Direct Puncture Research Articles

Single Incision Laparoscopic Surgery: Feasibility of the Direct Fascial Puncture Technique Without Working Trocars.

IntroductionAs single-incision laparoscopic surgery (SILS) became popular, many access platforms and techniques emerged. When we initially described the direct fascial puncture (DFP) technique, many suggested it was not practical for three reasons: (1) increased hernia formation, (2) inability to complete operations without instrument changes and (3) insurmountable instrument drag. This study sought to determine whether the technique was a feasible approach by evaluating the outcomes with DFP-SILS in a single surgeon unit.MethodsThis was a retrospective audit of all consecutive patients who had unselected SILS operations by a single surgeon. For the DFP-SILS operation, a single optical trocar was used at the umbilicus, a second was rail-roaded beside the optical trocar and a third was directly passed across the fascia at the left-lateral extent of the skin wound. We recorded the number of conversions or failed operations and examined the patients routinely after operation to evaluate for incisional herniae.ResultsThere were 50 DFP-SILS operations performed: 37 cholecystectomies, 12 appendectomies and one jejunal resection. The operations were successful in all cases with no conversions or mortality recorded. One patient (2%) developed a superficial surgical site infection after SILS-DFP appendectomy. The therapeutic outcomes were comparable to existing series of multi-port laparoscopy. There were no incisional herniae detected.ConclusionEven in the resource-poor setting, SILS operations are feasible and safe using the DFP technique. The theoretic concerns have not been realized in clinical practice.

Direct Puncture and Embolization of a Congenital Bronchial Artery to a Pulmonary Artery Fistula

A 55-year-old woman with an incidentally detected bronchial artery-to-pulmonary artery fistula (BPF) with dilation of 33-mm maximum diameter (Fig 1) underwent prophylactic embolization to avoid potential rupture and catastrophic hemorrhage. Three systemic arteries, the right bronchial, right superior thyroid (Fig 2), and aberrant right subclavian arteries, converged into a sac-like component of 16-mm diameter at the superior mediastinum. The sac proceeded as a single dilated outflow vessel meandering downward in the anterior mediastinum, narrowing and draining into the proximal part of the pulmonary artery.

Effects of Cnidoscolus aconitifolius on Some Hematological Parameters of Male Wistar Rats

Introduction: Medicinal plants have become increasingly useful as a form of alternative therapy. Cnidoscolus aconitifolius is a medicinal plant applied in folklore remedies in the treatment and prevention of various diseases.
 Aim: The aim of this study is to assess the effects of Cnidoscolus aconitifolius on some hematological parameters of male Wistar rats.
 Methodology: A total of 15 male Wistar rats weighing between 100-250 g were randomly placed in groups. Group 1 served as control and received distilled water only; group 2 received 200 mg/kg and group 3 received 400 mg/kg of the hydromethanolic leaf extract of Cnidoscolus aconitifolius. Extract was administered once daily using oro-gastric cannula for 30 days. Blood samples were collected by direct cardiac puncture into appropriate sample tubes for estimation of hematological parameters including red blood cell count (RBC), packed cell volume (PCV), haemoglobin (Hb) concentration, white blood cell count (WBC) and platelet count.
 Results: Results showed a significant (P<0.05) increase in RBC, PCV, Hb and platelet count with the higher dose of 400 mg/kg body weight of the extract compared to control group. However, the WBC count was not significantly (P>0.05) altered.
 Conclusion: Oral administration of the leaf extract of Cnidoscolus aconitifolius increases red blood cell count, packed cell volume, hemoglobin level and platelet count at 400 mg/kg body weight.

Feasibility of a Novel Mobile C-Reactive Protein-Testing Device Using Gold-Linked Electrochemical Immunoassay: Clinical Performance Study.

