Catheter Repositioning Research Articles

Emerging Role of Laser Lithotripsy for Bladder Stones: Real-World Outcomes from Two European Endourology Centers with a Systematic Review of Literature.

Introduction and Objective: We aimed to look at the evidence for laser lithotripsy for bladder stones (BSs) to provide results from two centers on bladder calculi treatment. In addition, the outcomes of prostatic and other surgical interventions performed in nearly half of all patients. Methods: A retrospective analysis of two large European endourology tertiary centers for patients who underwent laser lithotripsy for BS between 2016 and 2024 (7 years). All patients provided consent and were counseled for the study accordingly, and the studies were registered as an audit in the individual centers. Results: A total of 122 patients were analyzed (mean age of 68.17 ±16.38 years; male:female ratio of 97:25). Thirteen (10.7%) patients had a preoperative long-term catheter. Overall, 42 (34.43%) patients had multiple stones (n = 2.19, ±2.08), with a median stone burden of 32.36 ± 24.13 mm. The mean operative time was 61.6 ± 37.25 minutes, with an overall stone-free rate (SFR) of 95.1% (n = 116). Postoperative complications were noted in nine (7.38%) patients, which included urinary tract infection or sepsis (n = 4, 3%), pain (n = 2, 1.6%), and bleeding/acute urinary retention/urethral stone (n = 1 each, 0.82%). All the complications were Clavien-Dindo I/II and treated conservatively. Six patients (4.9%) with planned concomitant surgical intervention needed a completion (second) intervention at a later date. Sixty patients (49.2%) had concomitant procedure along with their BS treatment. Twenty-two patients (18%) with a mean prostate size of 60.71 cc (±30.50 cc) underwent a transurethral resection of prostate (n = 16, 13.1%) or bladder neck incision (n = 6, 4.9%). Others underwent ureteroscopy (n = 13, 10.7%), transurethral resection of bladder tumor (n = 5, 4.1%), suprapubic catheter repositioning (n = 10, 8.2%), or urethral dilation (n = 10, 8.2%). The mean hospital stay was 1.4 ± 1.33 days. Conclusion: Laser fragmentation of BSs stands out as a safe and efficient choice with a good SFR and low risk of major complications, and perhaps should be considered the new gold standard for BS management. It also allows for concomitant treatment of enlarged prostate and other endourologic procedures with good outcomes.

VARIPULSE: A step-by-step guide to pulmonary vein isolation.

The VARIPULSE™ variable-loop circular catheter (VLCC) is a bidirectional, multielectrode catheter that can perform electrophysiological mapping and deliver pulsed field energy through the TRUPULSE™ Generator for the treatment of atrial fibrillation. This ablation system, including the CARTO 3™ three-dimensional electroanatomical mapping system, represents a fully integrated system. Pulsed field ablation (PFA) is a novel, primarily cardiac tissue-selective ablation technology with a minimal thermal effect, potentially eliminating the collateral tissue damage associated with radiofrequency ablation or cryoablation. Integration of a mapping system may lead to shorter fluoroscopy times and improve the usability of the system, allowing tracking of energy density and placement to confirm no areas around the vein are left untreated. This step-by-step review covers patient selection, mapping, the step-by-step ablation workflow, details on catheter repositioning and ensuring contact, considerations for ablation of specific anatomical variations, and discussion of ablation without fluoroscopy based on our initial clinical experience. The VLCC is part of the fully integrated PFA system designed for pulmonary vein isolation, using mapping to guide catheter placement and lesion set creation. The current workflow, which is based on our initial clinical experience, may be further refined as the PFA system is used in real-world settings.

