Double Lumen Research Articles

P87: Fracture Of A Dual Lumen Protekduo Cannula With Ventricular Perforation And Tamponade In A Recovery COVID-19 Patient

Background: In the absence of formal registry data anecdotal reports of cannula complications provide the only mechanism of risk assessment in the extended use of short term mechanical circulatory support devices. We report an unrecognized cannula fracture with perforation of the right ventricular apex and subsequent tamponade at the time of de-cannulation. Methods and Results: Patient is a 38 yo AAF with a history of asthma diagnosed with COVID 19 (nasal PCR) and admitted to an OSH with hypoxia (O2 sat 70%) and progressive dyspnea on exertion requiring HFNC and subsequent deployment of a right internal jugular 29 Fr Protek-DUO double lumen cannula with in-line oxygenator for venovenous ECMO respiratory support. After 36 days of VV ECMO support and mechanical ventilation, the patient was transferred with a diagnosis of COVID ARDS for transplant evaluation. Fourteen days post-transfer the patient was ambulatory and no longer required mechanical ventilation. No flow related issues were noted during the entire period of ECMO support (flow 2.8 to 3.4 L/min, delta P 20 mmHg or less, single oxygenator exchange on ECMO day 38). On ECMO day 67 the patients CxR was clear (Figure 1) and the RIJ cannula was removed without complication. Approximately two minutes after cannula removal the patient became unresponsive with tachycardia and hypotension (SBP 60 mmHg) which initially responded to volume resuscitation. With progressive loss of systolic blood pressure chest compressions were started with complete hemodynamic collapse. A transthoracic ECHO suggested tamponade and the chest was opened at the bedside demonstrating a chronic appearing hematoma with blood extravasation at the apex of the right ventricle (Figure 2). Bleeding was controlled with a single prolene stitch. Subsequent examination of the cannula demonstrated a fracture in the wire reinforced cannula at the point where the catheter transitioned from the apical RV into the RVOT (Figure 3). Conclusion: Given the progressive pulmonary hypertension frequently seen with prolonged COVID ECMO support, the RA to PA dual-lumen cannula has proven an effective MCS strategy (1) with survival advantage when compared to standard VV ECMO support (2). The Protek-DUO cannula was not designed for prolonged ambulatory MCS (> 60 days). Given the recent report of a seemingly identical cannula fracture event (3), clinicians should be aware of the potential for cannula fracture over time. Literature Cited (1) Mustafa AK, et al. (2020) ECMO for patients with COVID-19 in severe respiratory failure. JAMA Surg 155(10):990-992. (2) Saeed O, et al (2022) Outcomes by cannulation method for venovenous ECMO during COVID-19: a multicenter retrospective study. 46(8):1659-1668. doi: 10.1111/aor.14213. (3) Odish MF, et al (2022) Fracture right atrial-pulmonary artery cannula (Protek-DUO) in a 164-day extracorporeal membrane oxygenation bridge to lung transplant. doi: 10.1097/MAT.0000000000001879. Online ahead of print.

Go with the flow: An experimental analysis with tubing alternative with irrigation

AbstractBackground and AimsLiterature regarding alternative tubing for fluid delivery in irrigation and debridement procedures is lacking. The purpose of this study was to compare three different apparatuses with varying quantities of irrigation fluid to assess efficiency of administration and evaluate overall time for fluid administration.MethodsThis model was designed to compare available methods of gravity irrigation used in practice. Fluid flow time was measured for three types of tubing: single‐lumen cystoscopy tubing, Y‐type double‐lumen cystoscopy tubing, and nonconductive suction tubing. Irrigation times were assessed for varying volumes of 3, 6, and 9 L to investigate the relationship between bag changes and irrigation time. Bag changes were not conducted for the 3 L trial, but were for 6 and 9 L trials. Dimensions of cystoscopy tubing consisted of 4.95 mm internal diameter and 2.1 m length in both single‐lumen and Y‐type double‐lumen apparatus. Nonconduction suction tubing dimensions were 6.0 mm internal diameter and standard 3.7 m in length.ResultsThe mean flow time for suction tubing was significantly faster than the cystoscopy tubing for the 3 and 9 L trials (p < 0.001). At 6 L, flow time for the suction tubing and the double lumen cystoscopy tubing were similar, 264 versus 260 s, respectively. At 9 L, the mean flow time for the suction tubing was 80 s faster (410 vs. 491 s) compared with single‐lumen cystoscopy and was nearly 30 s faster compared with Y‐type cystoscopy tubing.ConclusionThe results of this study provide insight into a faster, widely available, and cost‐efficient alternative to commonly used cystoscopy tubing.

