Carotid Artery Puncture Research Articles

Carotid artery stenting by non-femoral arterial approach in patients with difficult anatomy

Background: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are safe, effective, and standard methods to treat significant carotid artery stenosis. CAS is generally performed through femoral arterial access. We had six patients with significant carotid artery stenosis, who had difficult anatomy prohibiting a trans- femoral CAS. Those patients were given an option for CEA. However, they refused for surgical intervention. Aim: We investigated the feasibility of performing CAS from a non-femoral arterial approach in patients with difficult anatomies like severe aortic/aorto-iliac disease, tortuous aortic arch, and tortuous carotid artery origin. Materials and Methods: Six patients with difficult anatomy presented to us with either transient ischemic attack or stroke with high-grade carotid artery stenosis. Out of the six patients, three had aorto-iliac disease, one had high-grade coarctation of aorta, two had tortuous aortic arch and or tortuous carotid artery origin. All these patients were treated with CAS though non-femoral arterial route. Results: CAS could be done successfully in all these six patients; four of them were done through trans-brachial arterial route and two were done through a direct carotid artery puncture. There were no new neurological deficits seen in any of the patient post -procedure. Conclusion: CAS can be done safely through non-femoral arterial approach in patients with difficult anatomy.

Polygonum amplexicaule Extract: An Effective Herbal Cure to CCl4 Induced Liver Damage In Vivo

Introduction: Liver damages are mainly caused by toxic chemicals, alcohol, infections and autoimmune disorders. Polygonum amplexicaule is a member of the genus Polygonum having high antioxidant contents and it has traditional medicinal attributes in treatment of many ailments particularly liver damage. Objectives: Keeping in view the medicinal importance of P. amplexicaule, present study was constructed for in-vivo hepatoprotective activity of its rhizome extract in albino mice. Methods: BALB/C albino mice were selected for experimental assays and sorted in nine groups (group i-iii control groups, group iv-ix herb treated groups) with six mice in each group for six days treatment. Blood samples from anesthetized mice (20% chloroform) were collected by carotid artery puncture allowed to coagulate at room temperature for 30 min and then centrifuged at 3000 rpm for 8-10 min. The serum separated was preserved at -20°C for subsequent analysis of biochemical parameters. Animals were sacrificed under diethyl ether anaesthesia at fasting state, liver tissues were quickly excised and were stored in fixative sera (10% formalin), for histology. Results: Results revealed that CCl4 had significantly reduced the body weight and increased the level of ALT, AST, ALP and plasma bilirubin compared to toxic control. The pre-treatment of CCl4-administrated mice with extracts of P. amplexicaule at concentration of 200 mg/kg induced a profound decrease (62-94.4%) in the elevated activities of ALT, AST, ALP and plasma bilirubin level. Conclusion: P. amplexicaule extracts have hepatoprotective activity and it can be used as herbal medicine for use in food, medicines and healthcare products to cure liver damages.

Abstract 13849: Enhancing Anti-thrombotic Efficacy but Reducing Hemorrhage: Comparison and Combination Use of a Novel Integrin Outside-in Signaling Inhibitor With Current Anti-platelet Drugs

Introduction and Hypothesis: Current anti-platelets drugs cause excessive bleeding. We have developed a novel anti-platelet drug, M3mP6, which selectively inhibits integrin outside-in signaling but not ligand binding to integrin αIIbβ3. Here we test the hypothesis that M3mP6 may synergistically enhance anti-thrombotic effects of current anti-platelet drugs but reduce risk of hemorrhage. Methods and Results: One time bolus injection of M3mP6 (10 uMol/kg,15 min) has superior anti-thrombotic effect compared to high doses of clopidogrel (4 mg/kg, oral, 2 hours), and very high doses of aspirin (36 mg/kg, i.p., 1 hour), using a FeCl 3 -induced occlusive carotid artery thrombosis model in mice. However, unlike the high doses of clopidogrel and aspirin, M3mP6 did not affect bleeding using a tail bleeding time model. We found that M3mP6 was comparable with the loading doses of ticagrelor (3 mg/kg) and cangrelor (30 μg/kg) in anti-thrombotic efficacy. However, ticagrelor or cangrelor cause dramatically increased hemorrhage, which is in contrast to M3mP6’s lack of bleeding side effect. To mimic hemorrhage during intravascular/surgical procedures, we designed a carotid artery puncture model of surgical hemorrhage. Cangrelor caused dramatically excessive bleeding even treated with a hemostatic pad. In contrast, M3mP6-treated mice are not different from control. Importantly, M3mP6 exerts synergistic anti-thrombotic effects when used together with current anti-platelets drugs, without further increases in bleeding. Furthermore, when M3mP6 was used in combination with a reduced dose of cangrelor, the anti-thrombotic effect was significantly more potent than high dose cangrelor, but hemorrhage was greatly reduced. Conclusions: M3mP6 is potentially a superior new anti-platelet drug, ideal for patients with bleeding risk, and also for greatly enhancing anti-thrombotic effects of current anti-platelet drugs while reducing hemorrhage.

