Backflow Of Blood Research Articles

Varicosities in Pregnancy

Varicose vein is a dilated swelled leg veins with back flow of blood caused by incompetent valve closure which result in venous congestion and vein enlargement. It usually affects the saphenous vein and its branches. The condition may be worsening with menstrual cycle, with pregnancy and response to exogenous hormonal therapy( oral contraceptives).It deals about the causes of varicosities and how it occurs in pregnancy. Varicosities had different signs and symptoms which occurs during the time of delivery and also had preventive treatment alternative remedies and safe treatment option after pregnancy in varicose vein.

Economic Benefits of Surgical Aortic Valve Replacement on Patients With Symptomatic Aortic Valve Regurgitation.

Aortic regurgitation is distinguished by the backflow of blood from the aorta into the left ventricle. American College of Cardiology/American Heart Association guidelines recommend surgical aortic valve replacement (SAVR) for patients with symptomatic aortic regurgitation (sAR). This study estimates the difference in mortality, health care use, and costs between patients with sAR who receive SAVR within 12 months of diagnosis versus those who do not. We used the Optum United Healthcare database to identify 132 317 patients diagnosed with sAR from 2016 to 2021 who had at least 6 months of enrollment before sAR and 12 months of enrollment after. Criteria were no history of aortic stenosis or transcatheter aortic valve replacement and ≥2 visits for heart failure, angina, dyspnea, or syncope. Outcomes were all-cause mortality, health care use, and annualized cost. Baseline differences in demographics and comorbidities were adjusted with inverse propensity score weighting. We modeled survival and estimated health care use and costs using Cox proportional hazards and general linear models, respectively. Of the 132 317 patients, 400 underwent SAVR within 12 months of diagnosis. They were on average younger, more often men, and with a slightly higher Elixhauser Comorbidity Index score. After inverse propensity score weighting, patients with sAR who had SAVR had lower mortality, fewer inpatient and emergency department visits, fewer hospital days, and lower annualized cost. SAVR performed within 12 months of an sAR diagnosis is associated with improved mortality and lower annualized health care use and costs. These clinical and economic benefits should be considered when managing patients with sAR.

Giant Morgagni hernia and aorto-pulmonary collaterals in a Loeys-Dietz patient undergoing surgery for aortic root aneurysm and mitral valve prolapse.

The case of a Loeys-Dietz syndrome patient undergoing mitral valve repair and composite aortic root and valve replacement is here described: preoperative CT scan unravelled a previously misdiagnosed Morgagni hernia (anterior diaphragmatic), containing omentum only, compressing the right ventricle. Intraoperatively, an abnormal oxygenated blood backflow into the left ventricle was observed, postoperatively found to be caused by major aorto-pulmonary collateral arteries. This is the 1st case of Morgagni hernia and systemic-pulmonary shunt ever reported associated with Loeys-Dietz syndrome. These congenital features may be important in both phenotyping and surgical management.

Quantitative evaluation of lower limb varicose veins using photoacoustic imaging

PurposeVaricose veins in the lower extremities are dilated subcutaneous varicose veins with a diameter of ≥ 3 mm, caused by increased venous pressure resulting from backflow of blood due to venous valve insufficiency (Gloviczki in Handbook of venous disorders: guidelines of the American venous forum, Hodder Arnold, London, 2009). When diagnosing varicose veins, the shape and thickness of the blood vessels should be accurately visualized in three dimensions. In this study, we investigated a new method for numerical evaluation of vascular morphology related to varicose veins in the lower extremities, using a photoacoustic imaging (PAI) system, which can acquire high-resolution and three-dimensional images noninvasively.MethodsNine patients with varicose veins participated in the study, and their images were captured using an optical camera and PAI system. We visualized the vascular structure, created a blood presence density (BPD) heat map, and examined the correlation between BPD and location of varicose veins.ResultsThe obtained photoacoustic (PA) images demonstrated the ability of this method to visualize vessels ranging from as small as 0.2 mm in diameter to large, dilated vessels in three dimensions. Furthermore, the study revealed a correlation between the high-density part of the BPD heat map generated from the PAI images and the presence of varicose veins.ConclusionPAI is a promising technique for noninvasive and accurate diagnosis of varicose veins in the lower extremities. By providing valuable information on the morphology and hemodynamics of the varicose veins, PAI may facilitate their early detection and treatment.