A novel sequential endocardial mapping strategy for locating atrial fibrillation sources based on repetitive conduction patterns: An in-silico study

BackgroundIn persistent atrial fibrillation (AF), localized extra-pulmonary vein sources may contribute to arrhythmia recurrences after pulmonary vein isolation. This in-silico study proposes a high-density sequential mapping strategy to localize such sources. MethodCatheter repositioning was guided by repetitive conduction patterns, moving against the prevailing conduction direction (upstream) toward the sources. Sources were found either by locally identifying conduction patterns or by encircling the region harboring them. We simulated source tracking in an in-silico atrial model, comparing random vs. upstream-guided catheter repositioning (with and without encircling). To assess performance in increasing AF complexities, we simulated AF in 3 groups: atria with reentry-anchoring scars, without fibrosis, and with severe endomysial fibrosis. ResultsCompared to random mapping, the upstream-guided approach successfully located sources more often (anchored reentries: 70.6% vs. 10.6%; no fibrosis: 87.9% vs. 22.1%; with fibrosis: 95.0% vs. 60.9% of tracking procedures, all p<0.001), using fewer steps (median [IQR]: 11 [7;23] vs. 26 [13;35]; 10 [6;19] vs. 19 [10;27]; 11 [7;19] vs. 16 [8;30], respectively, all p<0.05). Adding source encircling increased source detection (98.1 %, 100 %, and 99.5 %, all p<0.01 vs. local detection only), reducing required steps (9 [6;12], 8 [6;12], and 9 [6;13], all p<0.05). In some cases (11.9 %, 17.1 %, and 10.5 % of procedures), the algorithm encircled regions >15 mm from the source. ConclusionMoving mapping catheters upstream improves source detection efficiency, even in the presence of severe fibrosis. Encircling sources may help find regions of interest in fewer steps.

A novel pulsed field ablation system using linear and spiral ablation catheters can create large and durable endocardial and epicardial ventricular lesions in vivo.

We investigated the preclinical safety and efficacy of ventricular pulsed field ablation (PFA) using a family of novel, 6-/8-Fr, linear, and spiral PFA/mapping catheters (CRC EP, Inc). QRS-gated, bipolar PFA (>2.0 kV) was performed in 10 healthy swine. Altogether, 20 endocardial and epicardial right and left ventricular applications were delivered. The catheters were inserted through an 8.5-Fr steerable introducer. The intensity of skeletal muscle activation was quantified using an accelerometer. Lesions were assessed by pre- versus post-PFA electrogram analysis, pacing threshold, 3D voltage mapping, necropsy, and histology. The swine rete mirabile, liver and kidneys were examined for embolic events. All applications were single-shot (56 ± 18 s) without catheter repositioning. Minimal microbubbling was observed without significant skeletal muscle stimulation (mean acceleration 0.05 m/s2) or ventricular tachyarrhythmias. There was significant reduction in post- versus pre-PFA electrogram amplitude (0.5 ± 0.2 mV versus 3.2 ± 0.9 mV, P < 0.001) with a marked increase in pacing threshold (>20 mA versus 7.5 ± 2.9 mA, P < 0.001). All lesions were large and durable up to 28 days, measuring 32 ± 5 mm (length), 27 ± 8 mm (width), and 8 ± 3 mm (depth) using the spiral catheters and 43 ± 1 mm (length), 7 ± 1 mm (width), and 8 ± 1 mm (depth) using the linear catheters. Despite higher waveform voltages and prolonged applications, no thermal effects were detected at necropsy/histology. Moreover, gross and microscopic examinations revealed no evidence of thromboembolism, vascular or collateral injury. A novel, QRS-gated PFA system using linear and spiral PFA catheters is capable of creating large and durable ventricular lesions in vivo without significant microbubbling, ventricular arrhythmias or thromboembolism.

Preclinical evaluation of a novel single-shot pulsed field ablation system for pulmonary vein and atrial ablation.

