Cannulation Rate Research Articles

Distal Versus Proximal Radial Intervention; Is It Really Worth of It?

Objectives: Distal transradial approach (dTRA) is a promising technique with a decreased risk of radial artery occlusion and puncture-related injuries. There has been no data which compare dTRA and proximal transradial approach (pTRA) in Turkish population group, so far. Thus, researchers aimed to compare the efficacy and safety of the dTRA versus the conventional pTRA in coronary procedures in this study. Methods: Between September 2021 and June 2022, patients scheduled for transradial angiography at a tertiary cardiac center were enrolled in this study. Patients were randomly selected to undergo coronary imaging using either the distal dTRA or the conventional pTRA in equal numbers. A total of 79 patients were randomized to the proximal approach, and 77 patients were randomized to the dTRA. The primary endpoint was defined as procedural failure. Results: The success rate of cannulation of the dTRA was significantly lower compared to proximal pTRA (pTRA [89.6%] and pTRA [79%] p=0.002). The rate of radial artery thrombotic complications was not different between groups (proxymal %10.6 vs. distal %5.8, p=0.288). The time of cannulation and total procedural time were longer in the dTRA group (20–40 min, median 25 min) compared to the proximal radial group (15–30 min, median 20 min) p = 0.005. However, this did not affect the total scope time duration 3.3 min. (1.6–6.4) versus 2.4 min (1.6–3.7). Conclusion: dTRA has a relatively long access time with no advantages in terms of thrombotic complications in the radial artery.

Morphology of the papilla can predict procedural safety and efficacy of ERCP—a systematic review and meta-analysis

Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary therapeutic procedure for pancreaticobiliary disorders, and studies highlighted the impact of papilla anatomy on its efficacy and safety. Our objective was to quantify the influence of papilla morphology on ERCP outcomes. We systematically searched three medical databases in September 2022, focusing on studies detailing the cannulation process or the rate of adverse events in the context of papilla morphology. The Haraldsson classification served as the primary system for papilla morphology, and a pooled event rate with a 95% confidence interval was calculated as the effect size measure. Out of 17 eligible studies, 14 were included in the quantitative synthesis. In studies using the Haraldsson classification, the rate of difficult cannulation was the lowest in type I papilla (26%), while the highest one was observed in the case of type IV papilla (41%). For post-ERCP pancreatitis, the event rate was the highest in type II papilla (11%) and the lowest in type I and III papilla (6–6%). No significant difference was observed in the cannulation failure and post-ERCP bleeding event rates between the papilla types. In conclusion, certain papilla morphologies are associated with a higher rate of difficult cannulation and post-ERCP pancreatitis.

Comparative Study of Periarterial Infiltration of Nitroglycerine with Lignocaine vs Lignocaine Alone for Ultrasound Guided Radial Artery Cannulation in ICU Patients

Background: Radial arterial cannulation is a commonly done procedure in ICU. Multiple cannulation attempts can lead to radial artery spasm resulting in low pulse volume, decreased pulse palpability and cannulation failure. This study evaluates the effects of periarterial nitroglycerine infiltration with lignocaine vs lignocaine alone in USG guided radial artery cannulation in ICU patients.
 Methods: A total of 60 ICU patients in age group 18-65 years who required radial artery cannulation for ABG analysis and invasive blood pressure monitoring were enrolled. They were randomly allocated to Group LN (periarterial infiltration with 0.2ml nitroglycerine+0.8 ml lignocaine 2%) and Group L (periarterial infiltration with 1ml of lignocaine 2%) of 30 patient each. Both groups were compared with respect to radial artery dimensions before and after infiltration of drug, pulse palpability score, no of attempts, time of cannulation and failure rates.
 Results: There was significantly greater increase in radial artery dimensions in group LN as compared to group L after intervention. Pulse palpability score was also better in group LN. Mean time required for cannulation, number of attempts and insertion failure were significantly lesser in group LN as compared to another group. No hemodynamic adverse effect was reported in either group.
 Conclusion: Periarterial infiltration with lignocaine and nitroglycerine combination increase radial artery dimension with improved cannulation success rate.

Contralateral Suppression in Adrenal Venous Sampling Predicts Clinical and Biochemical Outcome in Primary Aldosteronism.

