Cutdown Approach Research Articles

Rapid atrial pacing stimulation combined with carbachol to establish atrial fibrillation/atrial flutter model in mice

Objective To establish atrial fibrillation/atrial flutter (AF/AFL) model in C57B6N mice using rapid atrial pacing combined with carbachol. Methods 62 male C57B6N mice, weighing (25±3) g. A surface electrocardiogram (ECG) was recorded from surface limb leads. 20 mice were randomly and respectively selected as sham operation group and twice simple atrial pacing groups. An octapolar electrode catheter was inserted via jugular vein cutdown approach for simultaneous atrial endocardial recording and pacing in the remaining 22 mice as a simple atrial pacing group. After the carbachol (50 ng/g) was injected into the retro-orbital vein of mouse, the same combination of bursts was applied to the combined induction group mice. ECG electrophysiological parameters and AF/AFL duration were analyzed. Statisticalanalysis of data using the statistical product and service solutions 22.0 software. Results Spontaneous supraventricular arrhythmias were not observed in the sham-operated group (n=20); In the twice simple atrial pacing group (n=20), AF/AFL was induced in 4/20 (20.0%) mice; In the simple pacing group, AF/AFL was successfully induced in 4/22 (18.2%) mice with an average duration of (10.7±13.3) s. There was no statistically significant difference between the twice simple atrial pacing group and the simple pacing group(P>0.05); In the combined induction group, AF/AFL was induced in 13/20 (65.0%) mice with an average duration of (44.6±171.7) s. There was a statistically significant difference between the simple pacing group and the combined induction group in the success rate of introduction and AF/AFL mean duration (P<0.05). Conclusion A simple and effective mouse model of AF/AFL can be established by rapid atrial pacing combined with carbachol. Key words: Atrial fibrillation; Atrial flutter; Atrial pacing; Carbachol; Model, animal

A multi-institutional analysis of transcarotid artery revascularization compared to carotid endarterectomy

ObjectiveTranscarotid artery revascularization (TCAR) is a novel approach to carotid intervention that uses a direct carotid cut-down approach coupled with cerebral blood flow reversal to minimize embolic potential. The initial positive data with TCAR indicates that it may be an attractive alternative to trans-femoral carotid artery stenting and possibly carotid endarterectomy (CEA) for high-risk patients. The purpose of this study was to present 30-day and 1-year outcomes after treatment by TCAR and to compare these outcomes against a matched control group undergoing CEA at the same institutions. MethodsA retrospective review of all patients who underwent TCAR at four institutions between 2013 and 2017 was performed to evaluate the use of the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Inc, Sunnyvale, Calif). TCAR patients had high-risk factors and were either enrolled in prospective trials or treated with a commercially available TCAR device after US Food and Drug Administration approval. Contemporaneous patients undergoing CEA at each institution were also reviewed. Patients were propensity matched in a 1:1 (CEA:TCAR) fashion with respect to preoperative comorbidities. Data were analyzed using statistical models with a P value of less than .05 considered significant. Individual and composite stroke, myocardial infarction, and death at 30 days and 1 year postoperatively were assessed. ResultsConsecutive patients undergoing TCAR or CEA were identified (n = 663) and compared. Patients undergoing the TCAR procedure (n = 292) had higher rates of diabetes (P = .01), hyperlipidemia (P = .02), coronary artery disease (P < .01), and renal insufficiency (P < .01) compared with unmatched CEA patients (n = 371). Stroke rates were similar at 30 days (1.0% TCAR vs 1.1% CEA) and 1 year (2.8% TCAR vs 3.0% CEA) in the unmatched groups. After propensity matching by baseline characteristics including gender, age, symptom status (36.3%, 35.3%) and diabetes, 292 TCAR patients were compared with 292 CEA patients. TCAR patients were more likely to be treated preoperative and postoperatively with clopidogrel (preoperatively, 82.2% vs 39.4% [P < .01]; postoperatively, 98.3% vs 36.0% [P < .01]) and statins (preoperatively, 88.0% vs 75.0% [P < .01]; postoperatively, 97.8% vs 78.8% [P < .01]). Stroke (1.0% TCAR vs 0.3% CEA; P = .62) and death (0.3% TCAR vs 0.7% CEA; P = NS) rates were similar at 30 days and comparable at 1 year (stroke, 2.8% vs 2.2% [P = .79]; death 1.8% vs 4.5% [P = .09]). The composite end point of stroke/death/myocardial infarction at 1 month postoperatively was 2.1% vs 1.7% (P = NS). TCAR was associated with a decreased rate of cranial nerve injury (0.3% vs 3.8%; P = .01). ConclusionsThese early data suggest that patients undergoing TCAR, even those with high-risk comorbidities, achieve broadly similar outcomes compared with patients undergoing CEA while mitigating cranial nerve injury. Further comparative studies are warranted.