BackgroundHome-based care is one of the most promising solutions to provide sufficient medical care for several older patients in Japan. However, because of insufficient diagnostic devices, it is sometimes difficult to detect early signs of the occurrence or worsening of diseases, such as infections under home-based care settings. C-reactive protein (CRP) is highly sensitive to diagnosing infections, and its elevation can help diagnose acute infection in older patients. Therefore, a CRP-measuring device that can be used in such a specific occasion is needed for home-based care. However, aspects such as its size, weight, and procedure are still challenging with respect to the practical use of mobile devices that quantitatively measure CRP levels easily and quickly under home-based care settings.ObjectiveWe developed a new mobile, rapid CRP measurement device using a gold-linked electrochemical immunoassay (GLEIA) system. The aim of this study was to evaluate the feasibility of this mobile CRP-testing device.MethodsFirst, we assessed the performance of bare GLEIA-based electrode chips as the foundation of the device. After embedding the bare GLEIA-based electrode chips in a special plastic case and developing the mobile CRP-testing device, we further tested the device prototype using clinical blood samples. Finally, we evaluated the intra-assay variability for precision in the same condition and inter-assay variability for reproducibility in different conditions.ResultsBlood samples for analysis were obtained by direct vein puncture from outpatients (N=85; females: 57/85; males: 28/85; age: 19-88 years) at Kanazawa University Hospital in Japan. For performance evaluation of bare GLEIA-based electrode chips, we used 85 clinical blood samples. There was a significant positive correlation between the electrode-predicted CRP levels and the reference CRP concentrations (R2=0.947; P<.001). The assembled device was mobile (size 45×90×2.4 mm; weight 10 g) and disposable. The minimum volume of the sample needed for measuring CRP was 1.4 µL. The estimated preanalytical time was approximately 7 minutes and 40 seconds, and analysis time was approximately 1 minute and 10 seconds. Subsequently, for performance evaluation of the mobile CRP-testing device using GLEIA-based electrode chips, we used 26 clinical blood samples and found a significant positive correlation between the mobile device-predicted CRP levels and the reference CRP concentrations (R2=0.866, P<.001). The intra-assay variabilities were 34.2%, 40.8%, and 24.5% for low, medium, and high CRP concentrations, respectively. The inter-assay variabilities were 46.5%, 38.3%, and 64.1% for low, medium, and high CRP concentrations, respectively.ConclusionsOur findings suggest that this new mobile CRP-testing device might be suitable for use in home-based care settings.

Direct puncture of the carotid artery as a bailout vascular access technique for mechanical thrombectomy in acute ischemic stroke\u2014the revival of an old technique in a modern setting

PurposeTo describe our single-center experience of mechanical thrombectomy (MTE) via a direct carotid puncture (DCP) with regard to indication, time metrics, procedural details, as well as safety and efficacy aspects.MethodsDCP thrombectomy cases performed at our center were retrospectively identified from a prospectively maintained institutional MTE database. Various patient (age, sex, stroke cause, comorbidities), clinical (NIHSS, mRS), imaging (occlusion site, ASPECT score), procedural (indication for DCP, time from DCP to reperfusion, materials used, technical nuances), and outcome data (NIHSS, mRS) were tabulated.ResultsAmong 715 anterior circulation MTEs, 12 DCP-MTEs were identified and analyzed. Nine were left-sided M1 occlusions, one right-sided M1 occlusion, and two right-sided M2 occlusions. DCP was successfully carried out in 91.7%; TICI 2b/3-recanalization was achieved in 83.3% via direct lesional aspiration and/or stent-retrieval techniques. Median time from DCP to reperfusion was 23 min. Indications included futile transfemoral catheterization attempts of the cervical target vessels as well as iliac occlusive disease. Neck hematoma occurred in 2 patients, none of which required further therapy.ConclusionMTE via DCP in these highly selected patients was reasonably safe, fast, and efficient. It thus represents a valuable technical extension of MTE, especially in patients with difficult access.

Arm-only access for combined transarterial and transvenous neurointerventional procedures

A simultaneous arterial and venous approach has been widely described for the endovascular treatment of dural arteriovenous fistula (DAVFs) and recently for arteriovenous malformation (AVMs). Conventional venous approaches are performed...