Pulsed field ablation (PFA) is a nonthermal ablative strategy that achieves cell death via electroporation. Herein, we investigated the preclinical safety and efficacy of PFA using two novel 8-French, 16-electrode spiral PFA/mapping catheters (ElePulse; CRC EP, Inc.). Bipolar PFA (>1.8 kV) was performed using 30 s, single-shot, QRS-gated applications. Altogether, 94 atrial structures were ablated in 23 swine, one canine, and one ovine, including right and left atria and atrial appendages, pulmonary veins, and superior and inferior (IVC) vena cavae. We also examined the impact of PFA on the phrenic nerve (14 swine) and on a deviated esophagus after delivery of PFA from inside the IVC (five swine). All applications were single-shot without catheter repositioning. Minimal microbubbling was observed without significant skeletal muscle twitching/activation (mean acceleration: 0.05 m/s2 ). There was a marked reduction in post-PFA versus pre-PFA atrial electrogram amplitude (0.17 ± 0.21 vs. 1.18 ± 1.08 mV; p < .0001). Lesion durability was demonstrated up to 3 months in all targeted tissues. Histologically, lesions were contiguous and transmural, except in the atrial appendage, and without any thermal effects. Magnetic resonance, gross, and histologic examinations of the brain, rete mirabile, and kidneys revealed no thromboembolism. No acute/long-term phrenic nerve dysfunction was encountered. Although within 2 h of ablation, histologic examinations of the esophagus revealed acute PFA-related changes in the muscular layer, these completely resolved by 21 ± 5 days. A novel, single-shot, spiral PFA system is capable of safely creating large, durable atrial lesions without significant adverse effects on the phrenic nerve or the esophagus.

Wearable mixed-reality holographic guidance for catheter-based basal ganglia hemorrhage treatment

BackgroundBedside freehand catheter insertion for the treatment of basal ganglia hemorrhage currently remains the major method due to its simplicity and efficiency, but it is associated with low precision. We retrospectively evaluated the feasibility and accuracy of using a wearable mixed-reality holographic computer to guide catheter-based basal ganglia hemorrhage treatment compared to the freehand method. MethodsWe collected 30 patients who initially underwent either mixed-reality holographic guided catheter insertion (holographic guidance group) or freehand catheter insertion (freehand group). Data of pre- and postoperative CT images in both groups and surgical plans of the holographic guidance group were retrieved from the database. The additional time for holographic guidance was quantified. For both groups, we calculated the number of cases in which the catheter tip was initially outside the hematoma and the number of times for catheter repositioning. Catheter insertion accuracy was quantitatively evaluated using the target deviation. ResultsThe average additional time required for holographic guidance was 36.65 ± 15.18 min. In the holographic guidance group, all the cases had catheter tips initially inside the hematoma, and none of them needed catheter repositioning. In the freehand group, 3 cases had their catheter tips initially outside the hematoma, and 5 catheter repositioning procedures were performed. The mean target deviation was 5.46 ± 2.22 mm in the holographic guidance group and 12.57 ± 6.77 mm in the freehand group (p < 0.001). ConclusionsWe preliminarily demonstrated the feasibility and accuracy of wearable mixed-reality holographic guidance for the treatment of basal ganglia hemorrhage.

#5171 MODIFIED, NON-INVASIVE, TUNNELLED CATHETER REPOSITION (NTCR), SIMPLE AND SAFE TO RESTORE FUNCTION OF CENTRAL TUNNELLED CATHETER FOR HAEMODIALYSIS

Abstract Background and Aims Still many end stage kidney disease (ESKD) patients are dialysed using central tunnelled catheters (CTC) as vascular access. Catheter thrombosis and is a dominant, non-infectious CTC complication. There are a number protocols established, to resolve the problem, all are not always effective, time as well as cost consuming. Method The modified maneuver of non-invasive tunnelled catheter reposition (mNTCR) was introduced and studied, to obtain an immediate haemodialysis start, in case of CTC dysfunction. The NTCR is based on gentle movements of CTC or its part, with CTC lines flushing which resulted with quick CTC's tip reposition. The study was a continuation of previously published with modification including mandatory CTC lines flushing and locking lines with antithrombotic agent after the dialysis session. Results A number of 205 mNTCR were performed in 110 patients with CTC. Effective blood flow CTC was obtained after 115 procedures (56%), partial function followed 73 procedures (35,6%), and 17 attempts (8%) failed. Over 90% interventions improved a CTC patency allowing start of effective haemodialysis. The procedure could be successfully repeated with similar effect after the first, and the second attempt (28 vs 22 hemodialyses performed respectively). In the group of 50 elderly patients (median age 74 years) with CTC as the only vascular access, mNTCR was successful in 31 patients allowing dialysis continuation for median period 54 months. The mNTCR is safe as minor complications were observed after 5,1% of all procedures. Conclusion The novel mNTCR manoeuvre was safe and effective in a majority cases of CTC dysfunction. It permitted immediate dialysis without time consuming fibrinolytic agents usage protocols before the dialysis session, saving costs and nursing staff time.