Short-term outcome and mid-term access site complications of the percutaneous approach to endovascular abdominal aortic aneurysm repair (PEVAR) after introduction in a vascular teaching hospital.

The objective is to evaluate our center's experience with the safety and efficacy of the percutaneous approach to endovascular abdominal aortic aneurysm repair (PEVAR) with use of the Perclose Proglide device, in the first period after introduction in our center in 2014. We retrospectively identified all patients that underwent PEVAR or endograft extension with percutaneous approach in our center in the urgent and elective setting. Included were all procedures performed between the introduction of the technique in January 2014 and February 2016 when PEVAR had become the predominant technique in our center. Exclusion progressed from expected difficulty of the procedure as estimated by the operator to total calcification of the ventral wall of the CFA towards the end of the study period. Surgical and clinical reports were used to analyze patient characteristics, procedural success, and short-term outcome after 30days. Follow-up imaging was used to assess mid-term access site complications at 1 and 2 years postoperatively. A univariate regression analysis was conducted to determine significant predictors of access-related complications with the Perlcose Proglide system. Of all 78 patients (mean age 74, SD: 7years, 70 men), 68 (87.2%) underwent PEVAR and 10 (12.8%) underwent endograft extension procedures with percutaneous approach. Sixty-seven (85.9%) patients underwent an elective procedure and 11 (14.1%) patients underwent urgent PEVAR. The total number of vessels that was percutaneously accessed was 142. Direct technical success of the procedure as analyzed per vessel was 98.6% (140/142), with two cases of conversion to the femoral cut-down approach. A total of 274 Perclose Proglide devices were placed. Device failure of the Perclose device occurred in 5.8% (16/274) and was reason for conversion to cut-down procedure in one case. Mean duration of the procedure and median time of hospitalization were 100 (SD: 34) min and 2 (IQR 1, 3) days, respectively. Event-free survival per vessel after 30days was 91.0%, with two minor access-related complication. Fifty-five individual patients (105 vessels) were eligible for inclusion in the 1-year follow-up analysis. Of these patients, 19 (34 vessels) could be included in the 2-year follow-up analysis. No additional access site complications occurred at mid-term follow-up. No significant predictors of device failure were found. The percutaneous approach to EVAR appears to be a safe and effective option with high success rate and low complication rate in a real-world setting. Based on our findings, we conclude that the technique can safely be introduced in a vascular center.

A Prospective, Comparative Evaluation on Totally Implantable Venous Access Devices by External Jugular Vein versus Cephalic Vein Cutdown

The request for totally implantable venous access devices (TIVADs) has rapidly grown up through the last decades. TIVADs are implanted by direct vein puncture or by surgical approach with vein cutdown. The authors present a comparative prospective study evaluating external jugular vein (EJV) and cephalic vein cutdown techniques. Two hundred and fifteen patients were consecutively submitted to TIVAD implantation to perform chemotherapy. Patients were divided in two groups, depending on the implantation technique. Group A patients (106) underwent implantation via EJV cutdown and group B (109) patients underwent implantation by cephalic vein cutdown. The following variables were investigated: operating time, need for conversion to other approaches, complications, and intraoperative and postoperative pain. In Group A patients, the success rate of the procedure was 100 per cent, whereas in 11 patients (10.1%) of Group B, a modification of the initial approach was needed. Mean operative time was 23.9 ± 9.2 minutes in Group A and 35.4 ± 11.9 in Group B, and this was statistically significant (P < 0.05). Complication rates at 30 days were similar. Considering intraoperative pain, a difference was found between the two groups because the mean value of pain in Group A was lower than that in Group B (4.13 ± 0.3 vs 5.22 ± 1.24), even if not significant. External jugular vein cutdown approach is quick and safe and allows a very high success rate with very low risk of complications. For these reasons, this approach could be considered as a first choice in TIVAD placement.

