Cannulation Difficulty Research Articles

Early postoperative resistance index can predict radiocephalic arteriovenous fistula failure.

Ultrasonography is valuable for assessing arteriovenous fistula (AVF) maturation. Brachial artery flow volume (FV) measured at 6 weeks post-AVF creation can predict AVF failure. However, the association between early postoperative FV and AVF failure remains unclear. The resistance index (RI) may also serve as a prognostic factor for AVF maturation; however, it has not been extensively studied. Therefore, we aimed to investigate the relationship between AVF failure and early postoperative FV and RI. We retrospectively analyzed data from 102 patients (mean age, 67.8 ± 14.2 years; male, 68.6%; diabetes mellitus, 52.0%) who underwent new radiocephalic-AVF creation between January 2019 and December 2023 in Japan. An ultrasound device was used to measure brachial artery FV and RI on postoperative days 0 and 1. AVF failure was defined as occlusion or stenosis requiring vascular access intervention or surgical revision before the first cannulation, or cannulation difficulty or FV dysfunction requiring vascular access intervention or surgery at the first cannulation. On postoperative day 0, FV was 383.1 ± 146.8 mL/min, and RI was 0.65 ± 0.11. On postoperative day 1, FV was 466.9 ± 179.2 mL/min, and RI was 0.62 ± 0.11. FV significantly increased, and RI was significantly reduced on postoperative day 1 compared to those on day 0 (p < 0.01). Multivariate analyses revealed that higher RI (per 0.1; odds ratio (OR), 2.16; 95% confidence interval (CI), 1.22-3.82), but not FV, was significantly associated with AVF failure on postoperative day 0. On postoperative day 1, lower FV (per 100 mL/min; OR, 0.63; 95% CI, 0.42-0.95) and higher RI (per 0.1; OR, 2.17; 95% CI, 1.16-4.05) were significantly associated with AVF failure. This study highlights RI as a predictor of AVF failure in the early postoperative period when vasospasm is likely to occur.

Development of a Scoring System for Predicting the Difficulty of Bile Duct Cannulation and Selecting the Appropriate Cannulation Method.

Selective biliary cannulation in endoscopic retrograde cholangiopancreatography can be challenging due to factors like papillary morphology. Various patterns indicate cannulation difficulty, but the combinations causing difficulty and the optimal cannulation method for each scenario are unclear. This study aimed to identify cannulation difficulty patterns and develop a predictive scoring system for selecting the appropriate cannulation method. We retrospectively compared 776 patients with naïve papilla, dividing them into conventional contrast cannulation (N = 510) and salvage technique (N = 266) groups. The salvage group included patients using pancreatic duct guidewire placement and/or wire-guided cannulation due to difficulties with the contrast method. Papillary morphology (Haraldsson's classification), periampullary diverticulum (PAD), and scope operability were analyzed using multiple regression to identify risk factors for cannulation difficulties. Factors were scored based on hazard ratios to access combinations causing difficulties. The salvage group had more older patients and higher frequencies of type 2 (small), type 3 (protruding or pendulous), type 4 (creased or ridged) papillae, PAD, and poor scope operability. Significant risk factors in the multivariate analysis included type 2 [odds ratio (OR) 6.88], type 3 (OR 7.74), type 4 (OR 4.06) papillae, PAD (OR 2.26), and poor scope operability (OR 4.03). Pattern recognition scores were significantly higher in the salvage group (1.31 vs. 3.43, P < 0.0001). Type 2-4 papillae, PAD, and poor scope operability are significant risk factors for cannulation difficulty. Pattern recognition scores based on these factors can predict cannulation difficulty and aid in selecting between conventional and salvage methods.

Frequency and Pattern of Anomalous Origin of Coronary Artery in Bangladeshi Population: Coronary Angiogram Based Single Center Study