Study on the Analysis of Gender Trends Among the First Authors of Publications on Budd-Chiari Syndrome.

Budd-Chiari syndrome (BCS) is primarily a disease of hepatic vein blockage, which involves a backflow of blood to the liver. Although there have been many causes linked to this disease, most commonly, it occurs due to hypercoagulable states and blood disorders. In recent times, there has been a fast spread of knowledge regarding early diagnosis and various treatment modalities, which has enabled the prevention of mortality in most cases. This has primarily spread through research articles published in various journals. Thus, the article aims tocompare the gender trend ratios to identify the associated discrepancies in terms of male and female author contributions who have been the primary authors for articles pertaining to this disease. Methodology:A PubMed database between the years 2013 and 2022 was used for the bibliometric analysis. The gender of the primary author was analyzed by NamSor, an application programming interface (API). The statistical analysis was conducted using R software, the ARIMA model, and graphs were prepared using Datawrapper. Out of 667 articles extracted, the analysis showed that there were 455 (68.2%) first male authors and 212 (31.8%) first female authors. We also formulated various other results, which depicted a higher female-to-male author ratio including various journals and different countries. Although there has been an increasing trend of male authors as compared to female authors, this study found that male authorship for research on this disease is still higher. This study depicts that there is a necessity to draw attention to the inequitable systems favoring men over women for publications. The predictive analysis conducted also helps to foresee the trend in the next few years and explains the necessity of addressing the disparities among both genders in healthcare systems.

A New Cell Type in Pulmonary Veins

Pulmonary veins (PVs) carry oxygenated blood from lungs back to the heart and may play an important role in preventing blood backflow from the left atrium. Previous studies show that large PVs exhibit spontaneously pulsatile contractions in cardiomyocyte-like manner. However, the contractions of small PVs have not been investigated. We hypothesized that Ca2+ signaling mechanisms in the myocytes mediate small PV contractions. Small, 4th-order PVs from C57BL6 mice were obtained and imaged. Pressurized PVs showed ryanodine receptor-dependent Ca2+ signals and spontaneous contractions. Light sheet fluorescence microscopy and immunostaining showed the expression of troponin C, a cardiomyocyte marker, in the myocyte layer of small PVs, which was not observed in the pulmonary arteries, vena cava, or mesenteric veins. Based on these results, we termed these cells cardiomyocyte-like (CML) cells. In the study of mice with Myh11 Cre-driven tdTomato expression, Myh11 expression was observed in CML cells in small PVs, which was not seen in the smooth muscle cells (SMC) of small PAs. Endothelial protrusions crossing the connective tissue layer into the CML layer were also observed in PVs. Previous studies showed PV remodeling in pulmonary hypertension (PH), and impaired Ca2+ signaling in PAs contribute to higher pulmonary arterial pressure in PH. We further hypothesized that ryanodine receptor (RyR) Ca2+ signals in CML cells are impaired in PH. Results show that RyR Ca2+ signaling was reduced in CML cells of PH mice (injected with Su5416, subjected to chronic hypoxic conditions). Overall, our findings identify a new cell type in small PVs. Moreover, our data show that RyR Ca2+ signals in CML cells underlie spontaneous contractions in small PV, and are impaired in PH. We propose that RyR signaling mechanisms in CML cells may be possible targets for therapy in pulmonary vascular disorders. This work was supported by funding from the National Institute of Health to Swapnil Sonkusare (R01:HL146914, R01:HL157407). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