The role of hormone parameters at adrenal venous sampling (AVS) in predicting clinical and biochemical outcomes remains controversial. To investigate the impact of hormone parameters at AVS under cosyntropin stimulation on lateralization and on complete biochemical and clinical outcomes. We retrospectively evaluated 150 sequential AVS under cosyntropin infusion. The bilateral successful cannulation rate was 83.3% (n = 140), 47.9% bilateral and 52.1% unilateral. The lateralization index, aldosterone/cortisol ratio (A/C) in the dominant adrenal vein (AV), and relative aldosterone secretion index (RASI = A/C in AV divided by A/C in inferior vena cava) were assessed. The contralateral suppression (CS) percentage was defined by (1 - nondominant RASI) * 100. A nondominant RASI <0.5 (CS >50%) had 86.84% sensitivity and 92.96% specificity to predict contralateral lateralization. An A/C ratio in dominant AV >5.9 (74.67% sensitivity and 80% specificity) and dominant RASI >4.7 (35.21% sensitivity and 88.06% specificity) had the worst performance to predict ipsilateral lateralization. Complete biochemical and clinical cure was significantly more frequent in the patients with CS >50% [98.41% vs 42.86% (P < .001) and 41.94% vs 0% (P < .001)]. CS correlated with high aldosterone at diagnosis (P < .001) and low postoperative aldosterone levels at 1 month (P = .019). Postoperative biochemical hypoaldosteronism was more frequent in patients with CS >50% (70% vs 16.67%, P = .014). In multivariable analysis, a CS >50% was associated with complete biochemical cure [odds ratio (OR) 125, 95% confidence interval (CI) 11.904-5000; P = .001] and hypertension remission (OR 12.19, 95% CI 2.074-250; P = .023). A CS >50% was an independent predictor of complete clinical and biochemical cure. Moreover, it can predict unilateral primary aldosteronism and postoperative biochemical hypoaldosteronism. Our findings underscore the usefulness of CS for clinical decision-making.

Comparison of the Ultrasound-Guided Supraclavicular and Infraclavicular Approaches for Subclavian Vein Cannulation in Children With Congenital Heart Disease

Objective(s)Central venous catheterization (CVC) is widely used in pediatric critical patients. We thought to compare the success rate and safety of ultrasound-guided subclavian vein cannulation performed via infraclavicular and supraclavicular approaches. DesignWe compared the success rate of the first puncture and other information for cannulation in the children with congenital heart disease (CHD) requiring central venous catheterization who were randomly assigned to the supraclavicular approach group (Group A) or infraclavicular approach group (Group B). SettingMedical university hospital pediatric cardiac intensive care units (CICUs). ParticipantsPediatric patients diagnosed with CHD in the preoperative period who were admitted to the CICU and required subclavian vein catheterization. InterventionsUltrasound-guided subclavian vein cannulation. Measurements & Main ResultsSixty-seven children were included in the study, with 32 in Group A and 35 in Group B. Notably, there was a significant difference in the success rate of the first puncture between Groups A and B (90.6% vs. 71.4, %, p = 0.047). Furthermore, the access time in Group A was 11.8 (3.2–95) seconds, which was significantly shorter than that in Group B (16.0 [6.5–227] seconds, p = 0.001). In addition, the catheter malposition rate in Group A was significantly lower than that in Group B (0% vs. 11.4%, p = 0.049). Conversely, there were no significant differences in the total access time, overall success rate, and complications (e.g., pneumothorax, hemorrhage, puncture artery, and nerve injury) between the two groups. ConclusionsFor children with congenital heart disease requiring central venous catheterization during the perioperative period, the subclavian vein is a feasible site for catheterization. The supraclavicular approach, especially the left side, has a higher first-puncture success rate, shorter access time, lower complications, and the trend of lower incidence of catheter malposition. However, a larger sample size of randomized controlled study is expected to verify the advantages of ultrasound-guided subclavian catheterization in children.

Anatomy and anatomical variations of adrenal veins and its application to adrenal venous sampling.

