Catheter Position Research Articles

Conventional Radiology Evaluation of Neonatal Intravascular Devices (NIVDs): A Case Series.

Our radiology department conducted an assessment of 300 neonatal radiographs in the neonatal intensive care unit over almost two years. The purpose was to evaluate the correct positioning of intravascular venous catheters. Our case series revealed that out of a total of 95 cases with misplaced devices, 59 were umbilical venous catheters and 36 were peripherally inserted central catheters. However, all of the central venous catheters were found to be properly positioned. Misplacements of neonatal intravascular devices were found to occur more frequently than expected. The scientific literature contains several articles highlighting the potential complications associated with misplaced devices. Our goal is to highlight the potential misplacements and associated complications that radiologists may encounter while reviewing conventional radiology imaging. Based on our experience, which primarily involved placing UVCs and PICCs, we discovered that conventional radiology is the most effective method for assessing proper device placement with the lowest possible radiation exposure. Given the high number of neonatal vascular device placement procedures, it is essential for radiologists to maintain a high level of vigilance and stay updated on the latest developments in this field.

Morphine Consumption and/or Numerical Scale in Pain Studies: Silverman Integrating Approach (SIA SCORE)

Introduction: Ligamentoplasty pain management is dynamic performance, demanding constant vigilance and adaptation. The aim of this prospective study was to compare the analgesic efficacy of three techniques for knee ligamentoplasty using an integration score, the SIA score.
 Methods: The study included 165 patients undergoing primary reconstruction of the anterior cruciate ligament of the knee. The first group, systemic analgesia (SA), received balanced systemic analgesia postoperatively for a minimum of five days, based on Paracetamol, Diclofenac, and a morphine PCA. In addition to the systemic analgesia already described, the second group, femoral analgesia (FA), will benefit from a femoral peri-nervous catheter in the crural position. The third intra-articular analgesia (IAA) group received, in addition to the same systemic analgesia, an infusion through an epidural catheter of 20 ml of 0.125% bupivacaine, followed by maintenance with 8 ml/h of the same local anesthetic via an electric syringe pump for 36 h. Cumulative morphine consumption was assessed, as well as pain at rest, using a numerical scale (EN) from 1 to 10 and an integration of these two parameters.
 Results: Morphine consumption was lower in the AF group. The lowest mean rank was in the AF group, followed by the AIA group, and the difference was statistically significant with an H = 6.89 and a p= 0.032. The difference was significant between the AS group and the AF group (p = 0.09); the other inter-group differences were not significant. 23.2% of patients had an AIS score between [-100, -200], and were in little pain and consumed little morphine (effective treatment); 14.2% of patients had an AIS score between [100, 200] and were in great pain and consumed a lot of morphine (morphine-resistant or very sensitive to pain).
 Conclusion: Analgesia in the femoral peri-nerve group was more effective, with a reduction in mean EN compared with the other two groups.

Comparison of Ultrasound-Guided Umbilical Venous Catheter Insertion with Blind Method: A Randomized Controlled Trial

Introduction: Ultrasonography (USG) can be used in neonates to manipulate and place the umbilical catheter in the correct position. Although chest radiograph (CXR) is the gold standard, a noninvasive method like USG without radiation exposure may be an alternative bedside armamentarium to the clinician. The purpose of the study was to evaluate whether USG-guided umbilical venous catheter (UVC) insertion is superior to the conventional method for the successful insertion of UVC. Method: The neonates born between 25 and 42 weeks of gestation requiring parenteral fluids and admission to neonatal intensive care unit (NICU) between September 2020 and November 2022 were randomized in two weight-based strata: ≤1,200 and >1,200 g. USG-guided UVC insertion was done in the intervention group and blind UVC insertion was done in the control group. Results: Out of 112 enrolled neonates, 58 were in the USG-guided group and 54 in the blind group. There was no significant difference in the failure rate between the intervention and control groups (20% versus 29% [RR: 0.69, 95% CI: 0.36–1.33]). The sensitivity and specificity of USG in locating tip position were 97 and 46.8%, respectively. The mean procedure time in USG and blind groups was 8.9 and 8.3 min, respectively (p value 0.56). Conclusion: USG does not reduce the failure rates during the insertion of umbilical catheters. However, being a safe, noninvasive procedure, it can be considered a rescue modality to CXR in NICUs equipped with portable USG for guiding UVC insertion.