Background: Anomalous origin of coronary artery (AOCA) has been traditionally described by coronary angiography or autopsy. However the actual prevalence of such abnormalities is unknown in general Bangladeshi population. Beside conventional coronary angiogram(CAG), CT CAG and Multi-detector computed tomography (MDCT) offers higher possibility to visualize AOCA non-invasively. The purpose of this study was to report the prevalence AOCA in Bangladeshi population by using conventional CAG. Methodology: This was a single center, cross sectional, observational study, done in department of Cardiology, BSMMU over 1 year period. Sample size was 1167. Samples were taken following inclusion and exclusion criteria. Descriptive statistical analysis was done by using SPSS v29.0 Results: 1.3% population had AOCA. Commonest (0.6%) was ‘absent Left main (LM) with separate origin of Left Anterior Descending (LAD) and Left Circumflex (LCX) artery. Second commonest (0.45%) was ‘Right Coronary Artery (RCA) arising from left sinus’. 0.17% had RCA highup origin, and 0.08% had RCA origin from posterior sinus. Discussion: Among AOCA, RCA origin from left sinus, is potentially dangerious, due to high risk of sudden cardiac death (SCD) and surgical complications. Other varities of AOCA are mostly benign, but it may cause difficulties in cannulation during coronary angiography and coronary artery bypass surgery. Conclusion: Although coronary artery anomalies are rare, they may cause difficulties during coronary interventions or cardiac surgery and may occasionally result in sudden cardiac death. So, optimum precaution to findout the AOCA is needed during conventional CAG, and if suspicion, CT CAG and MDCT should also be used. (Bangladesh Heart Journal 2024; 39(2): 117-120

Impact of pancreatic and biliary stent on post-endoscopic papillectomy complications: A single-center retrospective study.

Endoscopic papillectomy (EP) is recommended as the first-line therapy for ampullary tumors, despite a relatively high incidence of complications. Pancreatic and/or biliary stents are placed at the endoscopist's discretion to prevent post-EP complications. The present study aimed to evaluate the efficacy of different stents. A total of 117 patients who underwent EP and met the criteria between June 2006 and October 2022 were enrolled in the study. These patients were divided into a pancreatic stent group (PS group, n = 47), a biliary stent group (BS group, n = 38), and a two-stent group (PBS [PS and BS] group, n = 32). Relevant clinical data were collected and compared among the three groups. Multivariate logistic analyses were performed to explore risk factors for post-EP complications. The incidence of all complications was 37.6% (44/117). Pancreatitis and hemorrhage were the two most common complications with incidence rates of 14.5% (17/117) and 17.9% (21/117). The incidence rates of post-EP pancreatitis were 10.6% (5/47), 23.7% (9/38), and 9.4% (3/32) in the PS group, BS group, and PBS group, respectively, with no significant differences. There were also no significant differences in other complications among the three groups. Age (odds ratio [OR]: 0.95; 95% confidence interval [CI]: 0.91-0.99; P = 0.022) was independently associated with post-EP pancreatitis while tumor size (OR: 1.66; 95% CI: 1.06-2.60; P = 0.028) was independently associated with post-EP hemorrhage. While pancreatic stenting is the first choice to prevent post-EP pancreatitis, biliary stenting could also be considered as a substitute for patients with difficulties in pancreatic cannulation. Two-stent (biliary and pancreatic stent) placement is unnecessary unless it is required due to other concerns.

Adrenalectomy in a child with Cushing’s syndrome: Anaesthetic challenges

Cushing’s syndrome is a rare entity, especially in children. The overall incidence of Cushing’s syndrome is approximately 2 to 5 new cases per million people per year. Cushing’s disease is a constellation of co-occurring health conditions and features that pose unique challenges during anaesthesia. A three year old child weighing 21 kg was posted for adrenalectomy. Intraoperatively we faced difficult airway, difficulty in cannulation, difficult regional anaesthesia and hemodynamic fluctuation during tumor resection. Patient was intubated with the aid of an intubating supraglottic device once attempts with fiberoptic failed. This case also highlights the unusual intraoperative hemodynamic fluctuations in adenoma resection similar to that seen in pheochromocytoma.

Development of an Automated Endoscopic Retrograde Cholangiopancreatography Quality Report Card Using an Integrated Analytics Suite