PULM14: Long-haul ECMO as Bridge to Transplant in COVID-19 ARDS

Background: Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (LT) is an established treatment modality for refractory acute respiratory distress syndrome (ARDS). Per the Scientific Registry of Transplant Recipients (SRTR) database, 215 patients supported on ECMO due to the Coronavirus disease of 2019 (COVID-19) related ARDS underwent LT between August 2020 and June 2022. The COVID-19 pandemic limited donor availability and increased duration of ECMO support in ECMO-dependent patients listed for LT. Outcomes of long-term ECMO as bridge to transplant (BTT) in this population remain unclear, and no cases of VV ECMO greater than 200 days has been documented in the literature. Methods: A single-center review was conducted to identify patients cannulated for VV-ECMO to treat COVID-19 associated ARDS between January 1, 2021 and January 1, 2022. Patients were selected who were supported by VV-ECMO for ARDS secondary to COVID-19 for greater than 200 days before receiving a lung transplant. Detailed analysis was performed for the outcomes and characteristics of all patients who received a lung transplant for post-COVID-19 ARDS after >200 days of VV-ECMO support. Results: Three patients were identified as long-term ECMO as BTT recipients (>200 days) for COVID-19-associated ARDS. Average age was 38 years (22,52), BMI 32.9 (31.6,34) and no patients had any known relevant respiratory medical history. One patient had a history of daily e-cigarette use. All patients were unvaccinated at the time of first positive COVID-19 test. All were successfully bridged to bilateral lung transplant (BLT) off of VV-ECMO. None required VV-ECMO post-operatively. One patient required VA-ECMO post-operatively for elevated pulmonary arterial pressures related to incidentally discovered septal defects. Average ECMO duration was 278 days (250, 324). Two patients were cannulated as bridge to recovery, and one as bridge to decision. Patients remained ambulant on ECMO support until they were able to undergo the transplant procedure. Cannulation strategies included double lumen right internal jugular (RIJ), RIJ to right femoral vein, and bifemoral venous cannulation. Complications on ECMO included sepsis, hemorrhage, stroke, reconfiguration, and atrial fibrillation. Two were discharged to home and one to inpatient rehabilitation. Average length of stay after transplant was 27 days (16,37). All 3 patients have continued to do well. Conclusion: We present three patients with the longest documented VV-ECMO support for COVID-19 ARDS a bridge to lung transplant. Our findings suggest long-term VV-ECMO support is a feasible bridge to LT for patients with COVID-19-related ARDS when used in the long-term (>200 days). The duration of ECMO support remains associated with known ECMO-related complications. Post-transplant survival to-date suggests that survival in long-term ECMO support as a BTT may be comparable to short-term ECMO in patients with COVID-19-related ARDS.