Our aim was to study the anatomy of the left and right main adrenal veins (LAV and RAV) and to identify their anatomical variations in order to see the practical application of these findings to adrenal venous sampling (AVS). Our work is based on dissection of 80 adrenal glands from fresh corpses in the forensic medicine department. We studied the number, the drainage, the direction and the level of termination of the main adrenal veins. The average length of the LAV was 21mm. It ended in 100% of cases at the upper edge of the left renal vein with a mean connection angle of 70° and after an anastomosis with the lower phrenic vein in 36 cases(90%). The average length of the RAV was 9mm. It ended in 100% of cases at the level of the retro hepatic inferior vena cava (IVC) mainly on its posterior face in 21 cases (53%) and on its right lateral border in 18 cases (45%). The mean angle of the RAV in relation to the vertical axis of the IVC was 40°, with extremes ranging from 15° to 90°. AVS seems to be easier on the left than on the right side because of the greater length of the adrenal vein (21mm vs. 9mm) and a greater angle of connection (70° with the left renal vein vs. 40° with the IVC), which explains the lower success rate of cannulation and the more frequent occurrence of blood sample contamination on the right side.

Efficacy and safety of the Valsalva maneuver in relieving venipuncture pain in children and adults: A systematic review and meta-analysis.

Venipuncture is a common invasive clinical procedure, and pain management during puncture has been of interest to healthcare professionals. The purpose of this systematic review and meta-analysis was to evaluate the efficacy and safety of the Valsalva maneuver (VM) for the relief of venipuncture pain in children and adults. PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang, VIP database, and CBM were searched from inception to December 2023 for all available randomized controlled trials (RCTs) that evaluated the impact of VM on venipuncture. Two reviewers independently performed study selection, data extraction, and risk of bias assessment. Continuous variables were analyzed by mean differences (MD) or standardized mean differences (SMD), whereas dichotomous variables were analyzed by risk ratios (RR). A total of 22 studies involving 1740 participants were included. The pooled results showed that VM relieved pain intensity during venipuncture in children (SMD = -0.89, 95% CI = -1.47 to -0.30, p = 0.003) and adults (SMD = -1.11, 95% CI = -1.46 to -0.77, p < 0.00001), reduced anxiety intensity (SMD = -1.07, 95% CI = -1.68 to -0.47, p = 0.0005), and shortened puncture time (MD = -13.52, 95% CI = -21.14 to -5.90, p = 0.0005). There was no significant difference in the success rate of venous cannulation, MAP, HR, or incidence of adverse events in subjects who performed VM compared to controls. VM was an effective and safe method of pain management that reduced pain intensity during venipuncture in children and adults without significant adverse effects. The results of this meta-analysis need to be further validated by more rigorous and larger RCTs.

Impact of duodenal papilla anatomy on needle knife papillotomy safety and efficacy in patients with difficult biliary canulation

Background and aimsNeedle-knife papillotomy (NKP) is widely performed when biliary cannulation is difficult during endoscopic retrograde cholangiopancreatography (ERCP). However, its safety and efficacy in different types of duodenal papilla are not clear.Patients and methodsThis retrospective study analyzed 217 patients with difficult biliary cannulation who underwent NKP during ERCP procedures from June 2013 to May 2022 in our institution. Patients were classified according to Haraldsson classification type of duodenal papilla: type 1, regular; type 2, small; type 3, protruding or pendulous; and type 4, creased or ridged. Outcome measures were successful biliary cannulation and incidence of adverse events.ResultsHaraldsson classification was type 1 in 115 patients, type 2 in 29, type 3 in 52, and type 4 in 21. Biliary cannulation was successful in 166 patients (76.5%) Success rates according to Haraldsson type were as follows: type 1, 74.8%; type 2, 82.8%; type 3, 80.8%; and type 4, 66.7%. The rates did not significantly differ among the types (p = 0.48). Overall incidence of adverse events was 9.22%. Incidence of adverse events did not significantly differ among the types (p = 0.69).ConclusionsNKP was useful to achieve successful cannulation in patients with difficult biliary cannulation. The rate of successful cannulation and incidence of adverse events were similar among the different types of duodenal papilla.

Radial Arterial Cannulation by Ultrasound-Guided Dynamic Needle-Tip Positioning Using the Short-Axis Out-of-Plane Approach Versus the Long-Axis In-Plane Approach: A Randomized Controlled Study.