Breakage and dislocation of the Hickman catheter in pediatric patient

Introduction. The Hickman catheter is a tunneled, open-type catheter often implanted in children for long-term intravenous treatment. Their application can cause numerous complications. Catheter breakage and dislocation of fragments to the intravascular system is a rare but life-threatening condition. When a complication occurs, depending on the patient's clinical condition, the first step is transcutaneous endovascular removal of the catheter's fragment. If this is not possible, surgical thoracotomy is necessary. The objective of this article was to present a case of breakage and dislocation of Hickman catheter in pediatric patient, as well as the diagnostic and therapeutic approach to complications. Case outline. We report a 14-month-old child who had a Hickman catheter because he was undergoing treatment for acute juvenile myelomonocytic leukemia. Due to a malfunction of the catheter, the existing catheter had to be removed. During the surgical procedure, a breakage and dislocation of the catheter fragment occurred. A chest x-ray and an echocardiography confirmed the position of the catheter fragment in the right atrium. A transcutaneous endovascular procedure was successfully performed to remove part of the catheter. Conclusion. Numerous complications can occur during the insertion, management, and removal of long-term catheters. It is necessary to periodically control the catheter's position by chest x-ray and ultrasound of the heart and neck. If a particular complication is detected, an individual approach to treatment with the lowest risk to the patient should be chosen. Dislocated fragments of the Hickman catheter can be safely removed by endovascular transcatheter procedures.

Precise Terminology and Specified Catheter Insertion Length in Ultrasound-Guided Infraclavicular Central Vein Catheterization.

Background and Objectives: As the latest research encourages the ultrasound-guided infraclavicular central venous approach, due to the lateral puncture site displacement, in comparison to the anatomical landmark technique based on subclavian vein catheterization, the need to re-calculate the optimal catheter insertion length and possibly to rename the punctuated vessel emerges. Although naming a particular anatomical structure is a nomenclature issue, a suboptimal catheter position can be associated with multiple life-threatening complications and must be avoided. The main study objective is to determine the optimal catheter insertion length by the most proximal ultrasound-guided, in-plane infraclavicular central vein approach, to compare results with the anatomical landmark technique based on subclavian vein catheterization and to clarify the punctuated anatomical structure. Materials and Methods: 109 patients were enrolled in this study. All procedures were performed according to the same catheterization protocol. In order to determine optimal insertion length, chest X-ray scans with an existing catheter were performed. The definition of punctuated vessel was based on computer tomography and evaluated by radiologists. Independent predictors for optimal insertion length were identified, prediction equations were generated. Results: The optimal catheter insertion length is approximately 1.5 cm longer than estimated by Pere's formula and can be accurately calculated based on anthropometric data. Computed tomography revealed: five cases with subclavian vein puncture and three cases with axillary vein puncture. Conclusions: Even the most proximal ultrasound-guided infraclavicular central vein access does not guarantee subclavian vein catheterization. A more accurate term could be infraclavicular central venous access, with the implication that the entry point could be through either subclavian or axillary veins. The optimal insertion length is approximately 1.5 cm deeper than the length determined for the anatomical landmark technique based on subclavian vein catheterization.

Very rare malposition of central venous catheter in cardiac surgery patients.

Malposition of a catheter is found in approximately 7% of cases after central venous catheterisation. This may result in haemorrhage, venous thrombosis and functional impairment, depending on the injury to the vessel wall. Uncomplicated catheterisation, easy aspiration of blood and monitoring of catheterisation do not guarantee correct placement of the catheter. In our rare case series, we share our experience of four cases of malposition into the left internal mammary vein (LIMV) that we experienced in a three-year period. The thinness and fragility of the vessel wall, particularly, increases the probability of complications in malposition into the LIMV. Administration of a catheter through the right jugular vein is associated with the lowest incidence of malposition. Performing the procedure under the guidance of ultrasonography (USG) and confirmation of the catheter position after puncture using one of the USG techniques will minimise the probability of malposition. In addition, a lung X-ray should immediately be taken, and venography and fluoroscopy should be considered in the presence of suspicion.

Intraprocedural C-arm dual-phase cone-beam enhancement patterns correlate with tumor absorbed dose after radioembolization.