CFD Based on The Visualisation of Aortic Valve Mechanism in Aortic Valve Stenosis for Risk Prediction at The Peak Velocity

Aortic valve disease plays a crucial role in the development of cardiovascular disease (CVD), leading to increased rates of mortality and morbidity. Two diseases, aortic valve regurgitation and aortic valve stenosis are known to occur in the aortic valve. However, aortic valve stenosis is gaining attention due to its severe impact on the patient. The malfunction of the aortic valve might be affected by blood flow, which leads to stenosis. This study aims to investigate the blood flow re-circulation on the aortic valve in different stenotic regions when the blood’s velocity reaches the pick flow of the time in the systole phases. Four different models of aortic valve stenotic are designed using computer-aided design (CAD) software. The computational fluid dynamics (CFD) approach governed by the Navier-Stokes equation is imposed to identify the characteristics of the blood backflow at the left ventricle. Several hemodynamic factors are considered, such as time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI) and relative residence time (RRT). The blood flow characteristic is expected to be chaotic, especially at the highest percentages of aortic valve stenosis, presenting the worst condition to the heart. This finding supports healthcare providers in foreseeing the deterioration of the patient’s condition and opting for aorta valve surgery replacement.

Monorail snare technique for retrieval of stretched coil.

Coil stretching is a recognized complication during cerebral aneurysm embolization.1, 3- 5 For over a decade, the microsnare has proven effective in retrieving migrated coils.1- 5 Fiorella et al. unveiled the "Monorail Snare Technique" in 2005, offering a specialized approach to stretched coil recovery.1 However, to gain a complete understanding of this technique, more than just textual descriptions are necessary; a thorough, practical demonstration is essential. In our technical video (video 1), we illustrated an episode of coil stretching during aneurysm embolization, where the "Monorail Snare Technique" was successfully employed to retrieve a stretched coil. Our video emphasizes the meticulous preparation and modification of the microsnare, showcasing enhanced steps to mitigate the potential blood backflow triggered by the exclusive use of one-arm hemostasis valve during the "Monorail Snare Technique."1, 5 This pivotal adjustment substantially lowers the threat of thromboembolic events. We highlighted essential precautions to ensure the procedure's safety and efficacy.4, 5.

An Enigmatic Discovery - Accidental Insertion of Internal Jugular Haemodialysis Catheter into the Vertebral Vein

A 40-year-old male was admitted to the medical ward with chronic kidney disease with uremic symptoms and a decision was made to initiate the patient on haemodialysis. It was decided to catheterize the right internal jugular vein directly as the patient would require an A-V fistula in the near future which would be created in the left arm subsequently.
 Procedure
 During the time of right internal jugular vein catheterization using the anterior landmark technique, the right carotid artery was punctured leading to hematoma formation on the right side of the neck, despite adequate haemostatic measures.
 It was decided to catheterize the left internal jugular vein subsequently. Using the anterior landmark technique again, venipuncture was performed on the left side of the neck and in the first attempt itself the guide wire was inserted without any difficulty or resistance.
 Safe back-flow of venous blood was achieved through all ports of the catheter; that is, the catheter tip was presumed to be well positioned in the left internal jugular vein (IJV), as seen on the chest X-ray taken following the procedure.
 Clinical Course
 The patient complained of numbness over the left shoulder and weakness of the left upper limb following the procedure and was evaluated for the same. Under the clinical suspicion of left vertebral artery catheterization, a vascular surgeon opinion was sought and a CT angiogram of the neck was advised.
 The CT angiogram revealed the catheter entering the left vertebral vein at the level of C6 vertebra, coursing anteroinferiorly reaching the left brachiocephalic vein with its tip noted at the confluence of subclavian vein with internal jugular vein.
 After the CT angiogram, the misplaced catheter was promptly extracted to prevent the onset of additional complications.
 No excessive resistance was encountered during the catheter removal, and there were no signs of hematoma formation.
 Over the next few days, the patient’s symptoms of numbness and weakness resolved spontaneously.
 The patient had no neurological complaints and deficits on examination during follow-up in the outpatient department.