Early rapid local impedance drop is associated with acute lesion efficacy during pulmonary vein isolation using a novel contact force sensing catheter

Abstract Introduction The predictive role of adequate local impedance drop in lesion formation using a novel contact force sensing ablation catheter for pulmonary vein isolation was recently described. The purpose of our study was to assess the temporal characteristics of local impedance drop during ablation and its correlation with acute lesion efficacy. Methods Point-by-point radiofrequency pulmonary vein isolation was performed in power-controlled mode with 50 W energy setup. The efficacy of applications was determined by pacing along the circular ablation line. The successful lesions were estimated if loss of capture was achieved. Local impedance, contact force and catheter position data of the applications with 5 msec resolution was analysed. The local impedance of successful and unsuccessful applications was compared at baseline and 2, 4, 6, 8, 10 and 12 sec time points, respectively. We characterized the local impedance for each time point with the mean of the 5 impedance value closest in time. The sum of the range of catheter position in x, y and z dimensions was also compared to assess stability during the application. Results 643 applications were analysed, 559 were successful and 84 were unsuccessful. Mean contact force was lower (p=0.04), while the sum of catheter position range was higher (p&amp;lt;0.001) in unsuccessful applications during ablation, suggesting worse catheter stability. The successful applications were characterized by a higher baseline local impedance (p&amp;lt;0.001), and a larger local impedance drop at the 2, 4, 6, 8 and 10 sec time points (p&amp;lt;0.001, for all). In case of unsuccessful applications, after a moderate but significant drop from baseline to the 2 sec time point (baseline: 153 Ohm vs 2 sec: 145 Ohm, p&amp;lt;0.001) local impedance did not change further over time (2 sec: 145 Ohm vs 12 sec: 143 Ohm; p=0.99). While on the other hand, in case of successful applications, the local impedance further decreased significantly up to the 10 sec timepoint, respectively (baseline: 161 Ohm vs 2 sec: 150 Ohm vs 10 sec: 141 Ohm, p&amp;lt;0.001 for all). The optimal cut-point for the local impedance drop indicating unsuccessful application was &amp;lt;9 Ohms at the 4 second time point [AUC=0.73 (0.67–0.76), p&amp;lt;0.001]. Failing to reach at least 9 Ohm impedance drop at the 4 second time point predicted unsuccessful applications [(p&amp;lt;0.001; OR: 3.82 (2.34–6.25)]. Conclusion Rapid and enduring drop of the local impedance may predict effective lesion formation, while slightly changing or unchanged local impedance is associated with unsuccessful applications. In case of a moderate local impedance drop during the first 4 seconds of radiofrequency application, it might be reasonable to stop the application and start a new one after catheter repositioning. Funding Acknowledgement Type of funding sources: None.

Clinical Practices in Central Venous Catheter Mechanical Adverse Events.