BACKGROUND AND AIMSQuality indicators (QIs) are essential for evaluating the safety and effectiveness of endoscopy but are difficult to measure accurately for endoscopic retrograde cholangiopancreatography (ERCP). We developed a fully automated, real-time endoscopy analytics tool using Health Level-7 standards that collects ERCP QIs from an endoscopy reporting system to generate an ERCP quality report card in a third-party analytics suite. METHODSERCP report data were collected between June 2021 and December 2022 from 4 referral centers. Discrete data elements from endoscopy reports generated in the EndoPro reporting platform were imported into the Qlik analytics suite, and QI data were aggregated into a report card. The collected data were manually validated to confirm accuracy. RESULTSPooled data were successfully used to generate a comprehensive institutional ERCP quality report card comprising a total of 2146 ERCPs performed by 12 endoscopists. Manual review confirmed high accuracy (96.5%-100%) of automatic extraction of ERCP QIs from endoscopy reports. Multiple procedural data elements were successfully extracted, including cannulation difficulty, success rate, and administration of post-ERCP pancreatitis prophylaxis for procedures with biliary and pancreatic indication. Generation of the report card required minimal additional work on the part of the performing endoscopist and was updated in real time. CONCLUSIONWe developed an automated ERCP analytics tool that accurately and automatically extracts QI data into a succinct ERCP quality report card without the need for manual data extraction or natural language processing. The use of the Health Level-7 standard provides a framework for the creation of similar tools in other electronic health records. This tool allows for accurate ERCP quality and performance data evaluation at individual and institutional levels.

Comparison of Open and Endovascular Aneurysm Repair in Native Arteriovenous Fistulas

Arteriovenous accesses develop aneurysms (FA) during their active use, resulting in pain, erosion, bleeding, and difficulty in cannulation. This study aims to evaluate the outcomes of open and endovascular management of single FA in arteriovenous fistulas (AVF). A retrospective review of all upper extremity primary AVFs over 12years was undertaken at a single center. Patients undergoing elective open and endovascular repair of a single FA were identified. Thirty-day outcomes, cannulation failure, line placement, re-intervention, and functional dialysis (continuous hemodialysis) for 3 consecutive months were examined. Three hundred and seventy nine patients presented with a single FA that met the requirements for intervention: 126 (33%) underwent endovascular repair, and the remainder 253 (67%) underwent open repair. Preoperative fistulogram identified anatomically significant issues in 91% of the cases, and these were treated by balloon angioplasty: 10% within the fistula tract, 44% within the outflow tract, and 47% in the central veins. In open repair, 57% underwent plication, 35% underwent resection and re-anastomosis, and the remainder (8%) underwent interposition grafting. In endovascular repair, successful placement of a stent was achieved in all cases with 1±2 (mean±standard deviation [SD]) covered stents (diameter: 6 -8 mm) placed, achieving successful exclusion of the FA. The combination of early thrombosis and cannulation failures led to the greater need for a tunneled central line in endovascular repair (6.5% vs. 2.4%; endovascular versus open repair; P=0.04). As a result, the mean time for establishing renewed access in the index AVF was significantly higher in endovascular repair (2±3 vs. 2±2weeks, mean±SD; endovascular open repair versus open repair; P=0.001). In follow-up, there were more secondary interventions per year in the endovascular compared to open repair groups (3.1 vs. 1.4 secondary interventions per year; endovascular versus open repair; P=0.04). Median functional dialysis durations were superior in the open repair (48±6%, mean + standard error) compared to the endovascular repair at 5years. (26±7%; P=0.03). Open repair results in a more rapid return to access use, lower need for a tunneled central line, lower secondary re-intervention rates, and superior functional dialysis durations compared to endovascular repair. Open FA repair should be considered for symptomatic single FA repairs before endovascular FA repair.

Papilla of Vater morphology as an influencing factor in successful cannulation during resident training in advanced endoscopy. A prospective clinical study

Introduction and aimEndoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure. Clinical guidelines assess competence in ERCP through a defined number of procedures, but multiple factors are involved. Our aim was to analyze the morphology of the papilla of Vater as an independent factor in selective common bile duct cannulation during resident training. Material and methodsPatients that underwent ERCP were studied consecutively. All ERCPs were begun by a resident in training. The type of papilla was classified according to Haraldsson, including those with previous sphincterotomy. Cannulation difficulty and success and their relation to the type of papilla were documented. The analysis was divided into three 4-month periods. ResultsOf the 429 patients, cannulation was difficult in 101 (23.5%). The residents achieved selective cannulation of the common bile duct in 276 (64.3%) and the cannulation success rate at the end of their training was 81.7%. Cannulation was performed with the least difficulty in papillae with previous sphincterotomy (2.8%), unlike the type 4 papilla, which was difficult to cannulate in 50% of the cases. The lowest overall cannulation success was in the type 2 papilla (81.8%). ConclusionPapilla type can influence cannulation success, but it is not the only related factor. Patients that underwent previous sphincterotomy appear to be the cases in whom ERCP training can be started.