Introduction Radial artery cannulation is a commonly performed invasive procedure for assessing a patient's hemodynamic status and collecting blood samples. Ultrasound guidance has shown benefits in improving the success rate of first-attempt cannulation. Two main approaches, short-axis out-of-plane (SAOOP) and long-axis in-plane (LAIP), are commonly used. A modified technique called dynamic needle-tip positioning (DNTP) using the short-axis out-of-plane approach has been reported to enhance arterial catheterization. This study aims to compare the first-attempt success rates of radial artery cannulation using the two techniques, DNTP versus LAIP, along with overall success rates, cannulation time, and number of attempts. Methods This prospective, randomized, controlled, clinical study was conducted after obtaining clearance from the Institute Ethics Committee of AIIMS, Raipur. Ninety-six patients between the ages of 18 and 50 years, undergoing elective surgery under general anesthesia, and required radial arterial cannulationwere randomized and equally allocated into two groups as the LAIP and DNTP approaches. The first-pass success rate, time to achieve successful cannulation, number of attempts needed, overall success rate within five minutes, and potential complications, such as thrombosis, vasospasm, and hematoma, were recorded. Results A total of 96 patients were included, with 48 in the LAIP group and 48 in the DNTP group. The DNTP group showed statistically significant advantages over the LAIP group, with a higher first-pass success rate (97.9% vs. 83.3%; p = 0.014) and shorter time to achieve successful cannulation (9.29±3.79 vs. 26.16±20.22 seconds; p = 0.001). Conclusion The ultrasound-guided short-axis DNTP technique for radial artery cannulation demonstrated a significant advantage as compared to the LAIP technique. The DNTP technique resulted in higher first-attempt cannulation success and shorter cannulation time.

A126 IMPACT OF TIME OF DAY ON PROCEDURAL OUTCOMES IN ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP): ANALYSIS FROM A TERTIARY REFERRAL CENTER

Abstract Background Endoscopic retrograde cholangiopancreatography (ERCP) is an established diagnostic and therapeutic tool for hepatobiliary disease. Given its technical demands, it remains one of the highest-risk endoscopic procedures. Addressing modifiable factors, such as operator fatigue, may mitigate procedural risk. In colonoscopy, there is conflicting data on whether procedure time of day, as a surrogate of operator fatigue, affects outcomes, with some literature demonstrating decreased procedure completion and polyp detection rates in the afternoon. There is a paucity of data evaluating this potential relationship in ERCP. Aims To evaluate the impact of procedure time of day on procedural success and short-term adverse outcomes in patients undergoing ERCP. Methods A retrospective review of ERCP's performed on adult patients at our tertiary referral center from January 1, 2011 to December 31, 2020 was performed. The primary outcome was the procedural success rate, defined as successful navigation to the papilla, selective duct cannulation and cholangiography, and realization of the intended therapeutic goals. Secondary outcomes included procedure duration, rate of deep ductal cannulation, rate of sphincterotomy, and short-term (30-day) adverse events (immediate bleeding, delayed bleeding, pancreatitis, perforation). Statistical analysis was conducted using R. Categorical variables were compared using the Chi-square test of independence or Fisher’s exact test. Continuous variables were compared using T-tests or the Mann-Whitney-U test. Results A total of 5755 ERCP’s were performed between 8 AM – 6 PM; 2863 were performed before 12PM (AM group) and 2892 after 12PM (PM group). Baseline characteristics were similar between the two cohorts, with the exception of hypertension (33.7% AM vs 30.1% PM; p=0.003), and anticoagulation (20.3% AM vs 18.3% PM; p=0.05). In both groups, the most common ERCP indication was choledocholithiasis. The primary operators in both cohorts were clinical fellows. There was no difference in procedural success rate (87.0 % AM vs 86.7% PM; p = 0.72), procedure duration (33.6 minutes AM vs 32.9 minutes PM; p = 0.29), rates of deep cannulation (82.6% AM vs 83.0% PM; p = 0.81) and sphincterotomies (63.2% vs 62.7%; p = 0.68). Rate of adverse events were similar, with slightly higher rates of immediate bleeding in the AM group (5.0% AM vs 3.8% PM; p = 0.03). Results were similar in a subgroup analysis of patients with altered anatomy. Conclusions In this large retrospective review of ERCPs performed at a tertiary referral center, the procedure time of day did not impact procedural success rate. There were slightly higher rates of immediate bleeding in the AM group, though this may be explained by higher rates of anticoagulation in that group. Funding Agencies None

Double-guidewire technique for selective biliary cannulation does not increase the rate of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with naïve papilla.