Recent studies have shown a clear relationship between absorbed dose and tumor response to treatment after hepatic radioembolization. These findings help to create more personalized treatment planning and dosimetry. However, crucial to this goal is the ability to predict the dose distribution prior to treatment. The microsphere distribution is ultimately determined by (i) the hepatic vasculature and the resulting blood flow dynamics and (ii) the catheter position. To show that pretreatment, intra-procedural imaging of blood flow patterns, as quantified by catheter-directed intra-arterial contrast enhancement, correlate with posttreatment microsphere accumulation and, consequently, absorbed dose. Patients who participated in a clinical trial (NCT01177007) and for whom both a pretreatment dual-phase contrast-enhanced cone-beam CT (CBCT) and a posttreatment 90Y PET/CT scan were available were included in this retrospective study. Tumors and perfused volumes were manually delineated on the CBCT by an experienced radiologist. The mean, sum, and standard deviation of the voxels in each volume were recorded. The delineations were transferred to the PET-based absorbed dose maps by coregistration of the corresponding CTs. Linear multiple regression was used to correlate pretreatment CBCT enhancement to posttreatment 90Y PET/CT-based absorbed dose in each region. Leave-one-out cross-validation and Bland-Altman analyses were performed on the predicted versus measured absorbed doses. Nine patients, with a total of 23 tumors were included. All presented with hepatocellular carcinoma (HCC). Visually, all patients had a clear correspondence between CBCT enhancement and absorbed dose. The correlation between CBCT enhancement and posttherapy absorbed tumor dose based was strong (R2=0.91), and moderate for the non-tumor liver tissue (R2=0.61). Limits of agreement were approximately ±55 Gray for tumor tissue. There is a linear relationship between pretreatment blood dynamics in HCC tumors and posttreatment absorbed dose, which, if shown to be generalizable, allows for pretreatment tumor absorbed dose prediction.

The value of transthoracic echocardiography and chest X-ray in locating the tip of central venous catheter in dialysis patients: a comparative study with computed tomography imaging

To determine the tip position of the central venous catheter (CVC) in patients with dialysis, the guidelines recommend that it be determined using chest radiography (CXR) after catheterization, without fluoroscopy. However, some researchers have proposed that transthoracic echocardiography (TTE) can replace CXR, but this has not been widely adopted. This study aimed to determine which of the two aforementioned methods is more suitable for locating the tip position of the CVC. This prospective study included 160 patients who underwent hemodialysis at our hospital from March 2021 to December 2022. After inserting the CVC through the internal jugular vein, we used transthoracic echocardiography and CXR to determine the tip of the CVC and compared the results with those of computed tomography (CT). In the comparison between TTE and CXR for locating the CVC tip, we obtained three main findings. (1) TTE was associated with fewer misdiagnosed cases than CXR. (2) TTE provided higher sensitivity (similar sensitivity in position 2), specificity, positive/negative predictive values, and accuracy than CXR. (3) When comparing the receiver operating characteristic curves of TTE and CXR, the area under the curve (95% confidence interval) for the former was larger. Additionally, we made anatomical discoveries: the "hyperechoic triangle" recognized by TTE was equivalent to the entrance of the superior vena cava into the right atrium shown by transesophageal transthoracic echocardiography. TTE is more suitable than CXR as the first examination for CVC tip localization, as it improves diagnostic accuracy and reduces X-ray radiation damage.

Using central venous pressure waveform to confirm the placement of an internal jugular central venous catheter in the intensive care unit

BackgroundA mobile chest X-ray is traditionally performed to confirm the position of an internal jugular central venous catheter (CVC) after placement in the intensive care unit (ICU). Using chest radiography to confirm CVC position often results in delays in authorising the use of the CVC, requires the deployment of additional human resources, and is costly. ObjectiveThis study aimed to determine the feasibility and accuracy of using the central venous pressure (CVP) waveform to confirm the placement of internal jugular CVCs. MethodsThis retrospective study was conducted in a single quaternary ICU over a 6-month period. We included adult patients who had internal jugular CVC inserted and CVP transduced as part of their routine care in the ICU. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CVP waveform analysis in confirming the position of internal jugular CVC relative to chest radiography were calculated. ResultsA total of 241 internal jugular CVCs were inserted (in 219 patients, 35.6% female), and the CVP waveform was assessed. In 231 cases, this suggested adequate placement in a central vein, which corresponded with a correct position on subsequent chest X-ray. On six occasions, the CVP waveforms were interpreted as suboptimal; however, on chest X-rays, the CVCs were noted to be in a suitable position (sensitivity: 97.5%). Four suboptimal CVP waveforms were obtained, and they correctly identified CVC malposition on subsequent chest X-ray (specificity: 100%). The average time from CVC insertion to radiological completion was 118 minutes. ConclusionCVP waveform analysis provides a feasible and reliable method for confirming adequate internal jugular CVC position. The use of chest radiography can be limited to cases where suboptimal CVP waveforms are obtained.