Evaluation of point of care ultrasound (POCUS) training on arteriovenous access assessment and cannula placement for haemodialysis.

Haemodialysis requires a permanent vascular access and relies on cannulation with two large bore needles. Point Of Care Ultrasound (POCUS) is a tool that may assist nursing staff with visualising cannula placement and prevent miscannulation. This can be particularly useful in regional hospitals with limited access to vascular access specialists. To examine the impact of POCUS provision and education for nursing staff on confidence in cannulation and to understand the patient experience at three regional hospital haemodialysis units in South Australia. A POCUS machine and dedicated nursing education were provided at each of the three sites. A pre-test post-test model was used to assess the individual nurses perceived competency before and after the delivery of a series of online ultrasound education modules and face to face training. Patient reported outcome measures (PROMs) were collected to understand the use of POCUS from the client perspective. There was a shift towards 'agree' or 'strongly agree' for all nursing surveys in regard to perceived competency (n = 15). This was statistically significant (p ⩽ 0.05) for all questions other than question 1 'I am confident in my ability to physically assess vascular access' (p = 0.06). The patients that completed the PROMs (n = 17) overall supported the ease and use of POCUS for haemodialysis cannulation and felt that it contributed to the nursing staff competency in cannulation. POCUS has the potential to be a valuable tool in regional haemodialysis units to support vascular access cannulation and potentially avoid metropolitan transfer due to cannulation difficulties. The non-significant change post intervention for question 1 likely reflects the haemodialysis nurses inherent pre-existing capacity to assess vascular access without the use of POCUS using the standard process of visual inspection, the use of a stethoscope and palpation ('look, listen and feel').

Morfología de la papila de Vater como factor que influye en el éxito en canulación durante el entrenamiento del Residente en Endoscopia Avanzada. Estudio clínico prospectivo

Introduction and aimEndoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure. Clinical guidelines assess competence in ERCP through a defined number of procedures, but multiple factors are involved. Our aim was to analyze the morphology of the papilla of Vater as an independent factor in selective common bile duct cannulation during resident training. Material and methodsPatients that underwent ERCP were studied consecutively. All ERCPs were begun by a resident in training. The type of papilla was classified according to Haraldsson, including those with previous sphincterotomy. Cannulation difficulty and success and their relation to the type of papilla were documented. The analysis was divided into three 4-month periods. ResultsOf the 429 patients, cannulation was difficult in 101 (23.5%). The residents achieved selective cannulation of the common bile duct in 276 (64.3%) and the cannulation success rate at the end of their training was 81.7%. Cannulation was performed with the least difficulty in papillae with previous sphincterotomy (2.8%), unlike the type 4 papilla, which was difficult to cannulate in 50% of the cases. The lowest overall cannulation success was in the type 2 papilla (81.8%). ConclusiónPapilla type can influence cannulation success, but it is not the only related factor. Patients that underwent previous sphincterotomy appear to be the cases in whom ERCP training can be started.

New Preloaded System for Renal and Visceral Arteries in Fenestrated Endografting.