Image-Guided Percutaneous Injection Sclerotherapy of Venous Malformations

Venous malformations (VM) are the commonest types of vascular malformations, with an appropriate clinico-radiological diagnostic pathway being critical for establishing the correct diagnosis, mapping the extent of disease and involvement of important structures, guiding appropriate therapy, and predicting prognosis. Ultrasound (US) with color Doppler examination is the first-line radiological investigation with magnetic resonance imaging being used for further evaluation, providing the exact lesion extent and involvement of muscles, bones, and neurovascular bundles. Direct puncture phlebography of the lesion confirms the diagnosis and classifies the lesion in four types. Type 1 is an isolated malformation without peripheral drainage, type 2 malformation drains into normal veins, type 3 malformation drains into dilated veins, and type 4 malformation represents dysplastic venous ectasia. Treatment is sought for cosmetic reasons, pain, and functional issues. Sclerotherapy is the first-line treatment and image guidance, either US or phlebographic, is employed for the same. Various techniques are described including double or multiple puncture technique, subtraction-guided technique, filling defect technique, or a combination of these. Various sclerosants have been used including dry ethanol, polidocanol, ethanolamine oleate, sodium tetradecyl sulfate, sodium morrhuate, OKC 432, bleomycin, and doxycycline, either in liquid form or as microfoam prepared using Tessari’s technique. Typically, multiple sessions are needed and the lesions may recur; however, overall response rate, quality of life improvement, and patient satisfaction are significantly improved. Local complications like pain, swelling, and ulcerations are common. Major complications of sclerotherapy are infrequent; however, pulmonary embolism, stroke, vision loss, compartment syndrome, tissue necrosis, hemolysis, anaphylaxis, nerve palsy, and pulmonary complications do occur and the patient and treating physicians should be aware of.

Direct carotid puncture for mechanical thrombectomy in acute ischemic stroke patients with prohibitive vascular access.

While the benefit of mechanical thrombectomy (MT) for patients with anterior circulation acute ischemic stroke with large-vessel occlusion (AIS-LVO) has been clearly established, difficult vascular access may make the intervention impossible or unduly prolonged. In this study, the authors evaluated safety as well as radiographic and functional outcomes in stroke patients treated with MT via direct carotid puncture (DCP) for prohibitive vascular access. The authors retrospectively studied patients from their prospective AIS-LVO database who underwent attempted MT between 2015 and 2018. Patients with prohibitive vascular access were divided into two groups: 1) aborted MT (abMT) after failed transfemoral access and 2) attempted MT via DCP. Functional outcome was assessed using the modified Rankin Scale at 3 months. Associations with outcome were analyzed using ordinal logistic regression. Of 352 consecutive patients with anterior circulation AIS-LVO who underwent attempted MT, 37 patients (10.5%) were deemed to have prohibitive vascular access (mean age [± SD] 82 ± 11 years, mean National Institutes of Health Stroke Scale [NIHSS] score 17 ± 5, with females accounting for 75% of the patients). There were 20 patients in the DCP group and 17 in the abMT group. The two groups were well matched for the known predictors of clinical outcome: age, sex, and admission NIHSS score. Direct carotid access was successfully obtained in 19 of 20 patients. Successful reperfusion (thrombolysis in cerebral infarction score 2b or 3) was achieved in 16 (84%) of 19 patients in the DCP group. Carotid access complications included an inability to catheterize the carotid artery in 1 patient, neck hematomas in 4 patients, non-flow-limiting common carotid artery (CCA) dissections in 2 patients, and a delayed, fatal carotid blowout in 1 patient. The neck hematomas and non-flow-limiting CCA dissections did not require any subsequent interventions and remained clinically silent. Compared with the abMT group, patients in the DCP group had smaller infarct volumes (11 vs 48 ml, p = 0.04), a greater reduction in NIHSS score (-4 vs +2.9, p = 0.03), and better functional outcome (shift analysis for 3-month modified Rankin Scale score: adjusted OR 5.2, 95% CI 1.02-24.5; p = 0.048). DCP for emergency MT in patients with anterior circulation AIS-LVO and prohibitive vascular access is safe and effective and is associated with higher recanalization rates, smaller infarct volumes, and improved functional outcome compared with patients with abMT after failed transfemoral access. DCP should be considered in this patient population.

Direct puncture of the superficial temporal artery for ethylene vinyl alcohol embolization of a type 3 arteriovenous fistula with a dual lumen balloon

Intracranial dural arteriovenous fistulas (dAVFs) may be difficult to treat by endovascular means, especially when the arterial feeders to the fistula are tortuous. 1 The usual main feeder to intracranial...

