Central Vein Thrombosis Research Articles

Machine Learning Predicts Peripherally Inserted Central Catheters-Related Deep Vein Thrombosis Using Patient Features and Catheterization Technology Features.

This study aims to use patient feature and catheterization technology feature variables to train the corresponding machine learning (ML) models to predict peripherally inserted central catheters-deep vein thrombosis (PICCs-DVT) and analyze the importance of the two types of features to PICCs-DVT from the aspect of "input-output" correlation. To comprehensively and systematically summarize the variables used to describe patient features and catheterization technical features, this study combined 18 literature involving the two types of features in predicting PICCs-DVT. A total of 21 variables used to describe the two types of features were summarized, and feature values were extracted from the data of 1,065 PICCs patients from January 1, 2021 to August 31, 2022, to construct a data sample set. Then, 70% of the sample set is used for model training and hyperparameter optimization, and 30% of the sample set is used for PICCs-DVT prediction and feature importance analysis of three common ML classification models (i.e. support vector classifier [SVC], random forest [RF], and artificial neural network [ANN]). In terms of prediction performance, this study selected four metrics to evaluate the prediction performance of the model: precision (P), recall (R), accuracy (ACC), and area under the curve (AUC). In terms of feature importance analysis, this study chooses a single feature analysis method based on the "input-output" sensitivity principle-Permutation Importance. For the mean model performance, the three ML models on the test set are P = 0.92, R = 0.95, ACC = 0.88, and AUC = 0.81. Specifically, the RF model is P = 0.95, R = 0.96, ACC = 0.92, AUC = 0.86; the ANN model is P = 0.92, R = 0.95, ACC = 0.88, AUC = 0.81; the SVC model is P = 0.88, R = 0.94, ACC = 0.85, AUC = 0.77. For feature importance analysis, Catheter-to-vein rate (RF: 91.55%, ANN: 82.25%, SVC: 87.71%), Zubrod-ECOG-WHO score (RF: 66.35%, ANN: 82.25%, SVC: 44.35%), and insertion attempt (RF: 44.35%, ANN: 37.65%, SVC: 65.80%) all occupy the top three in the ML models prediction task of PICCs-DVT, showing relatively consistent ranking results. The ML models show good performance in predicting PICCs-DVT and reveal a relatively consistent ranking of feature importance from the data. The important features revealed might help clinical medical staff to better understand and analyze the formation mechanism of PICCs-DVT from a data-driven perspective.

Concurrent Onset of Central Retinal Vein Occlusion and Inflammation of a Large Maxillary Odontogenic Cyst: Case Report and Analysis

Central retinal vein occlusion typically manifests in older individuals with underlying systemic pathology, leading to a spectrum of symptoms ranging from blurred vision to complete vision loss. While odontogenic infections are recognized for causing complications affecting the eye and vision, their potential role as an etiological factor in cases of sudden vision impairment merits consideration. This article presents a case involving central retinal vein thrombosis, wherein resolution was achieved through a combination of ophthalmic therapy and the surgical removal of a concurrently existing large inflamed odontogenic cyst located in the ipsilateral hemimaxilla. This case underscores the importance of recognizing odontogenic factors in the assessment of sudden vision impairment and the efficacy of a multidisciplinary therapeutic approach.

Experimental multiparametric magnetic resonance imaging characterization of iliocaval venous thrombosis pathological changes