PULM5: Hyperbaric Blood Oxygenation – Basic Considerations and First Results

Hyperbaric oxygen therapy is beneficial in several applications, but hyperbaric chambers are scarce. We are developing a novel technology for extracorporeal hyperbaric blood oxygenation (HBOX). This extracorporeal procedure uses pressure to increase the oxygen (O2) concentration in blood. The technology can provide support when large amounts of oxygen are needed: In the treatment of CO poisoning the dissolved oxygen displaces the CO from the blood, removing it from the organism. This way, the oxygen deficiency can be ended rapidly, reducing or preventing secondary damage that frequently occurs. In acute respiratory failure (ARF) the HBOX technology can support lung function, by significantly increasing oxygen transport across a specific membrane area, while maintaining adequate CO2-removal. The prototype of the HBOX consists of 2 roller pumps with a hollow-fiber membrane oxygenator (HFMO) placed in between, a control unit for gas and blood flow and a double lumen catheter. By varying the flow rates of the roller pumps, excess pressure is generated in the HFMO without causing significant blood damage. Simultaneously, the oxygen pressure in the HFMO is increased, allowing for hyperbaric oxygenation. To avoid bubble formation, either O2 increase is limited, or excess O2 is removed in second HFMO before reinfusion. The prototype was tested in-vitro using porcine blood that was either CO poisoned or conditioned to mimic ARF. In acute in-vivo experiments for CO poisoning, we used CO-poisoned pigs (ca. 75 kg, COHb = 43 %, n = 3). For in-vivo experiments for ARF, 70 kg sheep were used with ventilator settings simulating respiratory failure, resulting in SaO2 = 69 %, paCO2 = 72 mmHg (n = 2). In-vitro test results show that the HBOX can fully oxygenate hypoxic blood (sO2 ca. 40 %) with a hilite 800 LT at a flow rate of 2 L/min, which is twice the amount of oxygen transferred, compared to conventional mode, Fig. 1. In in-vivo trials, the CO elimination rate from the animals’ blood doubled when using HBOX + oxygen mask compared to oxygen mask alone, see Fig. 2. In the ARF trials, the HBOX approach resulted in SaO2 of 89, 95, and 99 % and paCO2 was 49, 46, and 39 mmHg at blood flows of 0.5, 1.0, and 1.5 L/min, respectively, see Fig. 3. The HBOX is a promising approach to increase oxygen transport across a specific membrane area. The increased oxygen levels can be used for efficient extracorporeal CO removal. For respiratory support, the hyperbaric technology adds a new dimension to ECMO treatment, allowing the use of smaller oxygenators, potentially reducing the need for anticoagulation, as well as inflammatory responses and thus invasiveness. The hyperbaric technology can be used gradually, so that the membrane efficiency can be increased during intervention. This allows us to build an oxygenator with an ideal flow distribution over a wide range of blood flows, which avoids thrombus formation in the device at lower blood flows.Figure 1. Laboratory results oxygenation performanceFigure 2. Elimination rate COHb in in-vivo trialsFigure 3. Arterial blood gases during in-vivo trial for ARF

Literature Review on the Different Types of Breast Implants: Advantages and Disadvantages

Breast implants are devices used in cosmetic and reconstructive surgery to increase the volume and improve the shape of the breasts. In this study, the different types of breast implants available in clinical practice were investigated. Four main types were identified: saline implants, silicone gel implants, highly cohesive silicone gel implants, and double lumen implants. Saline implants consist of a silicone shell filled with sterile saline. They have advantages such as the ability to adjust volume during surgery, easy rupture detection and lower cost. However, they may have a less natural feel and a higher risk of wrinkling and rippling. Silicone gel implants are widely used because of their more natural look and feel. Silicone gel is cohesive and offers a consistency similar to breast tissue. They have a lower incidence of wrinkling and rippling, greater durability and less sensitivity to cold. However, detection of ruptures can be more difficult and there is a potential risk of capsular contracture. Highly cohesive silicone gel implants, also known as anatomical implants, are designed to mimic the natural shape and projection of the breast. They have predictable aesthetic results, a lower incidence of capsular contracture and greater resistance to displacement. However, they may require longer incisions and have a higher cost. Double lumen implants have two separate shell layers, one internal with cohesive silicone gel and the other external with saline solution. They offer an additional layer of security in case of rupture of the inner shell and allow volume adjustment during surgery. However, they may have a less natural feel and greater technical complexity.

Comparison of silicone double-lumen tube and polyvinyl chloride single-lumen tube in fiberoptic tracheal intubation on a difficult airway model: a randomized controlled non-inferiority trial

The management of patients with history or suspicion of difficult intubation can be challenging, especially in surgical procedures requiring one-lung ventilation. The ease of insertion of silicone double lumen tube (DLT) have previously been shown to be comparable to polyvinyl single lumen tube (SLT) in fiberoptic bronchoscope (FOB) tracheal intubation. Hence, in difficult airway situation, we hypothesized that the performance of insertion of silicone DLT would also be non-inferior to polyvinyl SLT in FOB intubation. We used a neck collar to mimic patients with difficult airway. 80 patients who required one-lung ventilation were enrolled in a prospective, randomized, non-inferiority trial. Patients were randomly allocated to the DLT or SLT groups (SLT with bronchial blocker). Neck collar was supplied to all patients before FOB intubation. The time of insertion for FOB, railroading, tracheal intubation, and total procedure were measured. The difficulty of railroading was evaluated in 4 grades. In the DLT group, the railroading was significantly shorter and easier comparing to the SLT group. The total procedure was also simpler and faster in the DLT group. While simulated difficult airways may not fully replicate actual difficult airways, we suggest that fiberoptic intubation with silicone DLT could be a feasible first-line option for patients with expected difficult airways requiring lung separation, unless the size of the DLT relative to the patient’s airway is problematic.Trial registration: NCT03392766.