Direct percutaneous embolization of aneurysm sac: a safe and effective procedure to treat post-EVAR type II endoleaks

To report safety and effectiveness of type II endoleak embolization, with percutaneous direct aneurysm sac puncture. Fifty patients, 31 male (mean age 55 ± 5), with post-EVAR type-II endoleak underwent direct percutaneous sac puncture for embolization. Procedures were performed, under local anesthesia. Sac puncture was done using a 20G needle under rotational angiography guidance. A coaxial system (4Fr catheter + 2.7 microcatheter) was used to navigate the sac. During the follow-up period, all patients underwent contrast-enhanced ultrasound (CEUS) at 6 and 12months. Technical success, with complete exclusion of the aneurysm sac, was achieved in all cases. Time of procedure varied between 36 and 68min (mean 51.36min). Mean fluoroscopy time was 16.7min. A posterior left access was used in 41 cases, posterior right access in 6 cases, and an anterior approach in 3. In 19 cases (38%), one or more feeding vessels were visualized and embolized. Sac embolization was done using Onyx plus micro-coils in 31 cases (62%) and Onyx alone in 19 cases (38%). Mean amount of Onyx was 6ml. No complications, correlated with the direct percutaneous sac puncture, or to Onyx injection occurred. After 1-year follow-up, sac shrinkage occurred in 34 cases (68%), while in 16 patients (32%) sac size remained stable without evidence of sac perfusion. Percutaneous direct sac embolization using Onyx in combination or not with microcoils represents a safe and valid technique to solve post-EVAR type II endoleaks.

Feasibility and technique of endovenous laser ablation (EVLA) of recurrent varicose veins deriving from the sapheno-femoral junction-A case series of 35 consecutive procedures.

To assess the feasibility and technical success of endovenous laser ablation (EVLA) of recurrent varicose veins arising from the former sapheno-femoral junction (SFJ). We retrospectively analyzed all EVLA procedures treated in our institution by one surgeon between March 2019 and April 2020 and selected all consecutive cases with SFJ recurrence occuring after surgical high ligation and stripping or endovenous thermal ablation for incompetence of the great saphenous vein (GSV) in superficial venous insufficiency. The feasibility, technical success as determined by duplex ultrasound on the postoperative visit, complications and rate of endothermal heat-induced thrombosis (EHIT) were recorded. A subgroup definition was performed based on sonographic morphology of the recurrence and resulting strategy of ablation. Thirty-five limbs with SFJ recurrence in 34 patients were treated with EVLA in order to shut down the highest refluxing point. In 22 interventions, it was required to switch off a short stump or a neovascularization by direct puncture (Subgroup 1). In 13 treatments, the presence of residual GSV segments, or persistent, varicose transformed major tributaries like the anterior accessory great saphenous vein, enabled cannulation and advancing the laser fiber from distal to the former SFJ (Subgroup 2). The EVLA procedures could be successfully carried out in all 35 cases. There were no major complications, no thromboembolism or EHIT, and no local groin complications. In one case, the patient developed a phlebitic response that required temporary medication. Technical success was achieved with 34/35 treatments (97.1%). When comparing the subgroups, the morphological pattern of the SFJ recurrence and the resulting technique of puncture, cannulation and ablation did not influence the result. The results of this case series suggest that SFJ recurrences can also be successfully treated in situations where there are tortuous or short stumps that require direct puncture and ablation.

Trans-Carotid and Trans-Radial Access for Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

ObjectiveWe aim to demonstrate the safety and effectiveness of extra-femoral endovascular access for mechanical thrombectomy for acute ischemic stroke patients whose vascular anatomy precludes safe or maneuverable trans-femoral access.MethodsPreferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to conduct a systematic review and meta-analysis with articles published until March 2018. The search protocol, including research questions and inclusion and exclusion criteria, were developed a priori. Our own institutional retrospective data were included in the cohort of case series.ResultsEleven studies including 51 patients were included. Age ranged from 4th to 10th decade of life (average: 9.3rd decade) and 40.1% received IV tissue plasminogen activator. Initial National Institutes of Health Stroke Scale (NIHSS) score ranged from 1 to 36, (average: 17.6). Of the 51 patients, 39 (76%) patients suffered from anterior circulation large vessel occlusions versus 12 (24%) from posterior circulation occlusions. Site of access included 26 (51%) radial artery punctures, 23 (45%) direct percutaneous cervical carotid punctures, 1 brachial artery puncture, and 1 direct extradural vertebral artery puncture. Technical success was achieved in 43/51 (84%) of patients. The average modified Rankin Scale at discharge was 2.93 (n=26). There were no complications in 25 patients who underwent radial arterial access. Two (7.4%) of 27 cervical access patients developed hematoma.ConclusionsTrans-carotid and trans-radial access for intervention in acute ischemic stroke is safe and effective. There may be instances in which these approaches should be considered first line before standard femoral approaches.