Background: Over 5 million central venous catheters (CVCs) are placed annually. Pneumothorax and catheter malpositioning are common adverse events (AE) that requires attention. This study aims to evaluate local practices of mechanical complication frequency, type, and subsequent intervention(s) related to mechanical AE with an emphasis on catheter malpositioning. Methods: This is a retrospective review of CVC placements in a tertiary hospital setting from 1/2013 to 12/2013. Pneumothorax and CVC positioning were evaluated on post-insertion chest x-ray (CXR). Malposition was defined as unintended placement of the catheter in a vessel other than the intended superior vena cava on CXR. Catheter reposition was defined as radiographic evidence of a new catheter with removal of the old catheter less than 24hrs after initial placement. Data points analyzed included pneumothorax and thoracostomy rate, CVC malposition frequency, catheter reposition rate, catheter duration, and incidence of complications such as catheter associated venous thrombosis. Result: Among 2045 eligible CVC insertions, pneumothoraces occurred in 14 (0.7%; 95%CI 0.38, 1.17) and malpositions were identified in 275 (13.4%; 95% CI 12.3, 15.3). The proportion of pneumothoraces that required tube thoracostomy was 57%. The proportion of CVCs with malposition that were removed or replaced within 24h was 32.7%. "Malpositioned" catheters that were left in place by the clinical team (n = 185) had an average catheter duration of 8.2 days (95% CI 7.2, 9.3) versus 7.2 days (95% CI 6.17, 8.23) for catheters that were replaced after initial malposition (p = 0.14, t test). The incidence of venous thrombosis in repositioned "malpositioned" catheters was 7.8% versus 4.9% for "malpositioned" catheters that were left in place. Conclusions: Clinically significant catheter malposition and pneumothorax after CVC insertion are low. In this study, replaced and non-replaced "malpositioned" catheters had similar catheter duration and rates of complications, challenging the current dogma of CVC malposition practice.

INSP-17. Augmented Drug Delivery for Pediatric Diffuse Midline Glioma using Convection Enhanced Delivery

Convection enhanced delivery (CED), an alternative to systemic chemotherapy, spans nearly two decades of clinical experience. The application of CED in pediatric neuro-oncology has been mainly used in children with DMG. This exploratory period is highlighted by widely variable features including procedural technique, disease extent, device interface, infusion parameters, and therapeutic agent. This presentation is meant to critically assess if CED for DMG is a logical therapeutic strategy. Most convincing to the perpetuation of this platform is the reproducible demonstration of augmented drug delivery. Post-treatment ratios of intralesional to systemic drug concentrations consistently exceed 1000. CED in the brain stem satisfies a desirable goal of CNS drug delivery: achieving high target tissue drug concentrations while avoiding systemic exposure. Surgical targeting of the brain stem and cannula deployment are solidly established as safe and accurate. Catheter insertion complications such as clinically relevant hemorrhage, CNS infection, and neurological injury are exceptional. Likewise, targeting error is on a millimeter scale with infrequent need for catheter repositioning. The use of intrinsic MRI signals, direct drug labeling, and surrogate tracers have all been used for measuring distribution of the infusion. The experience using a radio-labelled theragnostic agent has provided detailed distribution and dosimetry information. Based on estimates of tumor and hence target volumes, a rationale goal is to reach volumes of distribution in the range of 15-25 cm3. Optimizing this goal has focused on surgical targeting, infusion duration, and multiple treatment plans. Computational predictive modeling is being employed as a preoperative adjunct for maximizing distribution. Experience in DMG thus far has been limited to feasibility and safety studies. There is a paucity of Phase 2 studies and hence outcome has not yet been rigorously tested. Anecdotal increase in survival and long-term survival has been reproducibly reported. Of particular interest are the occasional cases of children exhibiting late out-of-treatment field and even extra-CNS recurrence. Available data is convincing that CED should serve be further explored in future clinical trials designs for children with DMG. Important features of any Phase 2 study design however should include monitoring of drug distribution, measures of tumor coverage, early response monitoring techniques, and possibly combination with whole CNS axis treatment.

Early local impedance drop during pulmonary vein isolation using a novel contact force sensing catheter is associated with acute lesion efficacy

