both expression of cytokines and posterior annulus fibrosus rupture are essential for pain behavior changes induced by degenerative intervertebral disc: An experimental study in rats

The aim of this study was to analyze the relationship between intervertebral disc degeneration and low back pain (LBP). Rat L4/5 disc degeneration model was established by annular puncture using a 0.4 mm needle anteriorly or posteriorly. In both anterior and posterior puncture models, magnetic resonance imaging (MRI) and histological analyses revealed marked disc degeneration 2 weeks after puncture. Cytokine expression was up-regulated in different level in nucleus pulposus (NP) from 3 days after puncture. Pain behavioral tests indicated that the anterior disc puncture did not induce pain behavior changes, whereas the posterior disc puncture resulted in mechanical allodynia from 1 day to 21 days after injury. Besides, cytokine expression was significantly increased in dorsal root ganglion (DRG) at 1 and 2 weeks after posterior puncture, but not after the anterior puncture. These findings indicate the NP of the degenerative disc expresses different levels of inflammatory cytokines, and posterior disc puncture produced mechanical allodynia. The expression phase of cytokines in the NP was accordance with mechanical hyperalgesia in the posterior disc puncture model. Both expression of cytokines and posterior annulus fibrosus (AF) rupture in degenerative intervertebral disc are essential for pain behavior changes.

Intervertebral Disk Degeneration is not a Direct Cause of Pain Behavior: An Experimental Study Using a Disk Puncture Model in Rats

Introduction Low back pain (LBP) is a common symptom in patients with lumbar diseases. But the relationship between lumbar intervertebral disk degeneration and LBPis still a controversial issue. Some animal models were used to discuss this issue in prior studies. A recent study1 suggested that the pain behavior changes might be related to the epidural presence of the oozed nucleus pulposus in the posterior rat disk puncture model. In this study, an anterior rat disk puncture model was applied to exclude the epidural presence of nucleus pulposus, and the objectives of this study were to establish an intervertebral disk degeneration model in rats and to analyze the relationship between disk degeneration and pain behavior changes in this model. Materials and Methods Total 18 male Sprague-Dawley rats with an average bodyweight of 230 g were used in this study. The anterior intervertebral disk annular puncture model was established as follows: the L5/6 lumbar disks were punctured using a 0.4-mm-diameter injection needle under microscope in nine rats; another nine rats receiving same surgery were considered as control group. Magnetic resonance imaging (MRI) of the punctured rats' spine was taken to confirm the degeneration of the disk. Behavioral tests including assessment of motor function, mechanical threshold, and thermal withdrawal latency were performed before and after surgery in both groups. The behavior tests were performed on days 1, 3, 7, 14, 21, 30, and 45 after the surgery. Results MRI results showed visible degeneration in rats at about 3 weeks after disk puncture (Fig. 1A). There was no degenerative change in the control group in all time points. Regarding motor function, both groups exhibited normal gait during the entire observation period. No significant statistical difference was found between the two groups in both mechanical threshold and thermal withdrawal latency tests at different time points (Fig. 1B, C). Conclusion The degenerative lumbar intervertebral disk model in rats was successfully established by anterior disk annulus needle puncture. The degeneration of the lumbar disk caused by anterior puncture could not induce pain behavior change in rats. I confirm having declared any potential conflict of interest for all authors listed on this abstract No Disclosure of Interest None declared Elin Nilsson, Toshio Nakamae, Kjell Olmarker. Pain behavior changes following disc puncture relate to nucleus pulposus rather than to the disc injury per se: an experimental study in rats. The Open Orthopaedics Journal 2011;5:72–77.

You get what you inspect, not what you expect: can we make the transseptal puncture safer?