Safe Drip – IOT Empowered Saline Monitoring and Reversal Prevention

The proposed system is an IoT-based alert system for saline reversal in medical settings.Saline is administered to patients in medical facilities to aid in their recovery from dehydration and enhance their overall well-being. The occurrence of saline reversal arises when medical staff inject saline into a patient without being fully conscious of the situation in the hospital.The system utilizes sensors placed at various points in the saline delivery network to detect the flow of saline in the wrong direction i.e the back flow of blood. The system sends alerts to medical staff via message to their mobile when a saline reversal is detected. If the saline decreases over a certain threshold level the sensor will stops the saline flow and the medical staff will get a alert message that the “bottle is empty”, Also we can monitor the saline flow rate via a web application. This system aims to improve patient safety by reducing the occurrence of saline reversals, which can cause serious harm to patients. The system proposes the combination of sensors to detect the saline level, The system uses ESP8266 as master, a load cell to measure the weight of the saline bottle and the system uses servo motor to stop the saline drip. If the weight decreases under a certain threshold level, the load cell will send a signal to the master controller and the controller will stop the drip flow using servo motor. To alert the medical staff in the hospital, the system uses IFTT server. Through IFTT the medical staff will get a alert via SMS/call. Also the system had developed a web application, Through the web application the medical staff can monitor the current status of the saline level.

Molecular Pathways and Animal Models of Semilunar Valve and Aortic Arch Anomalies.

The great arteries of the vertebrate carry blood from the heart to the systemic circulation and are derived from the pharyngeal arch arteries. In higher vertebrates, the pharyngeal arch arteries are a symmetrical series of blood vessels that rapidly remodel during development to become the asymmetric aortic arch arteries carrying oxygenated blood from the left ventricle via the outflow tract. At the base of the aorta, as well as the pulmonary trunk, are the semilunar valves. These valves each have three leaflets and prevent the backflow of blood into the heart. During development, the process of aortic arch and valve formation may go wrong, resulting in cardiovascular defects, and these may, at least in part, be caused by genetic mutations. In this chapter, we will review models harboring genetic mutations that result in cardiovascular defects affecting the great arteries and the semilunar valves.

Impact of Hemostasis on the Lymphatic System in Development and Disease.

Lymphatic vessels form a systemic network that maintains interstitial fluid homeostasis and regulates immune responses and is strictly separated from the circulatory system. During embryonic development, lymphatic endothelial cells originate from blood vascular endothelial cells in the cardinal veins and form lymph sacs. Platelets are critical for separating lymph sacs from the cardinal veins through interactions between CLEC-2 (C-type lectin-like receptor-2) and PDPN (podoplanin) in lymphatic endothelial cells. Therefore, deficiencies of these genes cause blood-filled lymphatic vessels, leading to abnormal lymphatic vessel maturation. The junction between the thoracic duct and the subclavian vein has valves and forms physiological thrombi dependent on CLEC-2/PDPN signaling to prevent blood backflow into the thoracic duct. In addition, platelets regulate lymphangiogenesis and maintain blood/lymphatic separation in pathological conditions, such as wound healing and inflammatory diseases. More recently, it was reported that the entire hemostatic system is involved in lymphangiogenesis. Thus, the hemostatic system plays a crucial role in the establishment, maintenance, and rearrangement of lymphatic networks and contributes to body fluid homeostasis, which suggests that the hemostatic system is a potential target for treating lymphatic disorders. This review comprehensively summarizes the role of the hemostatic system in lymphangiogenesis and lymphatic vessel function and discusses challenges and future perspectives.