Feasibility and Safety of the Direct Occluded Vessel Puncture Technique as a New Access Site for Complex Peripheral Artery Occlusive Disease.

Aim: This study aims to describe the feasibility and safety of direct occluded vessel puncture as a new access site for complex peripheral artery occlusive disease.Methods: Eleven consecutive patients with symptomatic peripheral artery disease underwent endovascular therapy using the direct occluded vessel puncture technique. The occluded vessel was punctured using a dedicated 20 G needle and the Hi-Torque Command 18 ST guidewire under duplex echo or fluoroscopic guidance, and a 6 Fr sheath was then inserted. Hemostasis was achieved with the Exoseal® Vascular Closure Device.Results: Direct occluded vessel puncture was achieved in 10 of 11 cases (90.9%), and procedural success was achieved in all cases. There were no in-hospital deaths or any complications, including bleeding, pseudoaneurysms, thrombosis, or surgical conversion.Conclusion: The direct occluded vessel puncture technique using a 20 G needle and the Hi-Torque Command 18 ST is feasible and safe. This technique may also be used as an alternative option when there are no appropriate approach sites.

Su1331 PREDICTORS OF TECHNICAL AND CLINICAL SUCCESS OF ENDOSCOPIC GASTROENTEROSTOMY WITH LUMEN-APPOSING METALS STENTS

Lumen-apposing metal stents (LAMS) can be used for creation of gastrointestinal anastomoses under endoscopic ultrasound (EUS) guidance. This technique has mostly been evaluated as treatment for gastric outlet obstruction (GOO). Aim of this study was to further evaluate success and safety of this technique as well as to identify predictors of technical success. All patients that underwent EUS-guided gastrointestinal anastomosis with LAMS in our endoscopy unit between February 2016 and August 2019 were identified and evaluated retrospectively. Details on the endoscopic technique and on basic demographic and health characteristics were obtained by chart review and included in the study. Technical success was defined as successful insertion of the LAMS. In patients with GOO, an improvement ≥ 1 point in the GOO score (GOOS) was defined as clinical success. Thirty-five patients were included in the study. Twenty-two patients (62.9%) were female and the median age was 79 years (range: 32 – 93). Indication for the anastomosis was malignant GOO in 33 patients (94.3%). In one patient each the indication for the anastomosis was treatment of efferent loop syndrome and access for endoscopic retrograde cholangiography (ERC) after previous hepaticojejunostomy with Roux-en-Y reconstruction. In 10 patients the LAMS was inserted over a guidewire, in 22 patients direct puncture with the electrocautery delivery system of the LAMS was performed. In two patients other techniques were used. The overall technical success rate was 80.0%; in four patients two attempts were necessary to successfully create the anastomosis. The main reason for technical failure was dislocation of the distal flange in 4 patients (57.1%). Clinical success rate was 74.3% in the study population and 92.3% in patients with malignant GOO and technically successful creation of the anastomosis. The procedure as well resulted in clinical success in the two patients that underwent EUS-guided anastomosis for treatment of efferent limp syndrome and as access route for ERC. Adverse events occurred in 14.3%. Technical success increased and procedure time decreased significantly during the study period. The distance between the two lumina that were connected with the LAMS was significantly shorter (median: 9 mm) in patients with technical success compared to those without (median: 20 mm, P = 0.004). This distance was identified as predictor of success on multivariate analysis (Figure). Technical success of EUS-guided gastrointestinal anastomosis with LAMS mainly depends on the distance between the two lumina that are going to be connected by the LAMS. It is also influenced by the endoscopist’s experience. Overall this technique presents a promising and emerging treatment option, especially for patients with malignant GOO.