Subxiphoid epicardial access facilitated by saline infusion or carbon dioxide insufflation through a right atrial appendage controlled exit

Abstract Funding Acknowledgements Type of funding sources: None. Background Subxiphoid percutaneous access to the pericardial space for mapping and ablation of atrial and ventricular arrhythmia carries the potential risk of cardiac perforation and coronary artery laceration. Widening the pericardial space with saline solution or carbon dioxide (CO2) insufflation by intentional coronary vein exit prior to subxiphoid puncture reduces the risk of organ lesion. However, cannulation of a coronary branch is often difficult and adds complexity to the ablation procedure. Purpose To determine the feasibility and the safety of subxiphoid epicardial access facilitated by controlled pericardial saline infusion or neumopericardium through a right atrial appendage exit. Methods The right atrial appendage was transvenously cannulated using a steerable sheath following anatomical characterization of the right atrium on an electroanatomical navigation system. A 0.014" angioplasty guide was introduced with the proximal rigid end placed distally and progressed until the appendage was perforated and the guide-wire placed into the pericardial space. A double lumen microcatheter was then progressed over the wire. Saline solution (100-400 mL) or CO2 (100-500 cc) were infused through the microcatheter to achieve sufficient pericardial space widening or hemodynamic deterioration. Finally, pericardial access was obtained using the conventional subxiphoid approach. Results 17 consecutive patients (62±10 years, 15 male) with left atrial flutter (LAF n=11) or ventricular tachycardia (VT n=6) refractory to endocardial ablation were prospectively included. All patients with atrial flutter (uninterrupted oral anticoagulation plus heparin for ACT >300 sec) and ventricular tachycardia (heparin for ACT >300 sec) were fully anticoagulated at the time of the procedure. It was not possible to access epicardium in 4 patients due to adhesions (VT=3 LFA=1). The first 4 patients with successful access had saline infused and the remaining 9 patients had CO2 insufflated. Epicardial tachycardia ablation was successfully achieved in 8 patients (5 AFLs and 3 VTs) and partially successful in 1 patient (1AFL). A pericardial drainage was left in 6 patients before leaving the EP laboratory and removed in the remaining. There was no apparent right ventricular puncture, coronary artery laceration or other major complications. One patient had cardiac tamponade during the procedure and 2 other patients presented tamponade after the procedure following discharge from the interventional lab. One patient presented neumomediastinum and other patient presented subcutaneous emphysema, which resolved uneventful in 24 hours. Conclusions Saline infusion or carbon dioxide insufflation through a right atrial appendage controlled exit facilitates subxiphoid epicardial access for ablation of refractory atrial and ventricular arrhythmias. This approach can be performed in the majority the patients and appears to be safe.

Small-bowel capsule endoscopy in patients with Meckel's diverticulum: clinical features, diagnostic workup, and findings. A European multicenter I-CARE study.

Meckel's diverticulum (MD) may remain silent or be associated with adverse events such as GI bleeding. The main aim of this study was to evaluate indicative small-bowel capsule endoscopy (SBCE) findings, and the secondary aim was to describe clinical presentation in patients with MD. This retrospective European multicenter study included patients with MD undergoing SBCE from 2001 until July2021. Sixty-nine patients with a confirmed MD were included. Median age was 32 years with a male-to-female ratio of approximately 3:1. GI bleeding or iron-deficiency anemia was present in nearly all patients. Mean hemoglobin was 7.63 ± 1.8 g/dL with a transfusion requirement of 52.2%. Typical capsule endoscopy (CE) findings were double lumen (n= 49 [71%]), visible entrance into the MD (n= 49 [71%]), mucosal webs (n= 30 [43.5%]), and bulges (n= 19 [27.5%]). Two or more of these findings were seen in 48 patients (69.6%). Ulcers were detected in 52.2% of patients (n= 36). In 63.8% of patients (n= 44), a combination of double lumen and visible entrance into the MD was evident, additionally revealing ulcers in 39.1% (n= 27). Mean percent SB transit time for the first indicative image of MD was 57% of the total SB transit time. Diagnosis of MD is rare and sometimes challenging, and a preoperative criterion standard does not exist. In SBCE, the most frequent findings were double-lumen sign and visible diverticular entrance, sometimes together with ulcers.