Can migraine aura be provoked experimentally? A systematic review of potential methods for the provocation of migraine aura.

Background The nature of the migraine aura and its role in migraine pathophysiology is incompletely understood. In particular, the mechanisms underlying aura initiation and the causal relation between aura and headache are unknown. The scientific investigation of aura in patients is only possible if aura can be triggered. This paper reviews potential methods for the experimental provocation of migraine aura. Methods We systematically searched PubMed for studies of experimental migraine provocation, including case reports of patients with aura and reports of the occurrence of aura following exposure to any kind of suspected trigger. Results We identified 21 provocation studies, using 13 different prospective provocation methods, and 34 case reports. In the prospective studies, aura were reported following the administration of intravenous and sublingual glyceryl trinitrate, visual stimulation, physical activity, calcitonin gene-related peptide infusion, chocolate ingestion, and the intravenous injection of insulin. In addition, carotid artery puncture has consistently been reported as a trigger of aura. Conclusions No safe and efficient method for aura provocation exists at present, but several approaches could prove useful for this purpose.

Internal jugular dimensions and common carotid overlapping assessed in a cross-sectional study by ultrasonography at three neck levels in healthy volunteers.

Cannulation of the internal jugular vein may be associated with inadvertent puncture of the common carotid artery. Systematic use of ultrasound guidance has improved clinical success rates and reduced complications, but better knowledge of topographic relationships of the internal jugular vein and common carotid artery is desirable. This preclinical study was designed to determine by ultrasound technique relative topographic characteristics in humans of the internal jugular veins and common carotid arteries at different levels on both sides of the neck. One hundred and twenty healthy volunteers were examined bilaterally by ultrasound at three neck levels with and without contralateral rotation of the head. Twelve digital pictures were recorded and used to determine venous diameters and extents of arteriovenous overlapping in each subject. Venous dimensions and arteriovenous overlapping were larger on the right side (p = 0.008) regardless of head rotation at all levels. There was more arteriovenous overlapping with than without rotation at right high- and mid-cervical levels (p<0.001). The only difference between right mid- and low-cervical levels was less arteriovenous overlapping at mid-cervical level without rotation (p = 0.017). The smallest venous dimensions and extent of arteriovenous overlapping were recorded at high-cervical level. Despite similar venous dimensions, less arteriovenous overlapping regardless of head rotation at mid-cervical level, together with the pleural proximity at low-cervical level, propose the internal jugular vein to be anatomically (other factors disregarded) favorable for vascular access on the right side, at mid-cervical level, close to the angle between the sternocleidomastoid muscle bellies, and with minimal rotation of the head.

Central Venous Cannulation of the Internal Jugular Vein Using Ultrasound-Guided and Anatomical Landmark Techniques.

BackgroundCentral venous cannulation is a current and important procedure used in the operating room and intensive care unit. Some studies have shown that the application of ultrasound-guided cannulation can improve the success rate of surgery, save time, reduce the number of required needlesticks, and mitigate many complications compared to anatomical landmark-guided cannulation.ObjectivesThe aim of the present study was to draw a comparison between central venous cannulation of the internal jugular vein using ultrasound-guided and anatomical landmark-guided techniques.Patients and MethodsA total of 321 patients scheduled for cardiac surgery in the surgical ward of a general hospital were randomly treated with central venous cannulation using either anatomical landmarks (150 patients) or ultrasound guidance (170 patients). The demographic data of patients, the success rate of cannulation, the execution time, and the number of attempts for successful cannulation as well as the complications were recorded and subjected to statistical analysis.ResultsThe success rate of cannulation was 98.7% in the anatomical landmark-guided group and 99.4% in the ultrasound-guided group. The average operation times were 46.05 and 45.46 seconds in the anatomical landmark and ultrasound-guided groups, respectively. The two groups were not significantly different in terms of the success rates of treatment, the number of attempts, the time required for successful cannulation, or the prevalence of complications (P > 0.05) other than carotid artery puncture (P = 0.04)ConclusionsIn our conditions, the use of an anatomical landmark-guided procedure was the preferred treatment method due to limited resources and a lack of adequate training.