Embolization and sclerotherapy of maxillofacial arteriovenous malformations with the use of fibrin glue combined with pingyangmycin.

The objectives of this study were to document the results of using fibrin glue (FG) combined with pingyangmycin (PYM) for the embolism and sclerotherapy of maxillofacial arteriovenous malformations (AVMs). We reviewed the associated clinical data from December 2012 to June 2017 for 25 patients with maxillofacial AVMs. The major treatment method was direct percutaneous puncture and injection of FG combined with PYM. Treatment outcomes were assessed through physical examination, Doppler ultrasonography, computed tomography, and 3-dimensional computed tomography angiography scans. Follow-up time ranged from 12 months to 3 years after the last treatment (mean 21 months). Of the 25 lesions, 80% showed greater than 90% reduction, 12% showed greater than 75% reduction, and 8% showed greater than 50% reduction. Superficial skin necrosis or mucous ulcer occurred in 3 patients and healed without intervention. Regrowth was observed in 3 patients with extensive lesions involving multiple anatomic regions. These data suggest that embolization and sclerotherapy with the use of FG combined with PYM are safe and effective for the treatment of small- to medium-sized, locally dilated maxillofacial AVMs. For AVMs involving multiple anatomic regions, combined application of this approach with other options should be considered.

Direct Common Carotid Artery Puncture: Rescue Mechanical Thrombectomy Strategy in Acute Ischemic Stroke.

PurposeIn a minority of cases, the transfemoral approach cannot be performed due to unfavorable anatomical barriers. In such cases, direct common carotid artery puncture (DCCAP) is an important alternative for rescue mechanical thrombectomy. The purpose of this study was to evaluate the efficacy and safety of DCCAP in patients with an unaccessible femoral route for mechanical thrombectomy.Materials and MethodsThis is a retrospective study using data in the Turkish Interventional Neurology Database recorded between January 2015 and April 2019. Twenty-five acute stroke patients treated with DCCAP were analyzed in this study. Among 25 cases with carotid puncture, 4 cases were excluded due to an aborted thrombectomy attempt resulting from unsuccessful sheath placement.ResultsPatients had a mean age of 69±12 years. The average National Institutes of Health Stroke Scale score was 16±4. Successful revascularization (modified Thrombolysis In Cerebral Infarction 2b-3) rate was 86% (18/21), and 90-day good functional outcome rate (modified Rankin Scale 0–2) was 38% (8/21).ConclusionDCCAP is a rescue alternative for patients with unfavorable access via the transfemoral route. Timely switching to DCCAP is crucial in these cases.

Analysis of damage modes of glass fiber composites subjected to simulated lightning strike impulse voltage puncture and direct high voltage AC puncture

Understanding the damage mechanisms of fiber-reinforced polymer matrix composite materials under high voltage conditions is of great significance for lightning strike protection and high voltage insulation applications of composite structures. In this paper, we investigated effects of the lightning impulse (LI) voltage and high voltage alternating current (HVAC) puncture on damage modes of the electrically nonconductive glass fiber-reinforced polymer (GFRP) matrix composite materials through experimental tests and numerical simulations. The LI and HVAC tests represent the lightning strike and high voltage insulation cable puncture conditions, respectively. Our experimental examinations showed that GFRP composite specimens subjected to the LI voltage test exhibited distinct damage modes compared with those in the HVAC puncture test. The GFRP composite material suffered more charring and fiber vaporization in the HVAC puncture test, whereas less matrix charring and fiber vaporization but severe fiber breakage and delamination in response to the LI voltage tests. The findings indicate that the thermal effect dominates the damage of GFRP composites inflicted by the HVAC puncture test, whereas the mechanical impact effect governs the GFRP composite damage in the LI voltage test. In addition, the electric arc plasma formation during the puncture of the GFRP composite material was modeled through solving Maxwell’s equations and the heat generation equations using finite element analysis. Simulation results provided insights on the effects of duration and intensity of the high voltage electric discharge on the composite damage.