This study aimed to compare the safety of the double-guidewire technique (DGT) with that of the conventional single-guidewire technique (SGT) in real-world situations. A total of 240 patients with naïve papilla who underwent endoscopic retrograde cholangiopancreatography (ERCP) at Daegu Catholic University Medical Center between January 2021 and December 2021 were included. The primary outcome was the rate of post-ERCP pancreatitis (PEP) in the SGT and DGT groups. A total of 163 patients (67.9%) belonged to the SGT group, and 77 (32.1%) belonged to the DGT group. The rates of successful biliary cannulation were 95.7% and 83.1% in the SGT and DGT groups, respectively (p=0.002). In the study group, PEP occurred in 14 patients (5.8%). The PEP rates were not significantly different between the SGT and DGT groups (4.3% vs. 9.1%, p=0.150). In the multivariate analysis, the age of <50 years (odds ratio [OR], 9.305; 95% confidence interval [CI], 1.367-63.358; p=0.023) and hyperlipidemia (OR, 7.384; 95% CI, 1.103-49.424; p=0.039) were significant risk factors for PEP in the DGT group. DGT did not increase the PEP rate in patients with naïve papilla. In addition, the age of <50years and hyperlipidemia were significant risk factors for PEP in the DGT group.

Comparison of Doppler Guided Seldinger Technique Versus Classic Palpatory Seldinger Technique for Radial Artery Cannulation-an Open Label Randomized Controlled Trial

Objective: Radial artery cannulation is commonly performed by the conventional palpatory technique. However, in circumstances where the cannulation is difficult, other methods such as Doppler or ultrasound are used to guide the cannulation. Incorporating the Seldinger technique can further improve the successful cannulation. The aim of the study was to compare the first attempt success rate of radial artery cannulation between conventional palpatory Seldinger technique and Doppler guided Seldinger technique. Methods: Ninety patients undergoing major open abdominal surgeries were divided into two groups -the Classic palpatory and the Doppler guided radial artery cannulation. The Seldinger Technique was used in both the groups. First attempt success rate of radial artery cannulation and time to cannulation were noted by both the techniques. Results: The number of attempts and the time to cannulation were significantly less in the palpatory Seldinger group as compared with the Doppler Seldinger group. Complication rates were similar in both the groups but there were 4 failure in palpatory Seldinger group. Conclusion: The classic palpatory technique along with the Seldinger technique for radial artery cannulation is better in terms of first attempt cannulation rate and duration of cannulation than the Doppler guided Seldinger technique in patients undergoing elective surgeries. However, Doppler method had no failures and can be a useful rescue method in failed cannulation.

The impact of periampullary diverticula on cannulation and adverse events in endoscopic retrograde cholangiopancreatography.

Periampullary diverticulum (PAD) is commonly encountered in endoscopic retrograde cholangiopancreatography (ERCP) procedures. We sought to determine whether PADs are associated with a lower success rate of cannulation and an increased risk of adverse events. A retrospective cohort study was conducted using prospectively gathered nationwide registry data. Using the Swedish registry for gallstone surgery and ERCP, we analyzed a cohort of 66,974 prospectively registered ERCP procedures performed in 2006-2021. The presence of PAD was divided into two groups based on the PAD type: Boix type 1 (the papilla located inside the PAD) and Boix types 2-3 (the papilla located either at the edge of the PAD or immediately adjacent to the PAD). The primary outcomes were the success rate of cannulation and overall adverse events within 30 days. PADs were registered in 8130 (12.1%) of ERCPs included in the study population. In total, 2114 (3.9%) patients had Boix type 1 PAD, while 5035 (8.2%) patients had Boix type 2 or 3 PAD. The chance of successful cannulation was lower in patients with type 1 PAD compared to no PAD (80.1% vs 88.7%; odds ratio: 0.42, 95% confidence interval: 0.38-0.46). No differences were seen in overall adverse events or post-ERCP pancreatitis. Adverse events occurred in 14.6% of patients with PAD type 1 and 16.0% of patients with PAD type 2 or 3, compared to 16.5% of patients without a PAD. Cannulation appears less successful during ERCP when the papilla is located in the PAD (i.e., type 1). Adverse events seem not to increase with the presence of a PAD, but they could theoretically be influenced by the inability to cannulate.