Indications and outcomes for tunneled central venous line placement via the axillary vein in children.

To assess the indications, safety and outcomes of tunneled central venous catheters (CVCs) placed via a cutdown approach into the axillary vein in children, an approach not well described in this population. A retrospective cohort study was performed on pediatric patients who received CVCs via open cannulation of the axillary vein or one of its tributaries between January 2006 and October 2016 at two hospitals. A total of 24 axillary CVCs were placed in 20 patients [10 male (42%); mean weight 7.0kg (SD 2.9); mean age 10months (SD 6)]. The most common indications for axillary vein access included neck or chest wall challenges (tracheostomies or chest wall wounds) (n=18). The median duration of line placement was 140days (IQR 146). The most common indications for removal were completion of therapy (n=7, 39%) and infection (n=5, 28%). There were no early complications. Long-term complications included infection (n=5) or catheter malfunction (n=3). Tunneled CVC placement via a cutdown approach into the axillary vein or its tributary can be an effective alternative approach to obtain long-term vascular access in children. Outcomes may be comparable to lines placed in traditional internal jugular and subclavian vein locations.

IP267 External Jugular Vein Cutdown Approach vs Percutaneous Approach for Totally Implantable Venous Access Device Placement: A Safe, Fast, and Cheap Method

IP267 External Jugular Vein Cutdown Approach vs Percutaneous Approach for Totally Implantable Venous Access Device Placement: A Safe, Fast, and Cheap Method

Pleural Effusions and Pneumothoraces.

1. Katherine Cashen, DO* 2. Tara L. Petersen, MD† 1. *Department of Pediatrics, Children's Hospital of Michigan/Wayne State University School of Medicine, Detroit, MI 2. †Division of Critical Care, Department of Pediatrics, The Children’s Hospital of Wisconsin/The Medical College of Wisconsin, Milwaukee, WI * Abbreviations: BTS: : British Thoracic Society CHF: : congestive heart failure CT: : computed tomography VATS: : video-assisted thoracoscopic surgery 1. Clinicians should be aware of the causes and clinical presentation of pleural effusions and pneumothoraces. 2. Clinicians should understand the current role of diagnostic tests, imaging modalities, and timing of minimally invasive treatments. After completing this article, readers should be able to: 1. Describe the pathogenesis of pleural fluid accumulation. 2. Identify the most likely causes of pleural effusion and pneumothorax. 3. Understand the basic clinical presentation, diagnostic tests, and management of pleural effusions and pneumothoraces. 4. Differentiate between transudative and exudative pleural effusions. 5. Understand the natural history of spontaneous pneumothorax. The pleural space is created by the parietal and visceral pleura that line the chest wall and the lung surface, respectively. Normally, only a small amount (0.3 mL/kg) of hypotonic fluid is present within the pleural space due to homeostatic balances in physiologic fluid production and absorption. Various infectious and noninfectious processes can lead to pathologic filling of the pleural space with fluid (effusion) or air (pneumothorax). Such pathologic changes create a true space that can interfere with normal lung mechanics and, in severe cases, cardiac function. Although much less common in pediatric than adult populations, pleural effusions and pneumothoraces in both groups can lead to substantial complications, resulting in significant morbidity and mortality if unrecognized or untreated. Overall, the cause of pleural effusions and pneumothoraces differs in children compared to adults. In adults, congestive heart failure (CHF) and malignancy account for a substantial number of pleural effusions, but these are uncommon causes in children. Infectious pleural effusions in the setting of pneumonia (parapneumonic effusions) remain the most common cause of effusions in both children and adults. Unlike the adult population, children experience spontaneous …

Totally percutaneous versus surgical cut-down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair.