Holistic Approach in the Management of Venous Ulcer: A Case Study

Introduction: Venous ulcers (stasis ulcers, varicose ulcers) are wounds occurring due to inappropriate functioning of venous valves, usually of the legs. It is one of the most serious chronic venous insufficiency complications. When a venous valve gets damaged, it prevents the backflow of blood, which causes pressure in the veins that leads to hypertension and, in turn, venous ulcers.
 Incidence: Between 1.5 and 3.0/1000 people have active leg ulcers. Prevalence increases with age to about 20/1000 people aged over 80 years.
 Material and Methods: Varicose veins were defined as dilated, tortuous, subcutaneous veins usually seen in an upright posture. An unbiased consultant surgeon assessed any suspected chronic venous insufficiency on clinical examination. The severity of varicose vein was assessed by clinical grading from CEAP (Clinical-Etiological-Anatomical-Pathophysiological) system in which there are six classes.
 Discussion: Due to the lekahana effect of kshara is does srotoshodhana and hence increases the peripheral circulation and helps in woundbed healing by increasing the blood flow to the wound bed to improve the vitalityand metabolites supply to aid healing. the patient was given manjista which by virtue of its rakta sodhaka and praasdana property will increase the metabolites in the blood and helps in providing sufficient substrates in the wound bed for its healing.
 Conclusion:Chronic venous ulcers that did not heal after a few months of multiple courses of antibiotics & and anti-inflammatory treatment healed within 20 days after Ayurveda treatment. This indicates that Ayurveda therapy is effective in healing chronic venous wounds. Non-reoccurrence of ulcer after a 3-month break from medicines indicates a complete reversal of venous level pathology. However, a more in-depth study with a larger sample size will help to develop treatment protocols in such cases.

GATA2 regulates blood/lymph separation in a platelet-dependent and lymphovenous valve-independent manner.

Lymphatic vessels collect interstitial fluid, immune cells, and digested lipids and return these bodily fluids to blood through two pairs of lymphovenous valves (LVVs). Like other cardiovascular valves LVVs prevent the backflow of blood into the lymphatic vessels. In addition to LVVs, platelets are necessary to prevent the entry of blood into the lymphatic vessels. Platelet thrombi are observed at LVVs suggesting that LVVs and platelets function in synergy to regulate blood/lymphatic separation. The primary objective of this work is to determine whether platelets can regulate blood/lymph separation independently of LVVs. The transcription factor GATA2 is necessary for the development of both LVVs and hematopoietic stem cells. Using various endothelial- and hematopoietic cell expressed Cre-lines, we conditionally deleted Gata2. We hypothesized that this strategy would identify the tissue- and time-specific roles of GATA2 and reveal whether platelets and LVVs can independently regulate blood/lymph separation. Lymphatic vasculature-specific deletion of Gata2 results in the absence of LVVs without compromising blood/lymph separation. In contrast, deletion of GATA2 from both lymphatic vasculature and hematopoietic cells results in the absence of LVVs, reduced number of platelets and blood-filled lymphatic vasculature. GATA2 promotes blood/lymph separation through platelets. Furthermore, LVVs are the only known sites of interaction between blood and lymphatic vessels. The fact that blood is able to enter the lymphatic vessels of mice lacking LVVs and platelets indicates that under these circumstances the lymphatic and blood vessels are connected at yet to be identified sites.