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The predictive role of adequate local impedance drop in lesion formation using a novel contact force sensing ablation catheter for pulmonary vein isolation was recently described. The purpose of our pilot study was to assess the temporal characteristics of local impedance drop and its correlation with acute lesion efficacy. Methods Point-by-point radiofrequency pulmonary vein isolation was performed with 50 W energy setup in power-controlled mode. The efficacy of applications was assessed by pacing along the circular ablation line. We considered the lesions successful if loss of capture was achieved. Local impedance, contact force and catheter position data of the applications with 10 msec resolution was analysed. The local impedance of successful and unsuccessful applications was compared at baseline and 2, 4, 6, 8 and 10 sec time points, respectively. We characterized the local impedance for each time point with the mean of the 5 impedance value closest in time. Results 184 applications were analysed, 167 were successful and 17 were unsuccessful. There was no difference in mean contact force (p=0.142) and contact force range (p=0.606) between successful and unsuccessful applications. The baseline local impedance was significantly lower in the unsuccessful group (p&amp;lt;0.0001), while successful applications had significantly larger local impedance drop at the 2 (p=0.0006), 4 (p&amp;lt;0.0001), 6 (p=0.0066), 8 (p=0.016) and 10 sec (p=0.0106) time points compared with the unsuccessful group. Local impedance did not change significantly over time in case of unsuccessful applications (p=0.192), while it decreased significantly in case of successful applications (p&amp;lt;0.0001). Conclusion Early rapid drop of the local impedance may predict effective lesion formation, while slowly changing or unchanged local impedance is associated with unsuccessful applications. In case of a slow local impedance drop during the first 6 seconds of radiofrequency application, it might be reasonable to stop the application and start a new one after catheter repositioning.

Feasibility and clinical utility of transvenous intracardiac echocardiography in conscious, sedated horses

Introduction/objectivesIntracardiac echocardiography (ICE) is a method of obtaining echocardiographic images with a steerable ultrasound catheter placed within the heart via a venous or arterial approach. The objectives of this study were to assess the feasibility of a 5–10 MHz, 8 French, 90 cm ICE catheter to evaluate cardiac structures and function in standing, sedated horses, and describe standard views in this species. AnimalsTen apparently healthy horses weighing 458.1–618.2 kg from a university teaching herd. Materials and methodsEach horse had a physical examination, transthoracic echocardiography, and ICE performed through a 10 French introducer percutaneously placed in the right jugular vein in the proximal third of the neck with continuous ECG monitoring using telemetry. ResultsThree intracardiac echocardiography positions (cranial right atrium, mid right atrium, and right ventricle) with seven views were described with the associated 2D, pulse wave Doppler, continuous wave Doppler, color Doppler, and M-mode image acquisition standardized by referencing the intracardiac positions and common landmarks. The positions were confirmed with simultaneous transthoracic echocardiography. The procedure was well tolerated with only mild, occasional ventricular, and supraventricular arrhythmias that resolved with intracardiac echocardiography catheter repositioning. ConclusionsIntracardiac echocardiography is feasible, safe, and allows for the acquisition of diagnostic images in conscious, sedated horses.

Influence of peritoneal dialysis catheter type on dislocations and laxative use: a retrospective observational study

BackgroundThere is currently no consensus regarding the optimal type of peritoneal dialysis (PD) catheter. Although few studies showed that weighted catheters result in lower complication rates and superior long-term outcomes than non-weighted catheters, there are no studies on the use of laxatives linked to catheter malfunction, a patient-related outcome potentially affecting the quality of life. Thus, we compared the burden of acute and chronic laxative use in a cohort of PD patients having either weighted or non-weighted catheters.MethodsWe performed a single-center, retrospective, observational study in two renal units, comparing acute and chronic laxative therapy related to catheter drainage failure in a cohort of 74 PD patient,s divided by peritoneal dialysis catheter type. In addition, we evaluated the number of patients who experienced minor and major dislocations, catheter-related infection rate, hospitalization for catheter malfunctioning, episodes of catheter repositioning, and dropout from PD.ResultsLaxative use was significantly more common among patients in the non-weighted catheter group (acute: 30.3% vs. 9.8%, p = 0.03; chronic: 36.4% vs. 12.2%; p≤0.02). Furthermore, weighted catheters were superior to non-weighted catheters for all the secondary outcomes (dislocations: 12.2% vs. 45.5%; p = 0.001).ConclusionsWeighted self-locating catheters have lower drainage failure, thus reducing the need and burden of acute and chronic laxative use among PD patients.Graphical abstract

Abstract No. 222 Comparing apples to apples: the utility of intra-procedural CTPA during pulmonary artery thrombolysis