ObjectiveIliocaval thrombotic obstruction is a challenging condition, especially because thrombus age and corresponding pathological remodeling at presentation are unknown, which directly impacts management. Our aim was to assess the ability of magnetic resonance imaging (MRI) in determining age thresholds of experimentally created inferior vena cava (IVC) thrombosis in pigs. MethodsWe used a previously described swine model of IVC thrombosis. The animals underwent MRI at baseline, immediately after thrombosis creation, and after a follow-up period extending from 2 to 28 days. Thirteen pigs were divided into three groups according to disease chronicity: acute group (AG; n = 5), subacute group (SAG; n = 4), and chronic group (CG; n = 4), with a mean thrombosis age of 6.4 ± 2.5 days, 15.7 ± 2.8 days, and 28 ± 5.7 days, respectively. A T1-weighted volumetric interpolated breath-hold examination sequence was used to anatomically delineate IVC thrombus as a region of interest. Three other MRI sequences were used to assess the thrombus signal. ResultsThe Kruskal-Wallis test showed a statistically significant difference in T1 relaxation times after contrast injection (P = .026) between the three groups of chronicity. The AG (360.2 ± 102.5 ms) was significantly different from the CG (336.7 ± 55.2 ms; P = .003), and the SAG (354.1 ± 89.7 ms) was significantly different from the AG (P = .027). There was a statistically significant difference in native T2 relaxation times (P = .038) between the three groups. The AG (160 ± 86.7 ms) was significantly different from the SAG (142.3 ± 55.4 ms; P = .027), and the SAG was significantly different from the CG (178.4 ± 11.7 ms; P = .004). ConclusionsThis study highlighted MRI characteristics in a swine model that might have the potential to significantly differentiate subacute and chronic stages from an acute stage of deep vein thrombosis in humans. Further clinical studies in humans are warranted. Clinical RelevanceIn addition to providing a better understanding of venous thrombosis remodeling over time, magnetic resonance imaging has the potential to be a tool that could allow us to characterize the composition of venous thrombus over an interval, allowing for a refined analysis of the local evolution of venous thrombosis. We propose a noninvasive and innovative method to characterize different thresholds of chronicity with magnetic resonance imaging features of central deep vein thrombosis of the inferior vena cava experimentally obtained using a totally endovascular in vivo swine model, mimicking human pathophysiology. Being able to determine these features noninvasively is critical for vascular specialists when it comes to choosing between fibrinolytic therapy, percutaneous thrombectomy, or surgical management.

Prognostic Effect of Incidental Pulmonary Embolism on Long-Term Mortality in Cancer Patients.

The effect of incidental pulmonary embolism (PE) on long-term prognosis in cancer patients is unclear. This study assessed the characteristics of cancer and venous thromboembolism (VTE) and the effect of incidental PE identified by oncologists on long-term survival of patients with cancer.Methods and Results:This single-center, retrospective, cohort study used hospital-based cancer registry data from the Osaka International Cancer Institute linked with electronic medical records and administrative data from Japan's Diagnosis Procedure Combination Per-diem Payment System. Overall, 15,689 cancer patients underwent contrast-enhanced thoracic computed tomography during 2010-2018. After excluding patients with missing data, symptomatic patients, or patients with suspected PE, 174 with incidental PE (PE+ group) and 13,197 with no PE (PE- group) were identified. The total incidence of incidental PE was 1.3%. No deaths from thrombotic events were identified in the PE+ group. Both groups were adjusted for cancer- and VTE-related characteristics using inverse probability weighting. After adjusting for immortal time bias in the PE+ group, Kaplan-Meier analysis revealed that all-cause mortality was higher in the PE+ group (hazard ratio, 2.26; 95% confidence interval, 1.53-3.33). A Cox proportional hazard model revealed that metastatic cancer and a history of curative treatment were significant prognostic factors, whereas central PE and residual proximal deep vein thrombosis were not. Incidental PE in cancer patients indicates poorer prognosis. Cancer-related but not thrombosis-related factors determine prognosis.

Patterns of interventions for central venous catheter-associated deep vein thrombosis and outcomes in cancer patients.

This letter evaluated the impact of different management strategies, specifically the presence or absence of therapeutic anticoagulation, on clinical outcomes for central venous catheter (CVC)-associated deep vein thrombosis (DVT) in cancer patients. One-hundred ninety-eight adult cancer patients with a confirmed CVC-associated DVT diagnosis from February 2013 and February 2021 were included. Incidence of symptomatic recurrent venous thromboembolism (VTE) was similar between patients who received therapeutic anticoagulation and those who did not (14% vs 16%, p = 0.807). In addition, therapeutic anticoagulation did not significantly alter the incidence of grade 3 and above bleeding events despite most patients having hematologic malignancies (9% vs 8%, p = 0.826). Therapeutic anticoagulation was not associated with a reduction in the incidence of recurrent VTE or increase the incidence of bleeding in adult cancer patients following a CVC-associated DVT diagnosis.