Novel Interventional Radiology for the Treatment of Various Lymphatic Leakages: Lymphatic Intervention and Embolization.

Little progress has been made in modern lymphatic medicine since Dr. Kinmonth first described pedal lymphangiography in the 1950s. The clinical need for an effective treatment modality for managing lymphatic leakage greatly increased only after intranodal lymphangiography, which enabled the depiction of the exact location of the leakage. This review introduces five hypotheses that have been proposed while addressing various clinical scenarios involving lymphatic leakage: (1) various embolization techniques can be used to prevent lymphatic leakage; (2) lymph node embolization can treat postoperative pelvic lymphoceles that are refractory to sclerotherapy; (3) the technical success rate of thoracic duct cannulation can be improved by using retrograde thoracic duct access as a bail-out method; (4) non-traumatic chylothorax can be managed by understanding the underlying pathophysiology; and (5) chylous ascites can be managed by understanding the underlying pathophysiology. Five retrospective observational studies, one randomized prospective clinical trial, and two case reports (letters to the editor) were published after the hypotheses were validated. We provide a new systematic approach to lymphatic intervention by describing the process of the current comprehensive research.

Limited exposure to pancreatic ERCP during advanced endoscopy training impacts competence and performance in independent practice

Background/ObjectivesThe impact of competency-based training programs on pancreatic endoscopic retrograde cholangiopancreatography (ERCP) performance remains unclear. This study aimed to describe the learning curves of pancreatic ERCP and subsequent performance during independent practice. MethodsThis was a multicenter prospective cohort study involving advanced endoscopy trainees (AETs). In the 1st phase, trainees were assessed on every 5th ERCP using the ERCP and EUS Skills Assessment Tool (TEESAT). Cumulative sum (CUSUM) analysis of pancreatic ERCP evaluations was used to establish learning curves. During the 2nd phase (1st year of independent practice), now-graduated participants documented their performance on key ERCP quality indicators. ResultsA total of 24 AETs (20 training programs) received sufficient evaluations for CUSUM analysis. Pancreatic ERCP accounted for 14.6 % (196/1339) of all ERCPs evaluated with 45 % of pancreatic ERCPs carrying a Grade 3 level of complexity. A minority of AETs (16.7 %) performed enough pancreatic ERCPs to generate meaningful learning curves with no AETs achieving competence in pancreatic cannulation, sphincterotomy, or stone clearance during Phase 1. In Phase 2, a total of 3620 ERCPs were performed, of which 281 (7.8 %) were pancreatic ERCPs. While the overall pancreatic duct cannulation rate was 92.2 %, the native papilla pancreatic duct cannulation rate was 85.7 %, which was below the recommended 90 % threshold. ConclusionsAdvanced endoscopy training offers a low level of exposure to pancreatic ERCP, which is mirrored in independent practice, highlighting the inadequate training in pancreatic ERCP. Given the complexity of pancreatic ERCP, novel strategies are warranted to improve training in pancreatic ERCP.

Obesity and Risk for Incomplete Stone Clearance in Patients with Bile Duct Stones Undergoing ERCP.

Obesity degrades fluoroscopic image quality and could impact on the endoscopic retrograde cholangiopancreatography (ERCP) outcomes. Our study aimed to compare the clinical outcomes and adverse events (AEs) between obese and non-obese patients undergoing ERCP for biliary stone-related conditions. Patients who underwent ERCP for biliary-stone related conditions were included. The analyzed outcomes included the rates of successful bile duct cannulation, incomplete bile duct stone clearance, recurrent bile duct stones, and AEs. A total of 229 patients (116 obese patients and 113 non-obese patients) were included. All patients had successful bile duct cannulation. The rates of incomplete bile duct stone clearance (11.3% vs. 9.0%, P = 0.51), recurrent bile duct stones (1.9% vs. 4.2%, P = 0.24), and AEs (1.8% vs. 0.7%, P = 0.43) were not significantly different between the two groups, respectively. Our study demonstrates no associations between obesity and the rates of incomplete stone clearance, recurrent stones, successful cannulation, or AEs in patients undergoing ERCP for biliary stone-related disease.