Abdominal aortic aneurysms (AAAs) are a vascular condition with significant risk attached, particularly if they rupture. It is, therefore, critical to identify and repair these as an elective procedure before they rupture and require emergency surgery. Repair has traditionally been an open surgical technique that required a large incision across the abdomen. Endovascular abdominal aortic aneurysm repairs (EVARs) are now a common alternative. In this procedure, the common femoral artery is exposed via a cut-down approach and a graft introduced to the aneurysm in this way. This review examines a totally percutaneous approach to EVAR. This technique gives a minimally invasive approach to femoral artery access that may reduce groin wound complication rates and improve recovery time. The technique may, however, be less applicable in people with, for example, groin scarring or arterial calcification. This is an update of the review first published in 2014. This review aims to compare the clinical outcomes of percutaneous access with surgical cut-down femoral artery access in elective bifurcated abdominal endovascular aneurysm repair (EVAR). For this update the Cochrane Vascular Information Specialist (CIS) searched their Specialised Register (last searched October 2016) and CENTRAL (2016, Issue 9). We also searched clinical trials registries and checked the reference lists of relevant retrieved articles. We considered only randomised controlled trials. The primary intervention was a totally percutaneous endovascular repair. We considered all device types. We compared this against surgical cut-down femoral artery access endovascular repair. We only considered studies investigating elective repairs. We excluded studies reporting emergency surgery for a ruptured abdominal aortic aneurysm and those reporting aorto-uni-iliac repairs. Two review authors independently collected all data. Owing to the small number of trials identified we did not conduct any formal sensitivity analysis. Heterogeneity was not significant for any outcome. Two studies with a total of 181 participants met the inclusion criteria, 116 undergoing the percutaneous technique and 65 treated by cut-down femoral artery access. One study had a small sample size and did not adequately report method of randomisation, allocation concealment or pre-selected outcomes. The second study was a larger study with few sources of bias and good methodology.We observed no significant difference in mortality between groups, with only one mortality occurring overall, in the totally percutaneous group (risk ratio (RR) 1.50; 95% confidence interval (CI) 0.06 to 36.18; 181 participants; moderate-quality evidence). Only one study reported aneurysm exclusion. In this study we observed only one failure of aneurysm exclusion in the surgical cut-down femoral artery access group (RR 0.17, 95% CI 0.01 to 4.02; 151 participants; moderate-quality evidence). No wound infections occurred in the cut-down femoral artery access group or the percutaneous group across either study (moderate-quality evidence).There was no difference in major complication rate between cut-down femoral artery access and percutaneous groups (RR 0.91, 95% CI 0.20 to 1.68; 181 participants; moderate-quality evidence); or in bleeding complications and haematoma (RR 0.94, 95% CI 0.31 to 2.82; 181 participants; high-quality evidence).Only one study reported long-term complication rates at six months, with no differences between the percutaneous and cut-down femoral artery access group (RR 1.03, 95% CI 0.34 to 3.15; 134 participants; moderate-quality evidence).We detected differences in surgery time, with percutaneous approach being significantly faster than cut-down femoral artery access (mean difference (MD) -31.46 minutes; 95% CI -47.51 minutes to -15.42 minutes; 181 participants; moderate-quality evidence). Only one study reported duration of ITU (intensive treatment unit) and hospital stay, with no difference found between groups. This review shows moderate-quality evidence of no difference between the percutaneous approach compared with cut-down femoral artery access group for short-term mortality, aneurysm exclusion, major complications, wound infection and long-term (six month) complications, and high-quality evidence for no difference in bleeding complications and haematoma. There was a difference in operating time, with moderate-quality evidence showing that the percutaneous approach was faster than the cut-down femoral artery access technique. We downgraded the quality of the evidence to moderate as a result of the limited number of studies, low event numbers and imprecision. As the number of included studies were limited, further research into this technique would be beneficial. The search identified one ongoing study, which may provide an improved evidence base in the future.

Combined vascular and neurologic injury after cephalic vein cutdown approach for ICD implantation

In this article we discuss two cases that highlight possible complications of cardiac device implantation. In particular, our first case involves a patient who, during implantable cardioverter defibrillator (ICD) implantation, sustained injuries to her subclavian artery and vein and subsequently developed a self-resolving neuropraxia of the brachial plexus. In our second case, the patient, also during ICD implantation, had his left cephalic vein nicked during cutdown. Post-op he then developed a hematoma-induced left brachial plexus injury that also eventually self-resolved. A literature search has not shown other incidences of iatrogenic brachial plexus injuries from ICD implantation as described.