Preventive effect of aspirin on peripherally inserted central catheter-related vein thrombosis in patients with malignant tumors

AbstractThe majority of patients receiving chemotherapy undergo PICC catheterization. However, PICCs are significantly associated with catheter related complications, including deep vein thrombosis, blood infection, fibrin sheath, catheter prolapse, catheter displacement and blockage. Of all the risks, PICC-related VT was the most prevailing clinic symptom and resulted in a high risk of death. AimThe study aimed to investigate the preventive efficacy and safety of aspirin for patients with malignant tumors receiving venous thrombosis (VT) related with peripherally inserted central catheters (PICC) treatment. Patients and MethodsA randomized controlled trial was conducted. Participants with malignant tumors receiving chemotherapy who accepted PICC insertion operation were randomly allocated to the aspirin treatment group (n = 235) or the control group (n = 246). The patients in the aspirin group were administrated aspirin (100mg) for 30 days, whereas the patients in control group were administrated a placebo drug. The incidence of PICC-related VT in both groups and the aspirin related adverse effects were evaluated. ResultsThe incidence of PICC-related VT was 0.4% in the aspirin group, compared with 3.3% in the control group (P = 0.038). In addition, aspirin related bleeding was not observed. ConclusionPICC-related VT could be effectively prevented by aspirin in patients with malignant tumors.

Deep Vein Thrombosis in a Medical Ward - Incidence and Risk Factors

Objectives: Primary objective: The incidence of deep vein thrombosis in patients admitted to a medical ward. Methods: We conducted a prospective cohort to assess the incidence of deep vein thrombosis in patients admitted in a medical of our tertiary care center between October 2014 and May 2015. We excluded patients who had a preexisting deep vein thrombosis or a pulmonary embolism and patients on therapeutic anticoagulation. A bedside ultrasound machine was used for screening for deep vein thrombosis in the internal jugular, axillary, femoral, and popliteal veins. Noncompressibility of the vein compared to the artery was suggestive of thrombosis. Results: Among the 43 patients included in the study, 3 (6.98%) patients developed deep vein thrombosis. The incidence density is 7.48 per 1000 patient-days. One patient developed a central venous catheter-associated deep vein thrombosis. Multivariate analysis showed that the duration of hospital stay of more than 7 days was associated with a higher risk of development of deep vein thrombosis (odds ratio: 1.17 [confidence interval: 1.016–1.349]). Conclusions: The incidence of deep vein thrombosis among patients admitted in a medical ward of a tertiary care hospital in South India was 7.48 per 1000 patient-days. Hospital admission of more than 7 days was found to be a significant independent risk factor for development of deep vein thrombosis in our study.

Most complex brachiocephalic vein occlusion in hemodialysis patients can be treated with simple endovascular techniques in an office-based angiosuite

ObjectiveBrachiocephalic vein (BCV) obstruction can cause dialysis access dysfunction and failure. Central vein stenosis involving the BCV may require advanced endovascular procedures. We report that most BCV occlusions can be treated using simple endovascular techniques on an outpatient basis. MethodsFrom January 2009 to January 2022, 115 hemodialysis patients underwent BCV endovascular revascularization. Seventy-three of the initial procedures were performed in an office-based angiosuite. Indications for the procedure were BCV occlusion endangering the performance of a previous arm access or making the creation of a new arm access unadvisable. We recorded and analyzed risk factors and procedural results, patency rates, complications, and mortality. ResultsThe median age was 62 years (range, 23-91 years); 56% were female. Most prevalent associated conditions were diabetes mellitus (61%) and hypertension (68%). Fifty-six patients (48.7%) presented with severe upper extremity edema ipsilateral to the side of pre-existing functioning access. Obstruction recanalization was effective using standard catheter and wire in 106 cases (92.1%) and transseptal needle in nine cases (7.8%), that included seven using inside-out procedure. Initial management of the BCV stenosis was percutaneous transluminal balloon angioplasty alone in 74 patients (64.3%), stenting in 33 (28.7%), and HeRO conduit in eight cases (7%). Treatment of other central venous lesions included 49 cases (42.6%). The procedure was successful in 99.1% of patients. No intraoperative complications occurred. All 92 patients with previous arm access maintained adequate performance (100%). In 22 of 23 patients (95.6%), new upper extremity access creation was effectively performed after the venous intervention. Overall clinical success rate was 92%. The mean postoperative monitoring was 23 months, the median was 12 months, and the range was 1 to 84 months. During this monitoring period, 266 endovascular procedures, 91% in the office and 9% in the hospital, were required to preserve access performance. Eventually, 49 patients (42.6%) were stented. Eleven patients (9.56%) had infections, and six required complete access removal. Other causes of access failure included two patients with central vein thrombosis and one with massive pulmonary embolus. At the end, nine patients (7.8%) had access failure. Thirty-two patients (27.8%) died of unrelated causes during the follow-up period. Seventy-six patients (66%) have maintained functional access. Kaplan-Meier curves determined median primary patency of 9.6 months, median primary assisted patency of 56.2 months, and secondary patency of 75% at 80 months. ConclusionsSuccessful endovascular revascularization of BCV obstruction can be treated safely, with simple endovascular techniques in an office-based context with minor complication rates and durable results.