Puncture point-traction method: A novel method applied for right internal jugular vein catheterization.

The ultrasound probe and advancement of the needle during real-time ultrasound-assisted guidance of catheterization of the right internal jugular vein (RIJV) tend to collapse the vein, which reduces the success rate of the procedure. We have developed a novel puncture point-traction method (PPTM) to facilitate RIJV cannulation. The present study examined whether this method facilitated the performance of RIJV catheterization in anesthetized patients. In this study, 120 patients were randomly assigned to a group in which PPTM was performed (PPTM group, n=60) or a group in which it was not performed (non-PPTM group, n=60). One patient was excluded because of internal carotid artery puncture and 119 patients remained for analysis. The cross-sectional area (CSA), anteroposterior diameter (AD) and transverse diameter (TD) of the RIJV at the cricoid cartilage level following the induction of anesthesia and during catheterization were measured, and the number with obvious loss of resistance (NOLR), the number with easy aspiration of blood into syringe (NEABS) during advancement of the needle, and the number of first-pass punctures (NFPP) during catheterization were determined. In the non-PPTM group, the CSA was smaller during catheterization compared with that following the induction of anesthesia (P<0.01). In the PPTM group compared with the non-PPTM group during catheterization, the CSA was larger (P<0.01) and the AD (P<0.01) and TD (P<0.05) were wider; NOLR (P<0.01), NEABS (P<0.01) and NFPP (P<0.01) increased significantly. The findings from this study confirmed that the PPTM facilitated catheterization of the RIJV and improved the success rate of RIJV catheterization in anesthetized patients in the supine position.

Usefulness of Suction Decompression Method Combined with Extradural Temporopolar Approach During Clipping of Complicated Internal Carotid Artery Aneurysm

Surgical clipping of complicated internal carotid artery (ICA) aneurysms can be very difficult because strong adhesion may hinder dissection of the perforators and surrounding anatomical structures from the aneurysm dome. We describe our experience in the clipping of these aneurysms using retrograde suction decompression (RSD) combined with extradural temporopolar approach (ETA) and discuss its advantages and pitfalls. This retrospective study included 30 consecutive patients with complicated ICA aneurysms treated by direct clipping with RSD assistance between March 2004 and March2015. The aneurysms were located on the paraclinoid ICA in 20 cases, the posterior communicating artery bifurcation in 8, ICA bifurcation in 1, and the anterior wall of the ICA in 1. No patient suffered any complication related to the puncture of the common carotid artery. Surgical outcome was good recovery in 20 patients, moderate disability in 4, severe disability in 4, and vegetative state in 1. One patient died of re-rupture of the aneurysm caused by incomplete dome clipping. Two patients suffered cerebral infarction, caused by anterior choroidal artery infarction in 1 patient. Retrograde suction decompression combined with ETA is a useful technique for clipping of complicated ICA aneurysms.

Implantable venous ports in pediatric oncology: experience of single institution in Russia.

To review our experience with implantable venous port-systems (IVPs) in pediatric cancer patients. From 2010 to 2015 we were monitoring the treatment of 163 children (aged 3 months to 17 years) with oncologic diseases. These patients underwent venous port implantations. During insertion of 163 IVPs the following complications and technical difficulties were present: unintended puncture of the common carotid artery (CCA) during the puncture of the internal jugular vein (IJV) - 7 cases (4.3%); retrograde positioning of the distal end of the guidewire in the IJV - 17 cases (14.4%); placement of the distal end of the guidewire into the punctured subclavian vein (SV) - 12 cases (7.6%); difficulties driving the guidewire into the IJV after successful puncture - 15 cases (9.3%). The use of 163 IVPs was complicated by the following: venous port contamination - 4 cases (2.5%); occlusion of the IVPs by a clot - 8 cases (5%); withdrawal of the Huber needle bevel from the port chamber - 22 cases (13.6%); subcutaneous fat layer thinning above the port chamber - 3 cases (1.7%). There are many complications, but they can be reduced by proper choice of materials and methodology.