Abstract 212: Percutaneous Carotid access in Mechanical Thrombectomy ‐ a safe alternative to transfemoral approach

Introduction Emergent percutaneous carotid artery MER approach for acute ischemic large vessel strokes are rare given the risk of complications and seldom reported. Methods 75‐year‐old left‐handed functional male (mRs:0) with past medical history of HTN, HLD presented to ED after being found on the floor by his family with slurred speech, new onset right sided weakness, with a last known well of 17 hours. NIHSS on arrival was 14 for expressive aphasia, right visual field defect, right facial weakness, significant dysarthria, right hemiparesis, and sensory defect. CT Head demonstrated left MCA territory early ischemic changes. CTA head/neck demonstrated left M1 occlusion with large penumbra. Perfusion data demonstrated no area of core infarct with area of ischemic penumbra in the left MCA territory involving the left frontal, temporal and parietal lobes measuring 161 ml. ASPECT score 5‐6. The patient was deemed a candidate for mechanical endovascular thrombectomy (MER). The procedure was initiated via ultrasound‐guided right common femoral access. After multiple attempts using a wide range of techniques and wire/catheter combinations in order to establish left intracranial access and given extreme angulation/tortuosity/elongation in the proximal left common carotid artery, it was decided to proceed with the catheter position in the left common carotid or the left internal carotid artery that would allow for subsequent catheterization of the intracranial circulation for MER. Results Near complete revascularization with minimal distal thrombus material beyond endovascular reach corresponding to a TICI 2C degree of revascularization was achieved. Closure of the femoral puncture site was performed using an Angio seal femoral closure device. Surgical closure of the puncture site was performed by vascular surgery. The patient was eventually discharged to short term acute rehabilitation and continues to follow up outpatient with the Stroke clinic. Conclusion Older patients with ischemic stroke commonly have tortuous vessels or peripheral vascular disease. As a result, they may greatly benefit from emergent direct carotid access, as the trans‐femoral approach often poses challenges in accessing the thrombus. For patients with complex and unfavorable vascular anatomy for mechanical endo‐vascularization, direct percutaneous carotid puncture can be advantageous, effectively reducing the aforementioned difficulties. When opting for such an approach it is vital to factor in the aortic arch appearance and its branches.

Abstract 208: Optimal Catheter Position and Aspiration Technique Improves Safety and Efficacy Using Next Generation Funnel Catheter