Междисциплинарный подход в диагностике и лечении макулярного отека, обусловленного тромбозом центральной вены сетчатки или ее ветвей

Purpose. To present clinical cases of macular edema associated with central retinal vein thrombosis (CRVT) of various etiologies. Material and methods. A prospective study of patients with macular edema associated with thrombosis of the central retinal vein or its branches in real clinical practice was conducted. All patients underwent a standard ophthalmological examination, as well as optical coherence tomography (OCT), and a biochemical blood test was performed on a patient with suspected macroglobulinemia. Results. In the first clinical case, macular edema was associated with retinovasculitis. The patient was consulted by a rheumatologist, diagnosed with idiopathic dermatomyositis, polymyositis, confirmed seropositive form. A long-term regimen of glucocorticosteroid drugs (Prednisone), courses of lymphosorption was prescribed. Treatment was carried out for macular edema, occlusion of the central nervous system on the background of retinovasculitis: anti-VEGF therapy, retinal laser coagulation. In the second clinical case, macular edema on the background of CRV thrombosis associated with Waldenstrom's disease. It is recommended to monitor and treat the underlying disease with a hematologist. Conclusion. Thus, macular edema occurring against the background of thrombosis of the central nervous system and its branches, having atypical symptoms in the form of exudative retinal detachment, the presence of a bilateral process, young age and the absence of risk factors for the development of retinal vein occlusion, as well as resistance to anti-VEGF therapy requires careful collection of anamnesis taking into account the patient's somatic condition and the presence of other ophthalmological vascular pathology. Keywords: macular edema, retinovasculitis, Waldenstrom macroglobulinemia

The Effect of Serum Electrolyte Levels and Infusion Treatments on the Development of Femoral Central Venous Catheter-Associated Deep Vein Thrombosis in Pediatric Intensive Care Unit.

In this study, we aimed to determine the frequency of symptomatic central venous catheters-associated deep vein thrombosis (CVC-a DVT) among critically ill children with femoral vein implantation in our pediatric intensive care unit (PICU), and to compare the demographic factors, serum electrolyte levels, and types of the infusion treatments performed. A total of 215 patients aged 1 month to 18 years who had femoral CVC implanted between 2019 and 2021 were included in this study. The cases that were clinically symptomatic and had thrombosis diagnosed ultrasonography were accepted as CVC-a DVT (+), and the other cases were considered as CVC-a DVT (-). Of the total 215 cases, 57.2% (n = 123) were female and 42.8% (n = 92) were male. Catheters-associated deep vein thrombosis diagnosis were made in 9.8% of the cases (n = 21). The mean time to diagnose thrombosis in CVC-a DVT (+) cases was 8.33 ± 5.65 days. With regard to gender, age, blood type, intubation status, length of stay on mechanical ventilator, presence of extra hemodialysis catheter, acute and chronic disease status, number of days of PICU hospitalization, and Pediatric Risk of Mortality-3 scoring, no significant differences between CVC-a DVT (-) and CVC-a DVT (+) cases were observed (P > .05). The incidence of thrombosis in refugee cases was found to be significantly higher than in Turkish cases (P = .047; P < .05). There was no statistically significant difference between the groups in baseline, mean, and peak glucose, sodium, and magnesium values and who received magnesium, blood product, inotrope, and 3% hypertonic saline (HTS) infusion (P > .05). No effect of serum glucose, sodium, and magnesium levels on the development of CVC-a DVT was found. Magnesium, blood product, inotrope, and 3% HTS infusion treatments have not been shown to have an effect on the development of CVC-a DVT.