Asymptomatic Mediastinal Hematoma as a Complication of Ultrasound-Guided Internal Jugular Vein Catheterization

Central venous catheterization is a frequently performed procedure in the intensive care units (ICU) for various treatments such as iv therapy, parenteral nutrition and hemodialysis but occasionally encountered complications can be fatal. Therefore, safe insertion with confirmation of correct positioning of the catheter is vital. Ultrasound (US)-guided insertion of catheters has been used widely, and its safety and efficacy have been demonstrated in several studies. However, this technique is not free from complications, such as carotid artery puncture, hemothorax, pneumothorax and infection. In this case, anterior mediastinal hematoma proceeded after US-guided internal jugular vein (IJV) catheterization.

Retrograde Suction Decompression Through Direct Puncture of the Common Carotid Artery for Paraclinoid Aneurysm.

Surgical clipping of paraclinoid aneurysm can be very difficult because strong adhesions may hinder the dissection of the perforators and surrounding anatomical structures from the aneurysm dome. We describe our experience with using retrograde suction decompression during the clipping of paraclinoid aneurysms and discuss the relative advantages and pitfalls. This study included 23 patients with large and giant paraclinoid aneurysms who underwent surgical treatment consisting of direct clipping with suction decompression between March 2004 and August 2014. Direct puncture of the common carotid artery (CCA) was performed with a 20-gauge needle. The aneurysm was temporarily trapped by clamping of the CCA and external carotid artery (ECA), followed by temporary clipping of the intracranial internal carotid artery (ICA) distal to the aneurysm neck. Blood was then gently aspirated through a catheter introduced into the cervical ICA, resulting in collapse of the aneurysm. Therefore, safe aneurysm dissection was feasible during interruption of the blood flow, which could be maintained for up to 5 min. This procedure was repeated until dissection and clipping of the aneurysm were completed. Seven patients were admitted with SAH, 11 with asymptomatic unruptured aneurysm, and 5 with symptomatic unruptured aneurysm. The aneurysms were located on the paraclinoidal segment of the ICA in 15 cases, on the ICA-posterior communicating artery (PComA) in 6, at the ICA bifurcation in 1, and on the anterior wall of the ICA in 1. None of them suffered complications related to the CCA puncture. Surgical outcome was good recovery in 13 patients, moderate disability in 4, severe disability in 4, and vegetative state in 1. Retrograde suction decompression through direct puncture of the common carotid artery is a useful adjunct technique for the clipping of paraclinoid ICA aneurysms.

Venous Access in the Treatment of Children with Cancer: Results of A 10-Year Multicenter Study

Introduction. Chemotherapy is the definitive treatment for children with cancer. Intravenous administration is the most common method of chemotherapy, since most chemo drugs are easily absorbed through the blood. Thus a long-term venous access is one of the most important and urgent aims of pediatric oncology. Materials and methods . A total of 246 patients aged 2 months to 17 years were included in the analyses. Implanted venous access port systems (IVAPS) implantation was performed in all the patients during the period of 2006-2015. Results . We observe the following complications and technical difficulties in 42 (17%) patients: accidental carotid artery puncture during attempted internal jugular vein (IJV) puncture — 16 (6.5%) cases, retrograde positioning of the distal end of the guidewire in the IJV — 21 (8,5%) cases; insertion of guide wire's distal tip into the punctured SV — 12 (4,9%) cases; difficulties during catheter advancement into the IJV after successful puncture — 26 (10,6%) cases. The following complications were detected venous port contamination — 17 cases (6,9%); occlusion of the IVAPS by a clot — 34 cases (13,8%); subcutaneous fat layer thinning above the port chamber — 2 cases (0,8%). Conclusion . Complications reported in our study (75 cases) were not fatal, mostly preventable, and have not led to protocol violations in the treatment of children with cancer. However, it should be highlighted that there is a need in further training of nurses and doctors in order to disseminate the proposed procedures in other clinics of the Russian Federation and reduce the number of operational complications.