The New Preloaded System (NPS) for renal/visceral arteries (TVVs) is an emerging technology in fenestrated endografting (FEVAR) that allows TVVs cannulation and stenting through the same access of the endograft main body. However, only few preliminary experiences are currently available in the literature. The aim of this study is to report the outcomes of NPS-FEVAR in juxta/para-renal (J/P-AAAs) and thoracoabdominal (TAAAs) aneurysms repair. This is a prospective (NCT05224219), single-center/observational study of patients submitted to NPS-FEVAR for J/PAAAs and TAAAs between 2019 and 2022 (July). Definitions and outcomes were evaluated according to the current SVS-reporting standard. Technical success (TS) and TS preloaded related, spinal cord ischemia (SCI), and 30-day mortality were assessed as early endpoints. Survival, freedom from reinterventions (FFRs), and freedom from TTVs-instability (FFTVVs-instability) were analyzed during follow-up. Among 157 F/B-EVAR cases, 74 (47%) NPS-FEVAR were planned and enrolled in the study [48 (65%) J/P-AAAs; 26 (35%) TAAAs]. The main indication for NPS-FEVAR was the presence of a hostile iliac axis (54%-73%) or the necessity of expeditious pelvic/lower-limb reperfusion for SCI prevention in TAAAs (20%-27%). Overall, 292 TVVs were accommodated by 289 fenestrations and 3 branches; 188 of 289 (65%) fenestrations were preloaded. NPS-FEVAR configuration was from "below" and "from below to above" in 28 (38%) and 46 (62%) cases, respectively. TS and TS preloaded system-related was 96% (71/74) and 99% (73/74), respectively. Target visceral vessels patency at the completion angiography was 99% (290/292). Failures were 2 renal arteries loss and 1 massive bleeding from a percutaneous closure system breakage. The latter patient developed postoperative multiorgans failure and died on the fifth postoperative day, causing only 30-day/in-hospital mortality (1.3%). One (1.3%) patient with a JAAA and preoperative bilateral occlusion of the hypogastric arteries suffered SCI. The median follow-up was 14 (IQR: 8) months. The estimated 3-year survival was 91% with no aneurysm-related mortality during follow-up. The estimated 3-year FFR and FFTVVs-instability were 85 and 92%, respectively. New preloaded system FEVAR is a safe and effective option in the treatment of J/PAAAs and TAAAs in the presence of hostile iliac access or to guarantee an expeditious pelvic/lower limb reperfusion, leading to satisfactory results in terms of TS, early and mid-term clinical outcomes. New preloaded system for fenestrated and branched endografting allows to increase the feasibility of the advanced endovascular aortic repair in challenging iliac access, thoracoabdominal aneurysm repair and reduce difficulties in target visceral vessels cannulation.

Propensity score-matched analysis of physician-controlled wire-guided cannulation as an effective technique against difficult cannulation in endoscopic retrograde cholangiopancreatography: A retrospective study.

Advanced endoscopic retrograde cholangiopancreatography (ERCP) cannulation strategies for difficult cases could replace conventional techniques, in which assistants control guidewires. We aimed to compare the safety and efficacy of a new salvage cannulation strategy, physician-controlled wire-guided cannulation (PCWGC), with those of a conventional strategy. This retrospective study included patients with naïve papillae who underwent ERCP between January 2018 and December 2020. Patients, divided into two groups, received initial cannulation using a conventional catheter. After failed cannulation, the second attempt used PCWGC and double-guidewire technique (DGT) in the new and conventional strategy groups, respectively. Propensity score-matching (PSM) analysis compared outcomes between groups. Primary outcome included overall success rate, while secondary outcomes included cannulation time, adverse events, and cannulation difficulty subgroup analysis. The new strategy group comprised 255 (47.6%) of 536 patients who underwent ERCP. The total cannulation success rate was 98.4% (vs. 97.2%, p = 0.318), with similar post-ERCP pancreatitis (PEP) (1.8% vs. 2.4%, p = 0.64) rates. Following 1:1 PSM, 219/438 patients were allocated to both the conventional and new strategy groups, and 46 patients from the difficult cannulation subgroup were distributed evenly among groups. No difference in overall cannulation success rate existed between the groups before (97.2% vs. 98.4%) and after PSM (96.8% vs. 98.2%). The primary cannulation success rate was higher in the conventional strategy group, while the secondary cannulation success rate was higher in the new strategy group. However, the difficult cannulation subgroup PSM results showed that only the salvage cannulation success rate was significant (9/23, 39.1% vs. 18/23, 78.3%, p = 0.007). In the difficult cannulation subgroup, the salvage cannulation success rate for PCWGC was four times higher than DGT (95% confidence interval; 1.129-14.175), with no significant difference in PEP rate (p = 0.571). PCWGC demonstrated greater efficacy than the conventional salvage technique. PCWGC could be a safe and useful technique, especially for difficult biliary cannulation.

Contributions of nanotechnology to the intraductal drug delivery for local treatment and prevention of breast cancer

Breast cancer is a major public health problem, affecting millions of people. It is a very heterogeneous disease, with localized and invasive forms, and treatment generally consists of a combination of surgery and radiotherapy followed by administration of estrogen receptor modulators or aromatase inhibitors. Given its heterogeneity, management strategies that take into consideration the type of disease and biological markers and can provide more personalized and local treatment are required. More recently, the intraductal administration (i.e., into the breast ducts) of drugs has attracted significant attention due to its ability of providing drug distribution through the ductal tree in a minimally invasive manner. Although promising, intraductal administration is not trivial, and difficulties in duct identification and cannulation are important challenges to the further development of this route. New drug delivery strategies such as nanostructured systems can help to achieve the full benefits of the route due to the possibility of prolonging tissue retention, improving targeting and selectivity, increasing cytotoxicity and reducing the frequency of administration. This review aims at discussing the potential benefits and challenges of intraductal administration, focusing on the design and use of nanocarriers as innovative and feasible strategies for local breast cancer therapy and prevention.