Different diagnostic strategies using D-dimer for peripherally inserted central catheter-related upper extremity deep vein thrombosis

ObjectiveDeep vein thrombosis (DVT) in the upper extremities caused by a peripherally inserted central venous catheter (PICC) is distinct from the typical DVT. This specific type of mural thrombus might have an effect on the D-dimer levels. In the present study, we aimed to ascertain whether the D-dimer level might be considered an independent diagnostic marker to rule out upper extremity DVT caused by PICCs. MethodsWe performed a retrospective case-cohort study of 205 patients who had undergone D-dimer measurement and color Doppler ultrasound within 14 days after placement of a PICC to December 31, 2020, from January 1, 2018. The participants were followed up for 3 months to evaluate for upper extremity DVT. In addition, different D-dimer diagnostic strategies were analyzed. ResultsOf the 205 included patients, 53 (25.9%) had had a negative D-dimer level. Of the 53 patients, 10 had had upper extremity DVT attributable to a PICC using color Doppler ultrasound. Of these 10 patients, 3 had developed upper extremity DVT during the 3-month follow-up. Using the various D-dimer diagnostic techniques, the negative predictive value for the D-dimer levels was 81.1%. ConclusionsThe present study has shown that the different D-dimer diagnostic strategies are not effective for safely excluding the diagnosis of suspected PICC-related upper extremity DVT. Adding PICC placement as a special factor in the modified Wells score, in addition to the D-dimer level, could securely rule out PICC-related upper extremity DVT; however, the diagnostic efficacy was low.

Modified proximalization of arterial inflow using a hemodialysis reliable outflow graft in a patient with vascular access failure.

A 63-year-old man with end-stage renal disease and multiple failed vascular accesses (VAs) had been referred for creation of permanent dialysis access. He provided written informed consent for the report of his case details and imaging studies. His medical history included a failed kidney transplantation, aortic valve replacement, severe coronary artery disease requiring two coronary artery bypass grafts, and hypertension. A previous right groin and upper extremity VA had been complicated by chronic deep and central vein thrombosis, requiring stenting of the right innominate and superior vena cava (SVC) due to SVC syndrome.

Site‐specific venous thrombosis in essential thrombocythemia: Impact on subsequent vascular events and survival

Site‐specific venous thrombosis in essential thrombocythemia: Impact on subsequent vascular events and survival

S2934 Budd-Chiari Syndrome as the Sole Presentation of SARS-CoV-2 Infection

Introduction: The SARS-CoV-2 infection has been associated with a significant risk of venous thromboembolism. We present a case of a 22-year-old man with no prior medical history who is diagnosed with Budd-Chiari syndrome due to SARS-CoV-2 infection. Case Description/Methods: The patient had one month of dry cough and abdominal distention. He had worsening abdominal discomfort, dyspnea, orthopnea, and decreased urine output for a week prior to admission. At admission, the patient was in distress due to abdominal discomfort. He was hemodynamically stable, icteric, and pale, had a distended abdomen that was dull on percussion and had a fluid thrill with shifting dullness. His labs showed a picture of liver failure with INR 1.9 HI (0.9-1.1 HI), total bilirubin 2.8 mg/dl (0.2-1.2 mg/dl), albumin 3.3 g/dl (3.5-5.0 g/dl), ammonia 55 mcmol/l (11-32 mcmol/l), AST 94 U/L (10-43 U/L), ALT 58 U/L (13-41 U/L), and Alk Phos 264U/L (42-119 U/L). CBC, and CMP were normal. His SARS-CoV-2 reverse transcription-polymerase chain reaction (RT/PCR) was negative and the SARS-CoV-2 IgG antibody was positive. Inflammatory markers were elevated. Imaging of the abdomen showed a 10 cm mass-like area in the left hepatic lobe suspicious of hepatic malignancy versus altered vascularity and edema, thrombosis of all the hepatic veins, left portal vein, marked portal hypertension, liver failure, abdominal pelvic varices, and severe ascites. These findings were consistent with Budd Chiari Syndrome. A hypercoagulability workup was done as mentioned in the table. He underwent paracentesis three times during his hospital stay and underwent a liver mass biopsy for a definitive diagnosis. Biopsy showed bridging necrosis, central hepatic vein thrombosis, and congestion, negative for malignancy. The patient’s hypercoagulability, malignancy, and autoimmune workup were negative. Other tests like hepatitis panel, and HIV were negative. It was concluded that the Budd Chiari syndrome was due to mildly symptomatic SARS-CoV-2 infection. The patient was discharged on diuretics and was asked to follow up at a liver transplant center (Figure). Discussion: Budd-Chiari syndrome is an unusual and sometimes the sole manifestation of SARS-CoV-2 infection. These patients might have no or minimal respiratory symptoms and usually have no underlying liver disease. The usual workup should involve ruling out hypercoagulable state, malignancy, and autoimmune disorder. Unfortunately, it can be fatal and a liver transplant is the only definitive management for such patients.Figure 1.: Anticoagulation workup.