Progress in the field of catheter ablation for atrial fibrillation has resulted in a renaissance of the technique of transseptal (TS) catheterization. Conventionally, the procedure is performed under fluoroscopic guidance and pressure monitoring. In experienced hands, various modifications of this method have a reasonable safety profile. However, serious complications such as cardiac tamponade (1.31%) or aortic perforation can still occur 1 and can lead to death (0.15%). Even in a more recent, large Italian survey on 5520 TS procedures performed between 1992 and 2003 at 33 centres, some severe complications were reported. 2 Although the complication rate was low (0.79% in 2003 and 0.74% in the previous years), one death was described. To reduce the incidence of such complications, TS puncture can be done under transoesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) guidance. 3,4 Transoesophageal echocardiography in these settings necessitates a higher level of sedation and is often poorly tolerated. Intracardiac echocardiography requires an additional expertise and significantly increases the cost of the procedure. Mitchell-Heggs et al. 5 describe an alternative TEE technique to guide the TS puncture during atrial fibrillation ablation procedures using an ICE catheter introduced transnasally into the oesophagus. This technique was well tolerated and successfully performed in all 79 successive patients without any sedation. Insertion of the catheter was without any mechanical complication and TS puncture was successful and uneventful. The mean duration between the probe insertion and successful TS puncture was 4.5 min and the mean time of ICE in the oesophagus was only 10 min. The authors have concluded that the technique is safe and well tolerated. They recommend it for widespread use, especially due to its good value for money. At first sight, this report may not be so appealing for the electrophysiology community. However, it is an important online imaging strategy which can be used during complex interventions to maximize safety and efficacy. The use of echocardiographic guidance for TS puncture allows direct visualization of the tip of the TS needle within the fossa ovalis and thus, a safe TS puncture in every patient. In this respect, there seems to be no difference between the TEE and ICE approach. Our retrospective analysis of 1692 TS punctures guided by ICE between 2006 and 2009 revealed no complications associated with the puncture (unpublished data). This provides indirect evidence that the use of online imaging may increase the safety of the procedure, especially in anatomical variants of the intraatrial septum that make the procedure challenging (e.g. lipomatous hypertrophy, septal aneurysm, thick septum, or double membrane fossa, etc.). The safety of the echocardiographically guided TS puncture supports the use of a double TS access to prevent interference between the mapping and ablation catheters and to achieve greater mobility and manoeuvrability in the left atrium. It is also important to emphasize that the use of echocardiographic guidance enables selection of the site of the puncture within the fossa ovalis according to the expected type of the procedure (e.g. more anterior puncture for ablation of an accessory pathway at the mitral annulus or for ablation of ventricular tachycardia vs. a lower and more posterior puncture for ablation of atrial fibrillation). Although it is difficult to quantify the benefit of such a selective TS puncture, our experience has shown that even ,1 cm difference in the location of the puncture site can make a significant difference in manoeuvrability of the mapping and/or ablation catheter (Figure 1). This seems to be even more important when using ‘one-size-fits-all’ devices such as a cryoballoon or laser balloon. Today, we use an ICE-guided TS puncture even in cases of a patent foramen ovale since it allows us to optimize puncture in the lower and more posterior portion of the fossa ovalis. A group from Bordeaux has clearly documented that isolation of the pulmonary veins performed via a patent foramen ovale is more difficult, both for the left- and right-sided pulmonary veins. 6 Very superior and anterior location of the foramen ovale changes the radial movement of the catheter entering the left atrium and impedes the manipulation around the pulmonary veins. This results in less accurate positioning of the catheter and its greater instability. Although the authors did not

Treatment of Trigeminal Neuralgia with Percutaneous Glycerol Injection into Meckel’s Cavity: Experience in 4012 Patients

Percutaneous glycerol injection into Meckel's cavity is widely used to treat trigeminal neuralgia. Reports published to date summarized clinical experiences in small or intermediately sized groups of patients. The efficacy of this procedure in a large group of patients has not been evaluated so far. From December 1983 to November 2008, patients with primary trigeminal neuralgia were treated in our clinic using percutaneous glycerol injection into Meckel's cavity which was conducted according to the Hakanson's anterior puncture method with some modifications. In total, 4012 patients (2205 female) with a mean age of 56.5 (23-87) years were treated. The majority of patients (99.23%) experienced unilateral pain, while a small cohort of patients (31; 0.77%) had bilateral pain. The immediate success rate of the procedure was 97.1%. There was a significant (P<0.01) positive correlation between the presence of cerebrospinal fluid (CSF) outflow and the curative effect. Follow-up was done in 3157 patients for the period of 1-25years. The long-term success rate was 81.18%. No serious adverse effects were observed. The procedure is very effective and applicable to a wide variety of patients with trigeminal neuralgia. The presence of CSF outflow during puncture predicts better immediate and long-term outcomes.

Anterior Approach for Knee Arthrography: Tolerance Evaluation and Comparison of Two Routes

To prospectively evaluate patient tolerance and technical success of the anterior knee puncture approach for arthrography by using two different routes. The study had Strasbourg University Hospital review board approval. Informed consent was obtained from all patients (and from their parents, if patients were minors). In 159 patients (89 male and 70 female; age range, 14-82 years; mean age, 44.3 years +/- 16 [standard deviation]) referred for computed tomographic (CT) arthrography, anterior puncture of the knee was performed by using an anterolateral (n = 73) or anterior paramedian (n = 86) route. For each patient, body mass index, absolute pain on a visual analog scale, relative pain (compared with anticipatory pain), and history of previous knee arthrography were recorded. A score reflecting the technical success of the procedure was established by using a five-point scale. Factors influencing tolerance and technical success were analyzed with Pearson correlation coefficients. Student t and chi2 tests were used to compare the two routes. The anterior approach for knee arthrography was well tolerated (mean visual analog scale score, 12.9 +/- 16.4) and technically successful (mean technical success score, 1.36 +/- 0.84) in most cases. Absolute pain was not influenced by age, sex, or body mass index and was only weakly correlated (r = 0.33) with the technical success score. The technical success score weakly correlated (r = 0.23) with the body mass index. A slight but significant reduction in absolute (P < .05) and relative (P < .01) pain was observed for the anterolateral route compared with the anterior paramedian route, while no significant differences (P > .05) were found for other parameters, including the technical success score. The anterior approach for knee arthrography is technically successful and well tolerated, particularly when an anterolateral route is used.