Impact of periampullary diverticulum on biliary cannulation: A retrospective cohort study

AbstractThe prevalence of periampullary diverticulum (PAD) is relatively high in patients who undergo endoscopic retrograde cholangiopancreatography (ERCP). It is currently unclear if the presence of PAD impacts the success, difficulty, and complication rates of ERCP. The aim of the study is to investigate and compare the success rate, procedure difficulty, and complication rate between patients with or without PAD. Patients with PAD were further analyzed according to location and size. A total of 548 ERCP procedures were performed at our endoscopy center from 2015 to 2016. Those patients with previous ERCP, inability to locate the ampulla or abandoned procedure were excluded. 357 procedures were analyzed. A t test (normally distributed) or Mann‐Whitney U test (skewed) for continuous data and chi‐square or fisher's exact test for categorical data. A total of 116 were found to have PAD. The ampulla was located within the diverticulum in 8.9%, on the edge in 38.9%, and near in 52.2%. 64.3% of the PAD was large and 35.7% small. Patients with PAD were significantly older (P &lt; .001) and more likely to undergo ERCP for common bile duct stone (P = .007). There was no difference in ERCP grade, cannulation difficulty, cannulation success, procedure time, and complication rate between the two groups. Location and size of PAD also did not impact ERCP. The presence of PAD did not affect ERCP cannulation rates, increase the difficulty of cannulation or caused more complications.

Titanium Clip-dental Floss Traction-assisting Endoscopy in Patients With Difficulty in Cannulation Into the Duodenal Peridiverticular Papilla.

To assess titanium clip-dental floss traction-assisting endoscopy in patients with difficulty in cannulation into the papilla located at the lower, left or right side of the periampullary diverticulum. Sixty-eight patients who had difficulty in cannulation into the papilla located at the lower, left, or right side of the periampullary diverticulum upon endoscopic retrograde cholangiopancreatography (ERCP) were recruited at Taizhou Hospital from July 2016 to June 2020. A random number table was used to divide the patients into an intervention (with titanium clip-dental floss traction) group and a control group (n=34 in each group). Patients in both groups underwent ERCP. The cannulation time, cannulation success rate, incidence of postprocedural complications after ERCP, hospitalization time, and hospitalization expenses in the 2 groups were compared. The cannulation time was 15.3±4.1 minutes in the intervention group, which was less than that in the control group (25.7±6.5min). The cannulation success rate was 77±12.1% in the intervention group, which was higher than that in the control group (43±16.7%). Postprocedural complications occurred in 2 patients in the intervention group and 6 patients in the control group, with no significant differences. The hospitalization time and expenses were 3.8±2.6 days and 11.1±6 thousand yuan in the intervention group, respectively, and 6.1±3.7 days and 18.2±8 thousand yuan in the control group, respectively. The differences were statistically significant ( P <0.05). Titanium clip-dental floss traction-assisting endoscopy achieved excellent efficacy in patients with difficulty in cannulation into the papilla located at the lower, left or right side of the periampullary diverticulum. The cannulation success rate was improved after treatment, with good safety and prognosis.

Lower Limb Dialysis Grafts

The exponential rise in diabetes in India has led to a steady rise in end-stage renal disease patients requiring renal replacement therapy (RRT). Affordability and access to centers providing RRT and maintenance of functioning upper extremity vascular access for prolonged periods remain a challenge. Frequently facing no upper extremity access situations, we decided to reassess the feasibility of lower extremity vascular access. A retrospective study was carried out evaluating data from January 2009 to March 2022 including patients with a graft tunneled in the thigh (lower superficial femoral artery end to side to terminal great saphenous vein end to end). Totally 26 cases were studied with respect to age, sex, body mass index, comorbidities, difficulty in cannulation, complications, graft dysfunction, and patency rates. Follow-up was a dynamic ongoing process without a fixed endpoint. Graft dysfunction was seen in seven of 26 patients (26.92%), with a primary patency rate of 88.46% (23/26) at 1 year. Twelve subjects died during the study period, however, all had a functioning lower limb arteriovenous graft (AVG). Lack of surgical training, fear of complications, and absence of team approach in decision-making are some reasons why lower extremity permanent dialysis access is infrequently used. However, in view of increased survival on dialysis, advancing age of the dialysis population, associated comorbidities, and multiple access failures, lower limb AVGs may be considered a feasible access modality with acceptable patency rates and minimal complications.