Recurrent venous thromboembolism in cancer patients treated with direct oral anticoagulants.

e13648 Background: Malignancy associated thrombosis places a significant clinical and financial burden on all major oncology services worldwide. Cancer patients are at an increased risk of thrombosis and large studies have suggested a subsequent increased mortality. (1) Some studies have recorded higher risk associated with certain chemotherapy regimens such as platinum-based agents and gemcitabine. (2) Guidelines for anticoagulation often recommend low molecular weight heparin (LMWH) as first line for malignancy associated thrombosis. (3) In recent years ASCO guidelines have added DOACs as an option for VTE treatment. (4) We herein describe eight cases of recurrent venous thromboembolism despite direct oral anticoagulation. Methods: Data was gathered from electronic patient records for cancer patients attending a single centre in Western Australia between 2016 and 2021. Radiology and medication records were used to confirm VTE diagnoses and subsequent treatment. This data was recorded on an excel file and analysed accordingly. Results: We identified 8 patients with recurrent VTE on DOACs. Median age of patients was 61 years (range 50-72). The most common associated malignancy was pancreatic cancer (n = 3). Other associated cancer types were ovarian (n = 2), lung adenocarcinoma (n = 2) and colorectal cancer(n = 1). Most patients had metastatic disease at time of first VTE(n = 5). The most common site of thrombosis was in the upper limb with 3 cases of initial VTE and 4 cases of recurrent VTE. All of these occurred in patients with peripherally inserted central catheters. (PICC) One patient had a left central retinal vein thrombosis resulting in complete loss of vision in that eye. All but one patient had received either platinum based chemotherapy or gemcitabine. Median time to initial thrombotic event was 4 months from diagnosis. Median time to recurrent thrombotic event was 3.5 months. Rivaroxaban was the most common DOAC used with initial VTE (n = 5). All other patients received apixaban (n = 3). All patients were switched to either LMWH (n = 6) or unfractionated heparin (n = 2) following recurrent VTE. 75% of patients did not have further thrombosis after switch to heparin. One patient had chronic thrombosis on subsequent scans and another patient had recurrent pulmonary embolism despite unfractionated heparin and vena cava filter insertion. Conclusions: Venous thromboembolism is a common complication of malignancy with significant associated morbidity and mortality. A high index of suspicion is needed in patients with clinical signs of recurrent VTE while on a DOAC, especially for those with PICCs. While DOACs are common for patient preference, the differing rates of VTE recurrences should be further investigated and considered in oncology prescribing practice going forward.

Central venous catheter-associated deep vein thrombosis in critically ill pediatric patients: risk factors, prevention, and treatment

Central venous catheter (CVC) placement and ICU admission are the two most important risk factors for pediatric deep vein thrombosis. The optimal prevention and treatment strategies for CVC-associated deep vein thrombosis (CADVT) are unclear, but recently, seminal studies have been published. This review aims to summarize the recent literature on CADVT in critically ill children. Recent publications focused on three themes: risk factors, prevention, and treatment of CADVT. Newly identified risk factors for CADVT relate to Virchow's triad of hemostasis, blood vessel injury, and hypercoagulability. New risk prediction models have moderately good accuracy in predicting CADVT. Though previous data on pharmacologic CADVT prophylaxis was equivocal, recent studies indicate that low-molecular-weight heparin may be effective in preventing CADVT, particularly in critically ill children. Finally, new studies suggest that direct oral anticoagulants and shorter treatment times are noninferior to traditional agents and treatment durations in the treatment of CADVT. Recent research suggests new ways to accurately identify children at high risk of CADVT, effectively prevent CADVT, and optimize CADVT treatment. Future research should focus on understanding the pathobiology of CADVT formation, prevention, and treatment in critically ill children.