Stroke After Acute Type A Dissection Repair Using Right Axillary Cannulation First Approach

BackgroundThis study sought to analyze the details of strokes after acute type A dissection repair (ATAD) using a right axillary artery (RAX) first approach. MethodsA total of 356 consecutive ATAD repairs from 2005 to 2022 were analyzed on the basis of arterial cannulation site. Strokes were evaluated by head computed tomography. ResultsThe rate of RAX cannulation was 82.6% (n = 294), with a 38.2% rate of antegrade cerebral perfusion use, both of which had increased over the years. The non-RAX group had more cardiogenic shock (RAX, 16.3% vs non-RAX, 37.1%; P < .001), cerebral malperfusion (8.8% vs 25.8%, respectively; P < .001), and innominate artery dissection (45.9% vs 69.2%, respectively; P = .007). Eight patients died before undergoing a full neurologic assessment. The overall stroke rate was 8.4% (n = 30), and it was lower in the RAX group (5.1% vs 24.2%; P < .001). All strokes were ischemic, with concomitant hemorrhagic strokes occurring in 6 patients. Strokes diagnosed immediately after surgery (perioperative stroke) accounted for 70% (n = 21 of 30) of cases. Strokes predominantly affected the right anterior circulation (right anterior, 80% vs left anterior, 46.7% vs left posterior, 26.7%; P = .013), independent of arterial cannulation site. The proposed mechanism of perioperative strokes was not uniform (embolism, 33.3%; hypoperfusion, 42.8%; embolism and hypoperfusion, 14.3%; lacunar infarct, 10%), whereas most postoperative strokes were embolic (77.8%). The mean National Institutes of Health Stroke Scale score was 20.6 ± 9.9, and the modified Rankin score at discharge was 4.1±2.2. ConclusionsMost strokes in ATAD occurred perioperatively from various mechanisms predominantly affecting the right anterior circulation irrespective of the arterial cannulation site. This complication is most likely the result of unstable hemodynamics and dissection of the innominate artery (IA) or its downstream vessels.

The impact of transpancreatic precut sphincterotomy on the quality of ERCP in a low-volume setting

Background and aimsAlthough quality improvement is crucial for endoscopic retrograde cholangiopancreatography (ERCP), a low practice volume can pose challenges to achieving high-quality bile duct cannulation. Transpancreatic precut sphincterotomy (TPS) has been proven effective for advanced cannulation. However, existing data mainly come from skilled endoscopists in large medical centers. The impact of TPS on ERCP quality in a lower-volume setting deserves investigation. MethodsOur hospital performs approximately 200 ERCPs annually, with one expert performing approximately half of them and three nonexpert endoscopists sharing the remaining cases. TPS was started and became our predominant advanced cannulation technique in April 2016. We retrospectively reviewed ERCP cases three years before and after the introduction of TPS. The primary endpoints of the study were the differences in two ERCP quality indicators, the bile duct cannulation rate and the incidence of post-ERCP pancreatitis (PEP). ResultsA total of 701 ERCP cases with naïve papilla were analyzed, with 350 patients treated before the introduction of TPS and 351 patients treated afterward. The successful cannulation rate was significantly improved (before: 87.4%, after: 92.3%, P=0.032), while the incidence of PEP decreased, but not significantly (before: 4.0%, after: 2.8%, P=0.402). All endoscopists benefited from utilizing TPS, with nonexperts demonstrating a significantly higher improvement in the cannulation rate (before: 85.5%, after: 93.1%, P=0.019). ConclusionsTPS can effectively enhance the quality of ERCP irrespective of practice volume.

Right Axillary Artery Cannulation for Veno-Arterial Extracorporeal Membrane Oxygenation in Postcardiotomy Patients: A Single-Center Experience.