Progressão do cateter central de inserção periférica em região hemiclavicular de recém-nascidos

Objetivo: avaliar a progressão do cateter central de inserção periférica em região hemiclavicular direita, através da veia basílica e cefálica direita, em recém-nascidos. Métodos: pesquisa quase experimental, realizada em unidade neonatal. Amostra de 64 inserções de cateteres, em 58 recém-nascidos. A intervenção consistiu em manobra de elevação, protração e abaixamento do ombro, aplicada após não progressão do cateter, em região hemiclavicular, na punção direta em região cubital, em veia basílica ou cefálica direita. Resultados: das 64 inserções, progrediram sem manobra 28(43,7%); em mais da metade, aplicou-se manobra, obtendo-se 28(77,8%) progressões, sendo que 15(41,7%) progrediram após elevação, 12(57,1%) após protração e 1(11,1%) abaixamento do ombro, destes que progrediram, 21(75%) estavam em posição central. Verificou-se significância estatística (p&lt;0,05) entre progressão com manobra e veia cefálica, progressão sem manobra e veia basílica. Conclusão: a intervenção facilitou progressão do cateter, principalmente por veia cefálica.

Ten-year outcomes of transcaval cardiac puncture for catheter ablation after extracardiac Fontan surgery

Although they are at lower risk, patients with previous extracardiac conduit (EC) Fontan still may require catheter ablation for supraventricular arrhythmia. The purpose of this study was to determine the optimal approach to pulmonary venous atrium (PVA) access after EC Fontan operation. All electrophysiological procedures requiring PVA over a 10-year period at the UCLA Medical Center were reviewed. PVA was grouped by transcaval cardiac puncture (TCP) or direct conduit puncture. Procedural characteristics and outcomes were compared. Between June 2009 and November 2019, 23 electrophysiological procedures requiring PVA access were performed in 17 EC Fontan patients (53% male; median age 25 years; interquartile range 11-34). Cavoatrial overlap was identified in 14 patients by preprocedural imaging (10 cardiac computed tomography, 4 cardiac magnetic resonance). PVA access was obtained via TCP in 11, directconduit puncture in 6, pre-existing fenestration in 5, and pulmonary artery puncture in 1. Time to PVA was significantly shorter for TCP vs direct conduit puncture (0.2 vs 1.1 hours, respectively; P = .03). The only predictor of successful TCP was the length of cavoatrial overlap by preprocedural imaging (14 vs 3 mm; P =.02). No procedural complications occurred. No change in oxygen saturation was noted, and no evidence of residual shunting was detected by follow-up echocardiography. TCP is feasible in most patients after EC Fontan surgery and can be predicted by preprocedural advanced imaging. TCP is associated with shorter time to PVA and was uncomplicated in this single-center study. Preoperative assessment of cavoatrial overlap should be considered before catheter ablation for EC Fontan.

A minimally invasive approach for the treatment of isolated type intracranial dural arteriovenous fistula in a neurosurgical hybrid operating room

ObjectivesIsolated-type intracranial dural arteriovenous fistulas (DAVFs) could hinder the effective use of the transvenous approach. Direct trans-sinus embolization (dTSE) with craniotomy remains the treatment method for isolated-type DAVFs. We report our experience in using a neurosurgical hybrid operating room (NHOR) to treat cases of isolated-type DAVFs by dTSE using a single burr hole. Patients and methodsBetween April 2007 and March 2017, 189 DAVFs were treated by an endovascular procedure at our institution. Among these cases, 27 patients (14.3%) had isolated-type DAVF and 7 patients (3.7%) were treated by dTSE. The procedure accuracy and invasiveness of dTSE were compared with those of the transvenous embolization (TVE) group.The NHOR was equipped with a biplane angiography system and used to perform 3D rotational angiography (3DRA). The burr hole site was precisely determined by 3DRA. Only one burr hole was made to expose the target sinus and allow for direct puncture. The target sinus was occluded by using coils and liquid embolic material. ResultsThe NHOR allowed the accurate placement of the burr hole. Only a single burr hole and small skin incision (with minimal bleeding) were required for each dTSE case. The mean total contrast volume was significantly reduced in the dTSE group compared with that in the TVE group. Moreover, the dTSE group required shorter operation times and lower total radiation doses compared with the TVE group. ConclusionUsing dTSE could be performed with a single burr hole using a NHOR equipped with biplanar fluoroscopy. This approach is a minimally invasive and effective treatment for isolated-type DAVFs.