A randomised trial of intracavitary electrocardiography versus surface landmark measurement for central venous access device placement

Background: Malpositioned central venous access devices (CVADs) can lead to significant patient injury including central vein thrombosis and dysrhythmias. Intra-cavitary electrocardiography (IC ECG) has been recommended by peak professional bodies as an accurate alternative for bedside CVAD insertion, to reduce risk of malposition and allowing immediate use of the device. Our objective was to compare the effect of IC ECG on CVAD malposition compared to traditional institutional practice for CVAD placement. Methods: Randomised controlled trial of IC ECG CVAD insertion verses traditional CVAD insertion (surface landmark measurement with post insertion x ray). Patient recruitment was from December 2016 to July 2018. The setting was a 900-bed tertiary referral hospital based in South Western Sydney, Australia. Three hundred and forty-four adult patients requiring CVAD insertion for intravenous therapy, were enrolled and randomly allocated (1:1 ratio) to either IC-ECG ( n = 172) or traditional ( n = 172) CVAD insertion. Our primary outcome of interest was the rate of catheters not requiring repositioning after insertion (ready for use). Secondary outcomes were comparison of procedure time and cost. Results: Of the 172 patients allocated to the IC ECG method, 170 (99%) were ready for use immediately compared to 139 of the 172 (81%) in the traditional insertion group (difference, 95% confidence interval (CI): 18%, 11.9–24.1%). The total procedure time was mean 15 min (SD 8 min) for IC ECG and mean 36 min (SD 17 min) for traditional CVAD insertion (difference–19.9 min (95% CI–14.6 to −34.4). IC ECG guided CVAD insertion had a cost reduction of AUD $62.00 per procedure. Conclusions: Using IC-ECG resulted in nearly no requirement for post-insertion repositioning of CVADs resulting in savings in time and cost and virtually eliminating the need for radiographic confirmation. Trial registration: This trial is registered at the Australian New Zealand Clinical Trials Registry ( http://www.anzctr.org.au ). The registration number is ACTRN12620000919910.

Comparing bowel lengthening procedures: which, when, and why?

Purpose of reviewIntestinal failure secondary to short bowel syndrome is still a very serious condition. Treatment consists of parenteral nutrition to provide nutrients and maintain body weight. During the last decades, intestinal lengthening procedures have become more available. The goal of this review is to discuss the results of the literature on the most commonly performed intestinal lengthening procedures.Recent findingsLongitudinal Intestinal Lengthening, Serial Transverse Enteroplasty (STEP), and Spiral Intestinal Lengthening and Tailoring (SILT) are currently the most frequently reported intestinal lengthening procedures. The most recent literature of these procedures is described with respect to indication, technical details, complications, short and long-term outcome, and PN independence.SummaryOn the basis of indication, surgical complexity, complications, and clinical success, we conclude that the STEP procedure is probably the best choice for most centers.

Delayed care in carotid-cavernous fistula due to the Covid-19 pandemic

Direct carotid-cavernous fistula is a high-flow communication between the internal carotid artery and the cavernous sinus that requires early transarterial embolization for its resolution. We report a case of a patient with a direct carotid-cavernous fistula who subsequently developed a central retinal vein thrombosis due to a delay in treatment related to the health collapse experienced in the first months of the Covid-19 pandemic in Spain.

Основные аспекты этиопатогенеза, диагностики и лечения субгиалоидных кровоизлияний

Purpose. To present modern literature data on the main aspects of etiopathogenesis, diagnosis and treatment of subhyaloid hemorrhages. Material and methods. To perform the review, the search for literature sources on PubMed abstract databases was analyzed by the keywords «subhyaloid hemorrhages», «posterior hyaloidotomy» according to Russian publications on the topic of the article for the period up to 2020 inclusive. Results. Subhyaloid hemorrhage is a suspension of blood in a space bounded by a mesh membrane and a detached posterior hyaloid membrane. The most common cause of subhyaloid hemorrhages are retinal vascular diseases: diabetic retinopathy of the retina (30%), Valsalva hemorrhagic retinopathy (30%), central retinal vein thrombosis (20%). Subhyaloid hemorrhages are less common in hematological diseases, eye injury, rupture of the macroaneurysm, Terson syndrome. It has been established that the main complications due to untimely or inadequate treatment of subhyaloid hemorrhages are the formation of a premacular fibrous membrane, vitreoretinal fusion, traction retinal detachment, hemophthalmos, fibrosis and retinal atrophy, which require the right tactics in treatment. Conclusion. Thus, due to the prolonged presence of blood and fibrin in the premacular subhyaloidal space, there is a danger of mechanical and toxic effects on the retinal neuroepithelium of the macular region, which can lead to an irreversible decrease in visual functions. Key words: subhyaloid hemorrhages, Nd:YAG laser, posterior hyaloidotomy