To implement techniques of cutdown approach

In order to reduce the time of wound healing of the operated animals and the prevention of complications, we have developed the device of the wound notched hook form by increasing its non-invasive and handling, as well as the retractor for moving apart organs in the abdominal cavity to facilitate the surgical approach, sufficient visibility and control designated and recorded organs by it during surgery. Wound notched hook consists of framing handle with a longitudinal through hole connected to the retaining ring, while on the other side of the fixation ring is formed with the rod with operating element consisting of bent tines. Unlike the commonly used wound notched hook its free ends of the tines are made with drop-shaped thickening for their non-invasive reliance on soft tissue. Application of the developed wound hook notched allows you to: achieve fast and safe placing of the free end tines into the operating cavity as well as the smooth and safe removal of wound hooks notched outside the operating cavity or wound; avoid undue injury tissue of the operated animal. Upgraded retractor comprises a carcass handle connected to the retaining ring, while on the other side of the fixation ring formed conically widening plate bent at right angles and forming the operating element in the form of restrictive platforms. Unlike the conventional retractor restrictive site are made through identical longitudinal rectangular openings arranged parallel to each other and to the longitudinal axis of the retractor for moving apart organs. Developed retractor allows you to: reduce the overlapping area of the continuous operating member retractor in the side aperture of the abdomen; eliminate long clamping organs between the retractor and lateral aperture of the abdomen; reduce the time for the operation; facilitate ligation; reduce the weight of the retractor for moving apart organs; improve the usability of the tool. Together, these tools significantly improve performance with auxiliary surgical instruments and improves the safety of working with them.

Microbiological Evaluation of the Extension Wire and Percutaneous Epidural Lead Anchor Site Following a "2-Stage Cut-Down" Spinal Cord Stimulator Procedure.

There are concerns regarding bacterial colonization of the temporary extension leads and subsequent infection risk using the 2-stage cut-down approach in spinal cord stimulation (SCS). We sought to quantify the extent of bacterial colonization of the temporary extension wire and percutaneous epidural lead anchor site. We conducted a cross-sectional observational study recruiting a pragmatic sample of 25 consecutive patients listed for a cut-down trial of SCS. We excluded patients undergoing revision procedures and those who had previously received a spinal cord stimulator. The primary outcome measure was the rate and type of colonization of the extension wires and lead anchor site. No surgical site infections were recorded in any of the patients and no late infections subsequent to insertion of the implantable pulse generator. Overall, 24% of patients grew organisms from the temporary extension wire. Five patients grew coagulase-negative Staphylococcus aureus, and 1 patient grew Enterococcus faecalis. There were no positive wound cultures from the anchor site of the epidural lead. Despite the high colonization rate of the temporary extension wire, there were no surgical site infections. We conclude that provided appropriate strategies for the management of surgical site infections are implemented, the 2-stage cut-down procedure is a safe approach that is not associated with a higher incidence of infection.

A novel "shrug technique" for totally implantable venous access devices via the external jugular vein: A consecutive series of 254 patients.

The external jugular vein (EJV) approach for totally implantable venous access devices (TIVADs) is safe. However, the success rate is unsatisfactory because of the difficulty in catheterization due to the acute angle between the EJV and the subclavian vein (SCV). A novel "shrug technique" to overcome this difficulty was developed, and its efficacy was assessed in a consecutive case series. TIVAD placement was performed via the EJV cut-down approach. "Shrug technique," a simple way to straighten the EJV-SVC angle by shrugging the patient's shoulder, was applied to facilitate the passage of the guidewire and sheath-introducer when there was acute angulation between the EJV and SCV. A total of 254 patients underwent TIVAD implantation by the EJV cut-down approach. The "shrug technique" was applied in 51 cases (20%), and catheterization was successful in all cases. Thus, TIVAD implantation was successfully completed in all 254 cases (100%) in a single operative setting. The median operating time was 38 [IQR 30-45] min. Eleven complications (4%) were observed, but none of them were EJV-specific. The "shrug technique" is simple but very useful to achieve a higher success rate and safer insertion of TIVADs from the EJV. J. Surg. Oncol. 2017;115:291-295. © 2016 Wiley Periodicals, Inc.