The ex vivo on-ECMO amputated human limb model of atherosclerosis

Abstract Introduction The preclinical study of atherosclerosis has been traditionally centred around the use of small animal models, translating to large animal models prior to first-in-man studies. We propose to disrupt this paradigm by designing an ex vivo pump perfused “live” limb model, to enable the molecular targeting of atherosclerosis. Purpose To develop and test a novel experimental model of atherosclerosis, based on perfusion of an amputated human limb, to reduce time spent in translational pipelines and reliance on animal preclinical atherosclerotic research. Methods The novel model consists of taking a freshly amputated limb and incorporating it into an ex-situ pump-perfused bypass system (akin to ECMO) circulating warmed, oxygenated blood. A custom-made operating table was designed to allow the flow of venous blood back into the circuit. The outflow of the table was connected to an oxygenator followed by a pulsatile pump in series. A parallel circuit warms the system to 37°C using a thermocirculator. The circuit was connected to an outflow cannula sutured into the proximal end of the amputated limb artery, permitting the passage of an introducer sheath and guiding catheter for intravascular imaging and x-ray angiography (Figure 1A). The pump was set to provide an output of 15ml per stroke (to represent approximately 20% of clinical stroke volume), with an average pump rate of 70 strokes per minute (estimating a heart rate of 70 beats per minute). Thus, total pump output, or “cardiac output” to the limb was ∼1,050 ml/min. Regular monitoring was performed using arterial blood gas analysis, with correction of pH, oxygenation, haemoglobin, lactate and electrolytes. All participants provided written informed consent, and ethical permission was granted by the Imperial College Healthcare Tissue Bank (REC Wales 17/WA/0161; subcollection CAR_RK_17_070). Results The model has been successfully performed (n=3), maintaining oxygen saturations >99% for the length of perfusion (up to 6 hours). X-ray angiography (Figure 1B), intravascular ultrasound (Eagle Eye, Volcano, Philips; Figure 1C) and optical coherence tomography (Dragonfly Optis, Abbott Cardiovascular; Figure 1D) was performed. In one limb, indocyanine green, a near-infrared fluorescent dye (excitation 788/ emission 813nm) that localises to atherosclerotic plaque, was injected into the system (2 mg/kg) and left to circulate for 90-minutes. The arterial tissue (Figure 1E – posterior tibial [left] and fibular [right]) was then dissected, and fluorescence reflectance imaging performed at 790 nm on the extracted tissue (Figure 1F). This confirmed indocyanine green uptake in areas of calcific atherosclerotic plaque on intravascular ultrasound and optical coherence tomography. Conclusions This is the first demonstration of this novel ex vivo on ECMO “living” limb experimental model of atherosclerosis, which shows promise for future studies in translational interventional imaging and molecular targeting. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Wellcome Trust Clinical Research Fellowship

The Medical versus Zoological Concept of Outflow Tract Valves of the Vertebrate Heart.

The anatomical elements that in humans prevent blood backflow from the aorta and pulmonary artery to the left and right ventriclesare the aortic and pulmonary valves, respectively. Each valve regularly consists of three leaflets (cusps), each supported by its valvular sinus. From the medical viewpoint, each set of three leaflets and sinuses is regarded as a morpho-functional unit. This notion also applies to birds and non-human mammals. However, the structures that prevent the return of blood to the heart in other vertebrates are notably different. This has led to discrepancies between physicians and zoologists in defining what a cardiac outflow tract valve is. The aim here is to compare the gross anatomy of the outflow tract valvular system among several groups of vertebrates in order to understand the conceptual and nomenclature controversies in the field.

Mitral Valve Prolapse in Marfan syndrome: Case Report and Review of Literature

Mitral valve prolapse, an abnormal displacement into the left atrium of a thickened and redundant mitral valve during systole, is a relatively frequent abnormality in humans and may be associated with serious complications. One of the possible consequences of this condition is that the malfunctioning mitral valve allows backflow of blood in the left atrium, which, when severe, leads to left ventricular enlargement and failure. Besides severe mitral regurgitation, mitral valve prolapse has been associated with serious complications such as bacterial endocarditis and sudden death. Marfan syndrome is an autosomal dominant systemic disorder of the connective tissue. Patients affected by the Marfan syndrome carry a mutation in one of their two copies of the gene that encodes the connective tissue protein fibrillin-1. Marfan syndrome affects most organs and tissues, especially the skeleton, lungs, eyes, heart, and the large blood vessel that distributes blood from the heart to the rest of the body. We report a case of Marfan syndrome in a 30 years old patient presenting with mitral valve prolapse, tricuspid regurgitation associated with severe ocular, musculoskeletal abnormalities.

Bidirectional Glenn shunt with tricuspid valve resection in patients with infective endocarditis.