IS THE DIVERTICULARPAPILLA A FACTOR IN THE FAILURE OF CANULATION OF THE COMMON BILE DUCT IN BILIARY STONES PATHOLOGY?

Introduction: Duodenaldiverticulumiscommon (6-20%). Thesemaybe a difficulty in cannulation of the common bile duct and are more frequentassociatedwithbiliary stones. Objectives: To calculate the prevalence of juxta-papillarydiverticulum in patients withbiliary stones and to evaluate the influence of juxtapillarydiverticulum on the success rate of the cannulation of the CBD in biliary stones pathology. Patients and MethodsA prospspectivestudythat lead from April 2002 to september 2020. Wereincluded 1011 patients whobenefited of a ERCP for CBD stones. The presence or absence of a juxta-papillarydiverticulumwasnoted. Wecompared the success rate of cannulation of the common bile duct in patients with a juxta-papillarydiverticulum (Group I) versus patients withoutdiverticularpapillae (group II). ResultsThe meanage of the patients was 58 ± 14 yearswith 605 women and 406 men (sex ratio M / F: 0.67). Patients withdiverticularpapillae (group I) accounted for 9.1% of the patients enrolled (93 patients). Group II had 918patients (90.8%). The success rate of the cannulation of CBD was 92.3% in group II versus 87.1% in group I (p: 0.04). The overall rate of early complications was 6% in group II versus 7.4% in group I (p = 0.11). Conclusion The presence of a juxta-papillarydiverticulumappears to significantlydecrease the success rate of CBD cannulation in biliary stones pathologywithoutincreasing the risk of early complications. However, prospective studieswith large series are stillnecessary to confirmthese.

Fistulotomy versus standard cannulation as the primary technique for all patients undergoing ERCP with a native papilla: a protocol for a single center randomized controlled trial

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is an indispensable procedure for the management of pancreaticobiliary diseases. Post-ERCP pancreatitis (PEP) is the most common serious adverse event. One risk factor of PEP is difficulty achieving biliary access. The conventional ERCP technique involves the cannulation of the bile duct via the ampulla of Vater, followed by sphincter incision using electrocautery. Conventionally, if the standard method fails then, precut techniques have been utilized as an alternative means of gaining biliary access. The needle-knife fistulotomy (NKF) technique involves identifying the intra-duodenal segment of the bile duct and uses a needle knife to incise directly into the bile duct. This is done above and away from the natural office, thus minimizing thermal damage which may result in PEP. Our recent prospective study of 50 patients demonstrated the safety and feasibility of the NKF precut technique as a primary means of gaining biliary access. The next step is to conduct a randomized controlled trial to compare the efficacy and safety of initial NKF to the standard cannulation in a non-selective patient population undergoing ERCP.MethodsA randomized control trial of 538 consecutive, non-selective patients with pancreaticobiliary disease undergoing ERCP at a tertiary care center in Kingston, Ontario, Canada, will be conducted. Patients will be randomized to one of two treatment groups, standard cannulation or NKF. The primary outcome of the study will be the incidence of PEP. Secondary outcomes will include rate of successful cannulation of the common bile duct (CBD), time to successful cannulation, total procedure time, difficulty of cannulation, and incidence of complications.DiscussionThis RCT will yield important answers regarding the efficacy and safety of initial NKF to the standard cannulation in a non-selective patient population undergoing ERCP. The results of our study could alter ERCP practices and outcomes if NKF is shown to reduce PEP risk.Trial registrationClinicalTrials.govNCT04559867. Registered on September 23, 2020

Direction- and Angle-Assisted Buttonhole Cannulation of Arteriovenous Fistula in Hemodialysis Patients: A Multicenter Randomized Controlled Trial