Венозный доступ при лечении детей с онкологическими заболеваниями: результаты 10-летнего мультицентрового исследования

Introduction. Chemotherapy is the definitive treatment for children with cancer. Intravenous administration is the most common method of chemotherapy, since most chemo drugs are easily absorbed through the blood. Thus a long-term venous access is one of the most important and urgent aims of pediatric oncology. Materials and methods . A total of 246 patients aged 2 months to 17 years were included in the analyses. Implanted venous access port systems (IVAPS) implantation was performed in all the patients during the period of 2006-2015. Results . We observe the following complications and technical difficulties in 42 (17%) patients: accidental carotid artery puncture during attempted internal jugular vein (IJV) puncture — 16 (6.5%) cases, retrograde positioning of the distal end of the guidewire in the IJV — 21 (8,5%) cases; insertion of guide wire's distal tip into the punctured SV — 12 (4,9%) cases; difficulties during catheter advancement into the IJV after successful puncture — 26 (10,6%) cases. The following complications were detected venous port contamination — 17 cases (6,9%); occlusion of the IVAPS by a clot — 34 cases (13,8%); subcutaneous fat layer thinning above the port chamber — 2 cases (0,8%). Conclusion . Complications reported in our study (75 cases) were not fatal, mostly preventable, and have not led to protocol violations in the treatment of children with cancer. However, it should be highlighted that there is a need in further training of nurses and doctors in order to disseminate the proposed procedures in other clinics of the Russian Federation and reduce the number of operational complications.

A Randomized Crossover Study Comparing a Novel Needle Guidance Technology for Simulated Internal Jugular Vein Cannulation

Despite ultrasound guidance for central line placement, complications persist, as exact needle location is often difficult to confirm with standard two-dimension ultrasound. A novel real-time needle guidance technology has recently become available (eZono, Germany) that tracks the needle during insertion. This randomized, blinded, crossover study examined whether this needle guidance technology improved cannulation of a simulated internal jugular (IJ) vein in an ultrasound phantom. One hundred physicians were randomized to place a standard needle in an ultrasound neck phantom with or without the needle guidance system. Video cameras were placed externally and within the lumens of the vessels to record needle location in real time. The primary outcome measured was the rate of posterior wall puncture. Secondary outcomes included number of carotid artery punctures, number of needle passes, final needle position, time to cannulation, and comfort level with this new technology. The incidence of posterior vessel wall puncture without and with needle guidance was 49 and 13%, respectively (P < 0.001, odds ratio [OR] = 7.33 [3.44 to 15.61]). The rate of carotid artery puncture was higher without needle navigation technology than with needle navigation 21 versus 2%, respectively (P = 0.001, OR = 12.97 [2.89 to 58.18]). Final needle tip position being located within the lumen of the IJ was 97% accurate with the navigation technology and 76% accurate with standard ultrasound (P < 0.001, OR = 10.42 [2.76 to 40.0]). Average time for successful vessel cannulation was 1.37 times longer without guidance technology. This real-time needle guidance technology (eZono) shows significant improvement in needle accuracy and cannulation time during simulated IJ vein puncture.

Ultrasound Guidance Does Not Prevent Intracarotid Placement of Central Lines

Ultrasound guidance for all central line placements has been advocated in order to avoid vascular complications and misplacement. Ultrasound without sufficient anatomic knowledge, however, does not guarantee technical safety. We report the case of a 55-year-old woman who presented to the hospital with a right cerebellar stroke and diabetic ketoacidosis. A hospitalist physician placed an ultrasound-guided right internal jugular catheter for fluid resuscitation. The postprocedure chest X-ray image was interpreted as a successful placement of right subclavian catheter (Fig 1, A). A computed tomography angiogram was obtained 2 days later as part of the stroke evaluation. This showed the catheter traversing the jugular vein and entering the common carotid artery retrograde into the aortic arch (Fig 1, B). Vascular surgery was consulted. Because the patient had heparin-induced thrombocytopenia with a platelet count of 30,000, she was taken to surgery for open removal (Fig 2, A). After catheter removal, with distal clamping, there was no bleeding from the carotid artery puncture hole. A small transverse arteriotomy removed a 13-mm × 3-mm well-formed clot (Fig 2, B). The jugular and carotid vessels were both repaired primarily, with good flow maintained (Fig 2, C). The patient recovered without any additional neurologic deficits. Ultrasound guidance alone is not sufficient to prevent vascular complications of central line placement. An understanding of vascular anatomy can help prevent such complications and properly diagnose them on chest X-ray imaging. Open surgical removal prevented embolization of a large pericatheter clot that would have occurred with simple removal.Fig 2Artery exposure, thrombus, and repair. A, CVC exposed; B, thrombus; C, repair.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Ultrasound guided internal jugular venous cannulation: comparison with land-mark technique.