To describe a novel intra-procedural method of evaluating treatment response using hybrid CT-Angio imaging in catheter-directed thrombolysis (CDT) for intermediate-high risk pulmonary embolism (PE) A retrospective review was performed on 3 consecutive patients (1 female, age 40-73 years) who presented with acute, multisegment, intermediate-high risk PE from May-August 2020, and who were referred for intervention. All patients underwent second look thrombolysis evaluation within 24 hours from initiation of CDT. Intra-procedural CTPA was performed for all patients at the time of re-evaluation in a Siemens Nexaris Angio-CT hybrid suite with contrast injection via right internal jugular access sheath. Standard CTPA protocol with bolus tracking was utilized. Intra-procedural CTPA was found to be diagnostic to the proximal segmental level in all cases. One patient continued CDT at second look due to continued pulmonary hypertension, moderate residual clot burden, and need for repositioning of the infusion catheter. The remaining two patients completed thrombolysis at second look: one due to CT evidence of resolved abnormal RV:LV ratio and resolved saddle PE, the other due to CT evidence of improved RV:LV ratio and marked improvement in thrombus burden and pressures. Intra-procedural CTPA may provide evaluation of right heart strain, evaluating residual thrombus burden, and confirming intra-thrombus catheter position. This may allow for more information in determining the need for continued CDT and need for catheter repositioning.

Diagnosis and management of hemorrhagic complications of percutaneous transhepatic biliary drainage: a primer for residents.

Hemorrhagic complications are uncommon after percutaneous transhepatic biliary drainage. The presenting features include bleeding through or around the drainage catheter, hematemesis or melena. Diagnosis requires cholangiography, CT angiography or conventional angiography. Minor venous hemorrhage is managed by catheter repositioning, clamping or upgrading to a larger bore catheter. Major vascular injuries require percutaneous or endovascular procedures like embolization or stenting. A complete knowledge of these complications will direct the interventional radiologist to take adequate precautions to reduce their incidence and necessary steps in their management. This review presents and discusses various hemorrhagic complications occurring after percutaneous transhepatic biliary drainage along with their treatment options and suggests a detailed algorithm.

Non-invasive tunnelled catheter reposition (NTCR): A simple and safe method to restore central tunnelled catheter function for haemodialysis

Despite all efforts, still many end-stage kidney disease (ESKD) patients are dialysed using a central tunnelled catheter (CTC) as vascular access. When the CTC blood flow becomes ineffective, a number of protocols are advised. However, all of them are time- and cost-consuming. The manoeuvre of a non-invasive tunnelled catheter reposition (NTCR) was introduced to restore the CTC function. NTCR was based on gentle movements of the CTC, with or without a simultaneous flushing of the CTC lines, which resulted in a quick reposition of the CTC tip. This study comprises the analysis of a total of 297 NTCRs, which were performed in 114 patients, thus enabling an effective blood flow after 133 procedures (44.7%).Partially effective blood flow followed 123 procedures (41.4%), and it failed altogether in 41 cases (13.9%). Overall, 86% of conducted NTCRs improved the CTC patency to perform a haemodialysis session. The procedure could be successfully repeated, with a similar result after the first and the second attempt. Complications were observed only after 3.4% of all interventions. The novel NTCR manoeuvre was safe and effective in the majority of the CTC dysfunction episodes. It seemed to reduce fibrinolytic usage, allowed an immediate haemodialysis session commencement, therefore, it might save both the costs and the nursing staff time.

State of Fluoroless Procedures in Cardiac Electrophysiology Practice.

In the past decade, the use of interventional electrophysiological (EP) procedures for the diagnosis and treatment of cardiac arrhythmias has exponentially increased. These procedures usually require fluoroscopy to guide the advancement and frequent repositioning of intracardiac catheters, resulting in both the patient and the operator being subjected to a considerable degree of radiation exposure. Although shielding options such as lead gowns, glasses, and pull-down shields are useful for protecting the operator, they do not lessen the patient’s level of exposure. Furthermore, the prolonged use of lead gowns can exponentiate the onset of orthopedic problems among operators. Recent advancements in three-dimensional cardiac mapping systems and the use of radiation-free imaging technologies such as magnetic resonance imaging and intracardiac ultrasound allow operators to perform EP procedures with minimal or even no fluoroscopy. In this review, we sought to describe the state of fluoroless procedures in EP practice.