Background and Objectives: To analyze the patient outcome and complication rate of axillary artery cannulation for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients who could not be weaned from cardiopulmonary bypass after cardiothoracic surgery. Materials and Methods: We analyzed the data of 179 patients who were supported with VA-ECMO with femoral-axillary access (FA VA-ECMO) after cardiothoracic surgery between January 2014 and January 2019 in our department. Patients requiring central aortic cannulation and patients with respiratory failure requiring veno-venous ECMO were excluded. Primary outcomes were in-hospital mortality and 1-year survival rate of patients who were weaned from VA-ECMO support. Secondary outcomes were cannulation-related complications at the axillary site, VA-ECMO-related complications, and systemic complications. Results: In our cohort, 60 (33.5%) patients were female. Mean age was 67.0 ± 10.9 years. Overall, 78 (43.5%) patients were operated upon electively, 37 (20.7%) patients underwent urgent surgery, and 64 (35.8%) patients underwent emergency surgical treatment. Sixty-seven patients (37.4%) were resuscitated preoperatively. The mean duration of VA-ECMO support was 8.4 ± 5.1 days. Weaning from VA-ECMO was successful in 87 (48.6%) patients; 62 (34.6%) patients survived the hospital stay. The 1-year survival rate was 74%. Subclavian bleeding occurred in 24 (13.4%) patients, femoral bleeding in 4 (2.2%) patients, ischemia of the upper limb in 11 (6.1%) patients, intracerebral bleeding in 9 (5%) patients, and stroke in 19 (10.6%) patients. Conclusions: In patients with acute LV dysfunction after cardiothoracic surgery who cannot be weaned from cardiopulmonary bypass, right axillary artery cannulation is a safe and reliable method for VA-ECMO support with an acceptable complication rate.

Distal radial approach using a transdermal nitroglycerin patch : double-blinded randomized trial

Abstract Background The distal radial approach (DRA) provides a lower risk of radial artery occlusion than the conventional transradial approach (TRA) and has recently been used worldwide as an alternative access route for coronary catheterization. However, the small diameter of the distal radial artery causes difficulty in puncture and leads to DRA failure. Purpose The aim of this study is to elucidate whether a transdermal nitroglycerin patch improves the rate of successful DRA cannulation. Methods A total of 92 patients with angina pectoris scheduled for elective coronary angiography via DRA randomly received (1:1) a transdermal nitroglycerin patch pre-integrated with the covering material or only the covering material on their upper arm on the side of the puncture. The diameter of the distal radial artery was evaluated with ultrasound at baseline and after application. DRA procedures were performed in a double-blinded fashion. The primary outcome was the rate of successful palpation-guided distal radial artery cannulation with the first puncture. Results The nitroglycerin group had larger distal radial artery diameter after patch application than the no-treatment group (3.21 ± 0.68 mm vs. 2.71 ± 0.52 mm, P&amp;lt;0.001), but not at baseline (2.64 ± 0.48 mm vs. 2.64 ± 0.45 mm, P = 0.965, Figure 1).The nitroglycerin group had a significantly higher success rate of palpation-guided DRA cannulation with the first puncture than the no-treatment group (58.7% vs. 23.9%; P = 0.001; odds ratio, 4.5; 95% confidence interval, 1.9–11.0, Figure 2). Fewer punctures were required for successful sheath insertion in the nitroglycerin group compared with the no-treatment group (1 [1–5] vs. 3 [2–6]; P=0.019). Procedure time from puncture to sheath insertion was shorter in the nitroglycerin group, but the difference was not significant (142 [112–287] seconds vs. 202 [142–411] seconds; P=0.058). The incidence of vasospasm, hypotension (systolic blood pressure &amp;lt; 90 mmHg) before and during CAG, and puncture site hematoma was similar in the two groups. No patients experienced distal radial arterial occlusion. Conclusions The use of a transdermal nitroglycerin patch was associated with an increase in the diameter of the distal radial artery, higher success rate of DRA cannulation with the palpation-guided first puncture. The transdermal nitroglycerin patch has a potential to be an effective pretreatment for DRA.Changes in distal radial artery diameterResults of primary outcome