To compare real-time ultrasonography-guided technique versus the traditional land-mark technique for internal Jugular venous cannulation. Randomized controlled trial. Department of Anaesthesia, Combined Military Hospital, Rawalpindi, from September 2013 to July 2014. A total of 200 patients who required internal jugular vein cannulation were randomly assigned using either real-time ultrasound-guided technique or land-mark technique. Access time, number of attempts until successful cannulation, complications and the demographics of each patient were recorded. Access time was significantly less in real-time ultrasound group (34.95 ± 11.47 vs. 146.59 ± 40.20 seconds, p < 0.001). Cannulation was performed in first attempt in 99% of patients in ultrasound group as compared to 89% of landmark group. Complication rate was significantly higher in the land-mark group than in the ultrasound-guided group. Carotid artery puncture rate (9% vs. 1%) and haematoma formation (7% vs. 0%) were more frequent in the land-mark group than in the ultrasound-guided group. Brachial plexus irritation was also more in land-mark group (6% vs. 0%). Access time, failure rate and procedure related complications are reduced when real-time ultrasonography is used to cannulate internal Jugular vein.

Percutaneous balloon angioplasty for severe native aortic coarctation in young infants less than 6 months: medium- to long-term follow-up.

Background:Although balloon angioplasty (BA) has been performed for more than 20 years, its use as a treatment for native coarctation of the aorta (CoA) during childhood, especially in young infants, remains controversial. This study aimed to assess the effects and potential role of percutaneous transcatheter BA for native CoA as an alternative therapy to surgical repair in young infants.Methods:The 37 patients aged from 6 days to 6 months with severe CoA in congestive heart failure or circulatory shock were admitted for BA. Patient's weight ranged from 2.4 to 6.1 kg. All 37 patients were experiencing cardiac dysfunction, and eight patients were in cardiac shock with severe metabolic acidosis. Eleven patients had an isolated CoA, whereas the others had a CoA associated with other cardiac malformations. Cardiac catheterization and aortic angiography were performed under general anesthesia with intubation. Transfemoral arterial approaches were used for the BA. The size of the balloon ranged from 3 mm × 20 mm to 8 mm × 20 mm, and a coronary artery balloon catheter was preferred over a regular peripheral vascular balloon catheter.Results:The femoral artery was successfully punctured in all but one patient, with that patient undergoing a carotid artery puncture. The systolic peak pressure gradient (PG) across the coarctation was 41.0 ± 16.0 mmHg (range 13–76 mmHg). The mean diameter of the narrowest coarctation site was 1.7 ± 0.6 mm (range 0.5–2.8 mm). All patients had successful dilation; the PG significantly decreased to 13.0 ± 11.0 mmHg (range 0–40 mmHg), and the diameter of coarctation significantly improved to 3.8 ± 0.9 mm (range 2.5–5.3 mm). No intraoperative complications occurred for any patients. However, in one case that underwent a carotid artery puncture, a giant aneurysm formed at the puncture site and required surgical repair. The following observations were made during the follow-up period from 6-month to 7-year: (1) The PG across the coarctation measured by echocardiography further decreased or remained stable in 31 cases. The remaining six patients, whose PGs gradually increased, required a second dilation. No patient required further surgery because of a CoA; (2) in two cases, an aortic aneurysm was found with an angiogram performed immediately postdilatation and disappeared at 18 and 12 months of age, respectively; (3) tricuspid regurgitation and pulmonary hypertension improved in all patients; (4) all patients were doing well and were asymptomatic.Conclusions:Percutaneous BA is a relatively safe and effective treatment for severe native CoA in young infants, and should be considered a valid alternative to surgery because of its good outcome and less trauma and fewer complications than surgery.

Angioseal™ as a hemostatic device for direct carotid puncture during endovascular procedures.