Introduction The Advanced Neurovascular Access (ANA5, Anaconda Biomed) is a novel stroke thrombectomy catheter comprising a distal self‐expanding covered funnel designed to locally restrict blood flow in the Internal Carotid Artery (ICA) and, when used in conjuction with available stent retreiver, reduce clot fragmentation during clot ingestion. The ANAIS study aimed to investigate the safety and efficacy of the ANA5 device (‘Funnel’) in different deployment locations and aspiration conditions. Methods Prospective, single‐arm, multi‐center study to assess the safety and performance of ANA5 in combination with a stent retriever in patients with Acute Ischemic Stroke (ANAIS). An independent imaging corelab and Clinical Events Committee assessed the different predefined outcomes. Patients with anterior circulation vessel occlusion admitted within 24 hours from symptom onset were eligible. The primary efficacy endpoint was successful recanalization, defined as mTICI ≥2b in the target vessel within three passes of the Funnel device. The primary safety endpoint was a composite of symptomatic Intracranial Hemorrhage within 24 hours and any device related severe adverse event. The impact of the funnel deployment location in the different ICA segments (C1 to C4 or above) and the condition of the aspiration on angiographical outcome was also evaluated. Results A total of 39 subjects who complied with all inclusion/exlusion criteria were treated by 10 different physicians in 3 stroke centers. Mean age was 69.9 ±13.2 years, 52.5% women, and the median National Institutes of Health Stroke Scale on admission was 16.0 [12.5‐19.5]. Initial occlusion location was: TICA 25.0%, M1‐MCA 52.5% and M2‐MCA 22.5%. The rate of succesful reperfusion within 3 passes was 74.4% (29/39) (primary efficacy endpoint). First pass effect (FPE) mTICI 2b‐3 and 2c‐3 was 56.4% (22/39) and 48.7% (19/39), respectively. Zero sICHs at 24h or SADE at 5 days were reported (primary safety endpoint). At 90 days, the rate of modified Rankin Scale score 0‐2 was: 57.9% (22/38). The efficacy of the thrombectomy procedure using the Funnel increases when: 1. The funnel was deployed in the higher ICA segments (below ophtalmic artery) with diameter between 3.5‐5.0mm, ensuring full apposition of the funnel to the vessel wall: C1(n=10): 40.0% vs. C2 or higher (n=29): 86.2% (p < 0.002). 2. Continuous aspiration was applied during the full retrieval of the stentriever in the Funnel (89.3% (n=28) vs. 36.4% (n=11), p < 0.0005). 3. When both continuous aspiration and appropriate ICA location were achieved, the Clinical efficacy endpoint improved to 95.5% (n=22), and FPE mTICI 2b‐3 and 2c‐3 were 72.7% and 59.1% respectively. Conclusion The use of the next generation Funnel Device in the ANAIS study results in a high rate of successful recanalization with an optimal safety profile and favorable 90 days clinical outcomes. The performance improved when the Funnel was deployed above the C1 cervical segment of the ICA, and continuous aspiration was applied during the full stent retrieval.

Impact of catheter tip to hepatic vein ostium distance on the validity and prognostication of hepatic venous pressure gradient in cirrhosis

Hepatic venous pressure gradient (HVPG) is an accurate measure of portal hypertension in cirrhosis. However, the effect of catheter tip distance from hepatic vein ostium (HVO) on HVPG is unknown. We performed a retrospective study on 228 patients with 307 HVPGs in our institution. The objectives of this study were to assess the effect of catheter position on the validity of HVPG and its prognostication in cirrhosis. In this study, free hepatic vein pressure (FHVP) was considered optimal when difference between FHVP and inferior vena cava pressure was ≤ 2 mmHg. HVPG progressively decreased (p < 0.001) when measured at increasing distance from HVO due to an increasing FHVP (p = 0.036) but an unchanged wedged hepatic vein pressure (p = 0.343). Catheter tip distance > 5 to ≤ 8 cm [odds ratio {OR} 0.16 (95% CI 0.05–0.47), p = 0.001] and > 8 cm [OR 0.14 (95% CI 0.04–0.47), p = 0.002] compared to ≤ 3 cm from HVO were independent predictors of not achieving optimal FHVP. Baseline HVPG ≥ 16 mmHg was strongly associated with deaths due to cirrhosis and liver transplantation for end-stage liver disease compared to HVPG < 16 mmHg when FHVP was optimal (p < 0.001) but not when it was suboptimal (p = 0.359). Our study showed that FHVP is spuriously elevated when measured at > 5 cm from HVO, resulting in inaccurately low HVPG.

Umbilical Venous Catheter Position: The Value of Acquiring a Lateral in Addition to a Frontal Chest Radiograph.

Introduction Umbilical venous catheters (UVCs) are standardly used for central venous access in acutely sick neonates. Complications associated with UVCs include thrombosis, infection, diffuse intravascular coagulopathy, arrhythmia, tamponade, and liver injury, many of which are related to misplacement of the catheters. Therefore, this study aimed to institute a policy of obtaining lateral and frontal radiographs to improve the determination of the UVC position. Methods We retrospectively reviewed UVC placement from 132 radiographs. We compared interpretations by different reviewers of frontal versus frontal and lateral chest radiographs for the most accurate determination of the UVC position. The reviewers completed questionnaires indicating their assessment of the catheter tip position, as well as the appropriate catheter manipulation required for optimal positioning. Their assessment was derived from frontal chest radiographs followed by frontal plus lateral view radiographs a week later. Results The reviewers (junior neonatology fellow, senior neonatology fellow, pediatric radiology fellow, and senior pediatric radiologist) revised their assessment with regard to the UVC positioning between frontal and frontal plus lateral radiographs in 24.6%, 22.7%, 19.6%, and 15.9% of cases, respectively, and indicated that the lateral view was helpful in 18%, 13.6%, 19.6%, and 31% of the cases, respectively. UVCs were placed appropriately at the first attempt in only 13.6% of the cases. Conclusion Correct initial placement of a UVC is uncommon. A lateral radiograph is beneficial in determining the UVC position. Hence, we suggest the inclusion of a lateral view along with the frontal chest radiograph for the evaluation of the UVC position if real-time ultrasound cannot be performed before UVC usage.