Cost analysis of iliac stenting performed in the operating room and the catheterization lab: A case-control study

BackgroundIliac arterial stenting is performed both in the operating room (OR) and the catheterization lab (CL). To date, no analysis has compared resource utilization between these locations. MethodsConsecutive patients (n = 105) treated at a single center were retrospectively analyzed. Patients included adults with chronic, symptomatic iliac artery stenosis with a minimum Rutherford classification (RC) of 3, treated with stents. Exclusion criteria were prior stenting, acute ischemia, or major concomitant procedures. Immediate and two-year outcomes were observed. Patient demographics, perioperative details, physician billings, and hospital costs were recorded. Multivariable regression was used to adjust costs by patient and perioperative cost drivers. ResultsFifty-one procedures (49%) were performed in the OR and 54 (51%) in the CL. Mean age was 57, and 44% were female. Severe cases were more often performed in the OR (RC ≥ 4; 42% vs. 11%, P < 0.001) and were associated with increased total costs (P < 0.01). OR procedures more often utilized additional stents (stents ≥ 2; 61% vs. 46%, P = 0.214), thrombolysis (12% vs. 0%, P = 0.011), cut-down approach (8% vs. 0%, P = 0.052), and general anesthesia (80% vs. 0%, P < 0.001): these were all associated with increased costs (P < 0.05). After multivariable regression, location was not a predictor of procedure room or total costs but was associated with increased professional fees. Same-stay (5%) and post-discharge reintervention (33%) did not vary by location. ConclusionsThe OR was associated with increased length of stay, more ICU admissions, and increased total costs. However, OR patients had more severe disease and therefore often required more aggressive intervention. After controlling for these differences, procedure venue per se was not associated with increased costs, but OR cases incurred increased professional fees due to dual-provider charges. Given the similar clinical results between venues, it seems reasonable to perform most stenting in the CL or utilize conscious sedation in the OR.

A prospective evaluation on external jugular vein cut-down approach for TIVAD implantation.

BackgroundTotally implantable venous access devices can be implanted both by percutaneous approaches and by surgical approaches with cephalic vein or external jugular vein cut-down techniques that are related to low intraoperative complication rates. The authors report a prospective evaluation of 83 consecutive external jugular vein cut-down approaches for totally implantable venous access devices implantation.MethodsEighty three consecutive patients (28 M, 55 F, mean age 54.2) suffering from solid tumors (58) or hematologic diseases (25) were consecutively submitted to totally implantable venous access devices insertion through external jugular vein cut-down approach (75 on right side, 8 on left side).ResultsAll devices were surgically implanted; no instances of intraoperative complications were detected. After a minimum follow-up of 150 days, only one case of wound hematoma and one case of device malfunction due to incorrect catheter angulation were noted.Postoperative patient satisfaction was evaluated by the use of specific questionnaire that demonstrated a good satisfaction and compliance (92.8 %) of patients with implanted devices.ConclusionsDespite the lack of controlled studies comparing external jugular vein cut-down approach vs other approaches, this approach should be considered as a tool for long-term central vein catheters positioning, both as an alternative and for primary approach.

Commentary on: successful use of extracorporeal membrane oxygenation for pulmonary embolism, prolonged cardiac arrest, post-partum: a cannulation dilemma.

A 30-year-old female gravida 1 (37 weeks + 5 days gestation) underwent a crash Cesarean section for evidence of fetal distress, with the presumed diagnosis of placental abruption. Immediately post-op, the patient had a complete cardiovascular collapse with pulseless electrical activity, requiring cardiopulmonary resuscitation (CPR). Two doses of thrombolytics (Tenecteplase) were administered during the resuscitation, with a presumed diagnosis of a pulmonary embolism. After approximately 45 minutes into the resuscitation, the cardiac surgery team was called to initiate extracorporeal membrane oxygenation (ECMO).Case Study: Veno-arterial (V-A) ECMO was emergently attempted, with difficulty, through a left femoral cut-down approach and was successfully initiated 84 minutes into the resuscitation. Once the patient’s blood pressure and oxygen saturations were stabilized, the cannulae were switched to the right groin, using a Dacron graft in an end-to-side fashion. The left groin vessels were small and spasmodi...

Surgical cutdown versus percutaneous access in transfemoral transcatheter aortic valve implantation: Insights from the Brazilian TAVI registry.