Rationale & ObjectiveArteriovenous fistula cannulation with the buttonhole technique is often preferred by patients but has been associated with an increased infection risk. Guidelines disagree on whether it should be abandoned, thus we assessed a technologically simple method to facilitate gentler arteriovenous fistula cannulation with potentially less discomfort and damage to the epithelial lining of the buttonhole tract.Study Design8-week, prospective, open-label, randomized controlled trial.Setting & ParticipantsPatients with buttonhole tracts receiving hemodialysis at 7 dialysis centers in Norway were randomized to the intervention group (43 patients, 658 cannulations) or control group (40 patients, 611 cannulations).InterventionDirection and angle of the established buttonhole tract were marked on the forearm skin in the intervention group, whereas the control group had no structured cannulation information system.OutcomesThe primary outcome was successful cannulation, defined as correct placement of both blunt needles at the first attempt without needing to change needles, perform extra perforations, or reposition the needle. The secondary outcomes were patient-reported difficulty of cannulation (verbal rating scale: 1 = very easy, 6 = impossible) and intensity of pain (numeric rating scale: 0 = no pain, 10 = unbearable pain).ResultsAfter a 2-week run-in period, successful cannulation was achieved in 73.9% and 74.8% of the patients in the intervention and control groups, respectively (relative risk [RR], 0.99; 95% CI, 0.87-1.12; P = 0.85). However, the probability of a difficult arterial cannulation (verbal rating scale, 3-6) was significantly lower in the intervention group (RR, 0.69; 95% CI, 0.55-0.85; P = 0.001). There were no improvements for venous cannulations. Furthermore, the probability of a painful cannulation (numeric rating scale, 3-10) was lower in the intervention group (RR, 0.72; 95% CI, 0.51-1.02; P = 0.06).LimitationsUnable to evaluate hard end points such as infections and thrombosis owing to the small sample size.ConclusionsMarking direction and angle of cannulation did not improve cannulation success rates; however, patients more often reported an unproblematic procedure and less pain.FundingNone.Trial RegistrationClinicalTrials.gov (NCT01536548).

Abstract 13945: Central Cannulation During Pediatric Extracorporeal Cardiopulmonary Resuscitation is Faster Than Peripheral Approaches

Introduction: Favorable survivorship after pediatric extracorporeal cardiopulmonary resuscitation (ECPR) may be limited by prolonged resuscitations. Surgical cannulation metrics for pediatric ECPR have not been widely reported by centers that use time interval benchmarks with a cardiovascular service responding to different hospital locations. Hypothesis: We hypothesize that survival is associated with resuscitation duration, and cannulation duration differs between peripheral and central approaches. Methods: This was a single-center retrospective study of patients 0-18 years with in-hospital ECPR between January 2015 and December 2020. Primary outcome was survival to hospital discharge. Secondary outcomes were odds of favorable neurologic outcome (dichotomized pediatric cerebral performance category), total resuscitation duration defined as cardiac arrest start to ECMO flow start (CA-ECMO), and cannulation duration. Non-parametric and regression methods were used. Results: Of the 92 events that met ECPR criteria, median weight and age were 4 months (IQR 1 month, 16 years) and 4.4 kg (range 1.9-133 kg). Cannulation occurred in the cardiac intensive care unit (ICU) (66%, 61 of 92), followed by operating room (13%, 12 of 92), pediatric ICU (12%, 11 of 92), and catheterization lab (9%, 8 of 92). Central cannulation was performed in 43% (40 of 92), and 21% (19 of 92) had open chests at the time of the event. Median duration of CA-ECMO was 35 min (IQR 26, 45 min); cannulation duration was 11 min (IQR 5, 16.5 min) for central compared to 18.5 min (IQR 12, 23 min) for peripheral approaches (P=0.01). Survival was 40% (37 of 92), and favorable neurologic outcome occurred in 38% (35 of 92). Survival (adjusted OR, 0.94; 95% CI 0.91-0.99, P=0.018) and favorable neurologic outcome (adjusted OR, 0.95; 95% CI 0.917-1.000, P=0.053) were associated with CA-ECMO duration after adjusting for cannulation approach, location, difficulty, shockable rhythm, and weight. Conclusion: In pediatric in-hospital ECPR, total CA-ECMO duration remains a key metric associated with patient outcomes. Central cannulation is faster than peripheral approaches. Since cannulation strategy alters CPR maneuvers, CPR effectiveness with each approach needs further study.