Epidural anaesthesia with traditional technique versus epidural catheterization technique in buffaloes

Epidural anaesthesia in buffaloes is done at sacro coccygeal or at first inter-coccygeal space. A new technique of injecting epidural anaesthesia was compared with traditional technique at first inter coccygeal space. Two group were done with Group 1 consisting of 10 cases and Group 2 with 6 cases were with affections of Tail gangrene, prolapse of vagina, caesarean section, vaginal tear and tail wound studied at Department of Veterinary Surgery and Radiology, College of Veterinary and Animal Sciences, Udgir. Group 1 was anesthetized by traditional method by inserting needle at 45 degree angle at first inter coccygeal space. Group 2 was anaesthetized by catheterization where in first as traditional technique 16 G spinal needle passed into epidural space then catheter was inserted and directed inside 1 to 1.5 inch inside and placed by confirming site. Study showed catheterization useful when incremental dose is necessary. It required care and experience to maintain catheter in position. Injury or trauma was minimum compared to traditional technique.

Shaping the Future of Coronary Interventions by Highlighting Coronary Anatomy and Reducing Contrast Volume

Coronary interventions, and specifically the number of percutaneous coronary intervention (PCI) procedures, are increasing, together with their complexity. Contrast media administration during those procedures assists in visualising vessels anatomy, but also increases the risk of contrast-induced nephropathy (CIN), which remains one of the most common complications, and has been associated with poor clinical outcomes. Dynamic Coronary Roadmap (DCR) is a technology that creates a dynamic, motion-compensated, real-time view of the coronary anatomy overlaid on a 2D fluoroscopic image, creating a coloured map that adjusts automatically, and providing continuous visual feedback on the positioning of wires and catheters. The technology, which is already being used in clinical practice, has posed the promise of not only assisting in navigating wires and catheters, but also reducing the use of contrast during PCI. DCR4Contrast was a randomised clinical trial conducted in the USA, Europe, and Israel that enrolled more than 356 patients. The primary endpoint for the study was the reduction in contrast administered with the use of DCR, compared with the control group. The secondary endpoint was the potential reduction in the number of cineangiography runs. In the trial, DCR reduced the total contrast volume per PCI procedure by an average of 28.8%, and reduced the number of contrast-enhanced cineangiography runs per procedure by 26.3%. It was also demonstrated that the more complex the PCI procedure, the larger the reduction in contrast with DCR. Here, interventional cardiology experts discussed the need for contrast reduction, and the evidence for DCR.

ShuntScope-Guided Versus Free-Hand Technique for Ventricular Catheter Placement: A Retrospective Comparative Study of Intraventricular Catheter Tip Position and Complication Rate.

The position of the ventricular catheter (VC) is essential for a proper function of cerebrospinal fluid diversion system. A ShuntScope-guided (SG) method might be helpful in reducing complications. The purpose of this study is to compare the accuracy of catheter placement and the complication and revision rates between SG and free-hand (FH) techniques. This is a retrospective study based on a prospectively acquired database of patients who underwent VC placement between September 2018 and July 2021. Accuracy of catheter placement was graded on postoperative imaging using the 3-point Hayhurst grading system. Complication and revision rates were documented and compared between both groups with an average follow-up period of 20.84 months. Fifty-seven patients were included. The SG technique was used in 29 patients (mean age was 6.3 years, 1.4-27.7 years, 48.1% females), and the FH technique was used in 28 patients (mean age was 26.7 years, 0.83-79.5 years, 67.9% female). The success rate for the optimal placement of the VC with grade I on the Hayhurst scale was significantly higher in the SG group (93.1%) than in the FH group (60.7%), p = 0.012. The revision rate was higher in the FH group with 35.7% versus 20.7% in the SG group, p = 0.211. VC placement using the SG technique is a safe and effective procedure, which enabled a significantly higher success rate and lower revision and complication rate. Accordingly, we recommend using the SG technique especially in patients with difficult anatomy.