To compare the 1-year outcomes of complete percutaneous approach versus surgical vascular approach for transfemoral transcatheter aortic valve implantation (TAVI), among "real-world" patients from the multi-center Brazilian TAVI registry. Vascular access still remains a major challenge for TAVI via transfemoral approach. Vascular access through complete percutaneous approaches or through open surgical vascular techniques seems to be acutely similar. However, the long-term outcomes of both techniques remain poorly described. The study population comprised all patients treated via transfemoral route in the Brazilian TAVI registry, a "real-world", nation-based, multi-center study. Patients were divided according to the initial vascular access approach (percutaneous vs. surgical) and clinically followed-up for 1 year. The primary endpoint was the incidence of combined adverse events all-cause mortality, life-threatening bleeding, and/or major vascular complication at 1 year. A total of 402 patients from 18 centers comprised the study population (percutaneous approach in 182 patients; surgical cutdown approach 220 patients). The incidence of combined adverse events was not different in the percutaneous and the surgical groups at 30 days (17.6% vs. 16.3%; P = 0.8) and at 1 year (primary endpoint) (30.9% vs. 28.8%; P = 0.8). Also, the study groups overall were comparable regarding the incidence of each individual safety adverse events at 30 days and at 1 year. Total percutaneous techniques or surgical cutdown and closure may provide similar safety and effectiveness during the first year of follow-up in patients undergoing transfemoral TAVI.

Ultrasound-guided vein puncture versus surgical cut-down technique in totally implantable venous access devices (TIVADS): a prospective comparative study on safety, efficacy andcomplications.

otally implantable venous access devices (TI-VADs) consist of a central venous catheter(made of silicone rubber or polyurethane) and asubcutaneously-implanted injection port made oftitanium or plastic, providing a simple, safe, andpermanent means of accessing the vascular systemfor intravenous delivery of drugs and fluids.

S08 * SUBGROUPS OF ADDICTION AND THEIR SPECIAL TREATMENT

S08 * SUBGROUPS OF ADDICTION AND THEIR SPECIAL TREATMENT

Presented at the 64th Annual Scientific Meeting of the Japanese Association for thoracic surgery: wet-lab training for thoracic surgery at the laboratory animal facilities

The purpose of this study was to describe the animal thoracic training program for the thoracic surgery at the laboratory animal facilities The training was provided for 78 surgical students under the direction of thoracic medical specialists. Students attended lectures and then performed venipuncture, injection, intubation, tracheostomy, surgical cut-down, and thoracic and abdominal surgical approaches. We estimated the detailed surgical skills in two groups (67 residents and 11 thoracic fellows). All students demonstrated satisfactory impressions after training. We found significant difference between the skills of residents and fellows with regard to the haemostasis and suturing techniques. Wet-lab training for thoracic surgery at the laboratory animal facilities is useful for surgical residents and thoracic fellows.

Insertion of Totally Implantable Venous Access Devices

Comparison of two different insertion techniques for implantation of totally implantable access ports (TIAP). TIAP are introduced through different open and closed cannulation strategies and by various medical experts. The aim of this expertise-based randomized trial was to compare venous cutdown approach with puncture of subclavian vein. One hundred and ten patients scheduled for primary implantation of a TIAP were randomly assigned to either open insertion technique performed by surgeons or puncture of the subclavian vein under fluoroscopic guidance by radiologists at an outpatient single university center. The primary endpoint was the primary success rate of the cannulation strategy. A logistic regression model was used for analysis adjusting for age, Karnofsky index, body mass index and surgeons', and the radiologists' experience. Percutaneus cannulation was not superior to surgical venous cutdown in the intention-to-treat analysis (odds ratio, 0.37; 95% CI, 0.07; 2.15) and the as-treated analysis (odds ratio, 0.16; 95% CI, 0; 1.28). The procedure was shorter with surgery (median, 21 minutes; 95% CI, 14; 30) than with radiology (median, 45 minutes; 95% CI, 43; 50) (P < 0.001), and the dose of radiation was lower with surgery (median, 37 cGy/cm(2); 95% CI, 26; 49) than with radiology (200 cGy/cm(2); 95% CI, 200; 300) (P < 0.001). Central venous cannulation for insertion of TIAPs can be performed safely and effectively with both approaches. The open direct surgical access requires further strategies for successful placement of a TIAP, and percutaneous Seldinger technique requires more time and a higher dose of radiation and is associated with risk of pneumothorax.