Retrospective analysis of computed tomography-guided percutaneous nephrostomies in cancer patients.

ObjectiveTo establish an overview of computed tomography (CT)-guided percutaneous nephrostomy performed at a referral center for cancer, addressing the characteristics of patients submitted to this intervention, as well as the indications for it, the technical specificities of it, and its main complications.Materials and MethodsThis was a retrospective study involving a review of the electronic medical records and images of patients submitted to CT-guided percutaneous nephrostomy at a referral center for cancer between 2014 and 2016.ResultsA total of 201 procedures were evaluated. In most cases, the obstruction was caused by a malignant neoplasm. Complications occurred in 9.5% of the cases, and an additional intervention was required (typically for catheter repositioning) in 36.6%. Post-procedure complications were not found to be significantly associated with the type of previous cancer treatment, the technique used, the caliber of the drain used in the procedure, or the degree of dilatation of the collection system prior to the procedure.ConclusionIn cancer patients, CT-guided percutaneous nephrostomy is an effective treatment, with success rates and complication rates similar to those reported in the general population.

A Rare Case of Unilateral Pleural Effusion in a Pediatric Patient on Chronic Peritoneal Dialysis: Is it a Pleuroperitoneal Leakage?

Non-infectious complications of peritoneal dialysis (PD) are relatively less common than infectious complications but are a potentially serious problem in patients on chronic PD. Here, we present a case of a non-infectious complication of PD in a 13-year- old boy on chronic PD who presented with symptoms such as hypertension, edema, dyspnea, and decreased ultrafiltration. Chest and abdominal radiography showed pleural effusion and migration of the PD catheter tip. Laparoscopic PD catheter reposition was performed because PD catheter malfunction was suspected. However, pleural effusion relapsed whenever the dialysate volume increased. To identify peritoneal leakage, computed tomography (CT) peritoneography was performed, and a defect of the peritoneum in the left lower abdomen with contrast leakage to the left rectus and abdominis muscles was observed. He was treated conservatively by transiently decreasing the volume of night intermittent PD and gradually increasing the volume. At the 2-year follow-up visit, the patient had not experienced similar symptoms. Patients on PD who present with refractory or recurrent pleural effusion that does not respond to therapy should be assessed for the presence of infection, catheter malfunction, and pleuroperitoneal communication. Thoracentesis and CT peritoneography are useful for evaluating pleural effusion, and timely examination is important for identifying the defect or fistula. Key words: Peritoneal dialysis; Pleuroperitoneal communication; Peritoneography; Pleural effusion; PD catheter

Wang's Forceps‐Assisted Percutaneous Insertion and Fixation of Peritoneal Dialysis Catheter

Percutaneous insertion of peritoneal dialysis catheters is theoretically most preferred by nephrologists because of the advantages of bedside performing, surgery independence, and minimal injury over other procedures of catheter placement such as open surgical dissection or laparoscopic operation. However, blindly placing catheters in the percutaneous procedure brings the risk of catheter malposition or bowel perforation; this largely retarded it's implementation. We had previously developed a novel technique termed "Wang's forceps-assisted catheter insertion and fixation," which had been successfully applied in the open surgical catheter insertion and displaced catheter reposition in our center. In this study, we further explored the possibility of applying the Wang's forceps in the procedure of percutaneous catheter insertion both in porcine model and patients with end stage renal disease (ESRD). A total of three miniature pigs successfully received percutaneous catheter insertion using Seldinger's technique with Wang's forceps assistance. The catheters were all placed in the right position and functioning well in dialysate drainage. This novel method of percutaneous catheter insertion was then performed on 20 ESRD patients. The procedure showed effective time-saving with the average operating time of 29.2 ± 3.53 min and was well tolerated by patients with minimal pain and injury. During a follow-up time of 6 months, no complications of catheter displacement, leakage, or blockade occurred. Our preliminary observation demonstrates that utilization of Wang's forceps in a percutaneous procedure conferred benefits of accurately placing and fixing catheters while preserving the merits of minimal invasion and simple performance.