The effect of distal aspiration catheter position on collateral flow in mechanical thrombectomy - an in vitro study.

Endovascular mechanical thrombectomy for ischaemic stroke is one of the most effective treatments. Despite the devices and techniques that have been developed, thrombi are not always successfully retrieved. The incidence of futile reperfusion after successful clot retrieval also remains a major concern. We hypothesise that simply placing an aspiration catheter in the system compromises collateral flow which may have an impact on functional outcomes. An in vitro study was conducted using a physical pulsatile flow model designed in glass to mimic the anterior cerebral circulation with middle cerebral artery M1 segment occlusion. A 5Fr aspiration catheter was positioned at the supra-clinoid internal carotid (SC-ICA), carotid terminus (T-ICA) and M1. For each catheter position, the flow rate through the model's anterior cerebral (ACA) and posterior communicating (PCOM) arteries was measured (no aspiration applied). Our results showed significant mean percentage flow reductions in the ACA and PCOM with the catheter positioned at the SC-ICA (PCOM 59.14% ± 0.93, ACA 59.52% ± 0.82, p < 0.001), T-ICA (PCOM 81.54% ± 0.55, ACA 85.65% ± 1.54) and M1 (PCOM 75.79% ± 0.98, ACA 84.20% ± 0.43) (Mann-Whitney U Test, p < 0.001). These results indicate a significant reduction in collateral flow following the insertion of a wide bore catheter in an in vitro model. In a clinical setting, this could have an impact on patient outcome, particularly in prolonged procedures and those requiring several passes to achieve recanalisation.

Transesophageal echocardiography for thoracic spinal cord imaging and confirmation of epidural catheter placement in pediatrics

IntroductionTransesophageal echocardiography (TEE) use continues to expand to include extracardiac applications. However, there is limited research investigating the use of TEE as a tool to confirm the position of the epidural catheter. This prospective observational study aimed to evaluate whether TEE could be used to visualize the anatomy of the thoracic spinal canal in pediatrics. A subsequent prospective case series was conducted to evaluate whether TEE could be used to assist in the placement of epidural catheters in pediatric surgical patients. MethodsSeventy-five patients (50 pediatric and 25 adult subjects) were enrolled. The operators attempted to identify four structures (spinal cord, cerebrospinal fluid, dura mater, epidural space) within the thoracic spinal canal with TEE. After demonstrating the feasibility of this technique for observing the spinal anatomy, 20 pediatric surgical patients were enrolled in a case series. These patients had epidural catheter placement, and the final catheter position was confirmed with TEE. ResultsThe total number of thoracic spinal segment visualized in pediatric patients was 542 out of 550 (99%) segments, and 191 out of 275 (70%) segments in adult subjects (difference, 29% [95% confidence interval, 23–34]; p < 0.001). Additionally, a case series of 20 pediatric surgical patients demonstrated successful caudal or epidural catheter placement at target spinal level in 17 cases. ConclusionsThis observational study demonstrated the successful visualization of the thoracic spinal cord at virtually every level in pediatric patients. A subsequent case series demonstrated that TEE could be used to successfully confirm the position of the epidural catheter in the targeted thoracic spinal segment for pediatric surgical patients.

Analgesia for Knee Ligamentoplasty: Comparisons of Three Techniques using the Silverman Integrating Approach (SIA Score)