Bidirectional Glenn shunt with tricuspid valve resection in patients with infective endocarditis.

Iatrogenic catheterisation of subclavian artery while cannulating internal jugular vein.

Sir, Placement of a central venous catheter (CVC) carries a complication rate of 17.9%.[1] Use of ultrasound guidance has been advocated as standard of care to reduce complications and achieve higher success rate.[234] However, ultrasound-guided cannulation does not altogether negate accidental arterial puncture as has been found in our patient. A 3-year-old female child weighing 16.9 kg and having a midline brain stem tumour with hydrocephalus was posted for elective tumour excision. Following uneventful tracheal intubation and maintenance of anaesthesia with 50% oxygen in air, 1.5% sevoflurane and remifentanil (0.25 μg/kg/min) infusion, it was decided to place an arterial line and a CVC. Positive end expiratory pressure of 4-cmH2O was now momentarily applied, which resulted in a well-dilated right internal jugular vein (IJV) on imaging using linear probe of Mindray ultrasound machine (Shenzhen Mindray Bio-medical Electronics co. Ltd., Zhenzhen 518057, P.R. China). Right IJV was punctured at first attempt by a 4th-year anaesthesia resident with the needle directed at a 45° angulation. After free aspiration of blood, a guide wire was passed through the needle uneventfully. Following dilatation of the cannulation site, a 5.5 Fr paediatric multi-lumen CVC with blue flex tip (Arrow International, Inc, 2400 Bernville Road, PA, USA) was passed. All three ports were checked for free aspiration of blood. The CVC was fixed at 8 cm mark and sterile transparent dressing was applied. At this stage, an intravenous line containing 5% dextrose in 0.45% normal saline was attached to the distal 20-gauge catheter port. Contrary to expectation, there was no flow of the fluid although blood could be freely aspirated from this port. However, a minimal spontaneous backflow of blood was noted in the infusion line. Despite changing to a different port, the infusion was not dripping. At this stage, doubt was raised that the line could be in an artery, and the transducer of the arterial line was connected to the CVC and an arterial waveform was noted. Before removing the catheter, ultrasound imaging was done to confirm the position of the catheter in the artery. As expected, the puncture site and IJV were significantly to the right of the carotid artery. Further scanning and change of probe angle revealed a pulsating vessel underneath the jugular vein, which could be the subclavian artery (SA). Surprisingly, the catheter was seen to pass through the internal jugular lumen and then to lie in the SA [Figure 1]. The CVC was now removed and compression for 5 min was applied. A fresh CVC was placed in the same IJV uneventfully.Figure 1: Internal jugular vein and the subclavian artery with evidence of central venous catheter passing through them. (IJV-Internal jugular vein, SCA-Subclavian artery, CVC-Central venous catheter)We postulate a sequence of events that led to inadvertent SA puncture in our patient. The SA was about 2.5 mm deeper to the IJV as revealed by ultrasound [Figure 1]. The indentation of the wall of IJV while puncturing the vein or displacement of needle tip later after the probe was removed could be the reason for the needle tip entering the SA. We suggest five key points to avoid this mistake while cannulating IJV in paediatric patients where the SA is only a few mm away. First, needle should be kept angulated in relation to skin, close to 30° instead of 45° during puncture as this tangential approach results in less application of posterior forces that tend to collapse the vein wall. Also, angulation helps where the IJV diameter is less than the longitudinal length of bevel of needle.[5] Second, double wall puncture should be kept in mind where the vein diameter is small.[5] Third, it is essential that the tip of the needle be constantly identified with ultrasound as it approaches the vein and puncture is made.[6] Fourth, the path of guide wire should be confirmed by ultrasound prior to dilatation of the vessel. Lastly, a higher neck approach may be adopted in children so as to increase the distance between IJV and the SA, thereby reducing the possibility of its inadvertent puncture. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Prodigious Valve: Ultrasound Will Surely Help!!!

Prodigious Valve: Ultrasound Will Surely Help!!!