Direct carotid artery puncture (DCP) is employed in patients with tortuous anatomy and peripheral vascular disease when the peripheral arteries are not available for vascular access. Manual compression is the only method of achieving hemostasis following DCP and, till date, the use of a closure device for DCP has been reported in only one patient. In this study we sought to analyze our experience with the use of closure device for DCP. This is a retrospective study of patients in whom Angioseal™ was used following DCP for neuroendovascular procedures. Medical charts and imaging of these patients was reviewed for any abnormalities pertaining to the use of the closure device. A total of eight patients were included in the study. Angioseal™ was used in all the patients. There were no complications related to the use of the closure device in any of the eight patients. Immediate post-procedure angiography done in one patient did not show any structural or hemodynamic abnormalities within the carotid artery lumen. At 6 months follow-up imaging, there was no evidence stenosis or vascular wall abnormality in any of the patients. There were no adverse clinical reactions related to the use of closure device. In our experience, Angioseal™ may be a safe and off-label effective closure device for patients undergoing DCP for neuroendovascular procedures. It obviates the need for manual compression without causing any structural or hemodynamic changes within the carotid artery. Larger studies with longer follow-up are required to establish its safety in patients undergoing DCP.

Direct Percutaneous Carotid Access for Carotid Angioplasty and Stenting

Purpose: To describe a direct percutaneous carotid access technique for carotid artery stenting (CAS) that circumvents the potential for embolization that can occur during catheter manipulation in the aortic arch during femoral access. Technique: After inducing anesthesia, an ultrasound transducer is placed at the base of the neck above the clavicle. A 21-G, 7-cm needle from a micropuncture introducer is used for single-wall puncture of the common carotid artery (CCA). A 0.018-inch guidewire is inserted into the needle for placement of a 4-F, 10-cm introducer. After placing a 0.035-inch angled guidewire in the external carotid artery, the 4-F introducer is exchanged for the closure device sheath (preclose technique). A regular 6-F introducer is then placed inside the closure device sheath, and a low dose (2000 units) of heparin is administered for the brief CAS procedure, which is performed under cerebral protection. After a successful procedure is confirmed, the protection device is retrieved, and the closure device is applied to seal the puncture. Conclusion: This approach has a low rate of neurological and access site complications. Percutaneous direct carotid access could extend the indications for CAS to include difficult anatomies, high-risk patients, and certain emergent situations that warrant easy and rapid access to the CCA.

Comparative Sonoanatomy of Classic “Short Axis” Probe Position with a Novel “Medial-oblique” Probe Position for Ultrasound-guided Internal Jugular Vein Cannulation: A Crossover Study

BackgroundUltrasound (US)-guided short-axis approach for internal jugular vein (IJV) cannulation does not fully protect patients from inadvertent carotid artery (CA) puncture. Carotid puncture is not rare (occurring in up to 4% of all IJV cannulations) despite the use of US. ObjectivesCompare the sonoanatomy of the “medial-oblique approach” probe position with the classic US-guided “short-axis” probe position, specifically: relation of internal CA and IJV; vertical and horizontal diameter of IJV; and degree of overlapping of IJV with CA. MethodsOne hundred consecutive patients between the ages of 18 and 50 years, both male and female, and American Society of Anesthesiologists Physical Status classification system (ASA PS) I–II undergoing elective surgery under general anesthesia were recruited in this prospective, randomized, crossover, parallel-group study. ResultsThe transverse diameter of the IJV was found to be significantly higher in the medial-oblique probe position (p = 0.000, mean difference 0.43 cm; 95% confidence interval [CI] 0.34–0.52). The percentage of overlap was also significantly lower in the medial-oblique probe position (48.7 ± 10.7% in short-axis vs. 36.3 ± 13.2% in medial-oblique probe position; p = 0.000; mean difference 12.4%, 95% CI 9.1–15.8). However, there was no statistically significant difference in the anteroposterior diameter of the IJV between the two probe positions (1.11 ± 0.26 cm in short axis vs 1.07 ± 0.25 cm in medial oblique; p = 0.631). ConclusionThe medial-oblique probe position for IJV cannulation provides sonoanatomic superiority over the classic short-axis probe position. Further randomized, controlled trials may confirm the medial-oblique view's clinical benefit in the future.