The aim of this prospective study was to compare the analgesic efficacy of three techniques for knee ligamentoplasty using an integration score, the SIA score. Hypothesis. The use of a statistical approach to integrate data from pain scores and morphine consumption will identify four patient subgroups that may hamper the accuracy of the comparative study Material. - We included 165 patients undergoing primary reconstruction of the anterior cruciate ligament of the knee. All patients underwent spinal anaesthesia. The first group, systemic analgesia (SA), received balanced systemic analgesia postoperatively for a minimum of five days, based on Paracetamol, Diclofenac and a morphine PCA. In addition to the systemic analgesia already described, the second group, femoral analgesia (FA), will benefit from a femoral peri-nervous catheter in the crural position. 20 ml of bupivacaine at 0.125% concentration is injected; maintenance is set up immediately with a continuous flow of 8 ml/h for 36 h. The third intra-articular analgesia (IAA) group received, in addition to the same systemic analgesia, an infusion through an epidural catheter of 20 ml of 0.125% bupivacaine, followed by maintenance with 8 ml/h of the same local anesthetic via an electric syringe pump for 36 h. We evaluated cumulative morphine consumption, pain estimation at rest using a numerical scale (EN) from 1 to 10, and an integration of these two parameters. Results. - The mean age was identical for all three groups, at around 30 years. Analgesia in the femoral peri-nerve group was more effective, with a reduction in mean EN compared with the other two groups. Morphine consumption was lower in the AF group. The lowest mean rank was in the AF group, followed by the AIA group, and the difference was statistically significant with an H = 6.89 and a p= 0.032. The difference was significant between the AS group and the AF group (p = 0.09); the other inter-group differences were not significant. 23.2% of patients had an AIS score between [-100, -200], and were in little pain and consumed little morphine (effective treatment); 14.2% of patients had an AIS score between [100, 200] and were in great pain and consumed a lot of morphine (morphine-resistant or very sensitive to pain). For the difference (ranked pain score - ranked morphine), 4.5% of cases had values between [- 100, - 200] and were therefore not very painful but consumed a lot of morphine (propensity), while 3.9% had values between [100, 200] and were therefore very painful but consumed little morphine (intolerant). Discussion. - This study suggests that the use of a statistical approach to integrating data from pain scores and morphine consumption, such as the Silverman Integrating Approach (SIA), will yield four patient subgroups that may hamper the accuracy of the comparative study, including the morphine-resistant subgroup and the propensity subgroup. Comparison of the means of the therapeutic efficacy group will eventually be more precise. Continuous femoral block really does provide added analgesia and morphine sparing, and should therefore be preferred wherever possible to intra-articular or systemic therapy.

Comparative Study Between Systemic Balanced Analgesia, Continuous Femoral Perineural Analgesia and Continuous Intra-articular Analgesia for Primary Reconstruction Surgery of the Anterior Cruciate Ligament of the Knee

Introduction. The aim of this prospective study was to compare the analgesic efficacy of three techniques for knee ligamentoplasty and quadricipital deficit with a view to early physiotherapy. Hypothesis. Continuous intra-articular analgesia and well-managed systemic analgesia could replace continuous femoral peri-nerve analgesia in resource-limited countries. Material. - We included 165 patients undergoing primary reconstruction of the anterior cruciate ligament of the knee. All patients underwent spinal anaesthesia. The first group, systemic analgesia (SA), received balanced systemic analgesia postoperatively for a minimum of five days, based on Paracetamol, Diclofenac and a morphine PCA. In addition to the systemic analgesia already described, the second group, femoral analgesia (FA), will benefit from a femoral peri-nervous catheter in the crural position. 20 ml of bupivacaine at 0.125% concentration is injected; maintenance is set up immediately with a continuous flow of 8 ml/h for 36 h. The third intra-articular analgesia (IAA) group received, in addition to the same systemic analgesia, an infusion through an epidural catheter of 20 ml of 0.125% bupivacaine, followed by maintenance with 8 ml/h of the same local anesthetic via an electric syringe pump for 36 h. Cumulative morphine consumption, pain estimation at rest and on mobilization using a numerical scale (EN) from 1 to 10, and quadriceps deficit were evaluated. Results. - Morphine consumption was lower in the AF group and the difference was statistically significant with an F = 3.539(2) and a p = 0.031. A mean difference of 6.12 ± 2.41 between the AS and AF groups with a significant p = 0.012, a mean difference of 1.67 ± 2.41 with a non-significant p = 0.49 between the AF and AIA groups and a mean difference of 4.45 ± 2.31 with a p = 0.056 at the limit of significance between the AS and AIA groups. Analgesia in the femoral peri-nerve group was more effective, with a reduction in mean EN compared with the other two groups. Efficacy was statistically significant at H4, then from H24 to H36 compared with systemic analgesia, but not significant compared with intra-articular analgésia. Intra-articular analgesia was only significantly effective compared with systemic analgesia at H36. Quadriceps muscle deficit is an incident specific to femoral blocks. Discussion. - This study suggests that a continuous intra-articular or even a well-conducted systemic analgesia provides satisfactory analgesia for knee ligamentoplasty, compared with a more effective femoral peri-nerve. The quadricipital lock absent in intra-articular treatment could be an advantage in speeding up functional recovery.