Uniportal versus triportal video-assisted thoracic surgery in the treatment of tuberculous empyema

To examine the effectiveness of decortication to treat chronic tuberculous empyema (TE) using uniport video-assisted thoracoscopic surgery (VATS) versus conventional triport VATS. Data from consecutive patients with stage II or III TE who underwent decortication with either uniport VATS (uniportal group) between July and December 2017, or triport VATS between January and July 2018 (triportal group), were retrospectively analysed. VATS procedures were performed under general anaesthesia with double lumen endotracheal intubation and clinical outcomes were compared between the two groups. Clinical data were comparable between the groups (20 patients in each) regarding demographic and baseline characteristics, operative and postoperative characteristics, surgical procedure-related complications, and postoperative adverse events. No surgical procedure-related complications occurred during the perioperative period in either group. Threshold values for mechanical pain at 8 h postoperatively were significantly higher in the triportal group versus the uniportal group. Furthermore, the incidence of nausea and vomiting was significantly lower in the uniportal versus triportal group. In the triportal group, one patient required readmission and further intervention due to recurrence. Uniport VATS decortication for stages II and III TE may be a feasible and safe procedure in selected patients. Moreover, uniport VATS may be less painful than triport VATS.

A case of unanticipated intraoperative bronchial injury during esophagectomy and its anaesthetic management

Single lung ventilation is often used for thoracoscopic surgeries mainly for proper surgical exposure. Double lumen tubes are often used for this purpose. In patients undergoing thoracoscopic esophagectomy there are chances of lower airway injury which can lead to respiratory complication. This case report aims to bring to light the inadvertent complications which may occur intraoperatively while the single lung ventilation is used during the procedure.

Double-lumen catheter is a risk factor for complications of peripherally inserted central venous catheters in children

BackgroundAlthough peripherally inserted central venous catheters (PICCs) are useful for children because of the high burden of vascular puncture, no guidelines exist for PICC in terms of insertion site, blood vessel, and type of catheter. We investigated the risk factors of complications during PICC placement in pediatric patients. MethodsWe analyzed the medical records of children who were admitted to the Tokyo Medical and Dental University Hospital and had PICCs inserted between January 2016 and December 2020. A total of 92 patients with 141 PICCs (age at insertion: 0–18 years, average PICC per patient: 1.48) were analyzed. The median duration of indwelling catheter use was 49 days (interquartile range: 24–80 days). Exposures are patient characteristics (age, weight, primary disease) and variables that the surgeons have choices for during the clinical procedure, such as inserted vessel, inserted part, catheter diameter, catheter lumen, and catheter type (open or closed end). Multilevel logistic regression, considering the correlation among multiple PICCS within a patient, was performed. ResultsForty-four PICCs (31%) were removed because of catheter-related complications (18 suspected infections, 9 occlusions, 7 breakages, 6 dislodgements, and 4 phlebitis). Double-lumen catheters were significantly positively associated with complications (odds ratio: 3.91; 95% confidence interval: 1.03, 14.9) after adjusting for all covariates. The other factors were not significantly associated with the occurrence of complications. ConclusionsDouble-lumen PICCs were associated with complications. The double lumen is useful for the simultaneous administration of multiple drugs, but cases should be carefully monitored.

Chewing gum: The saviour of tracheal cuff of double lumen tube.

Chewing gum: The saviour of tracheal cuff of double lumen tube.

An Alternative Approach for Selective Lung Ventilation.

Single lung ventilation (SLV) with the double lumen tube (DLT) has been an effective process for providing surgical exposure in the thoracic cavity and has been applied effectively in the operating room. SLV also aids in protecting a healthy lung from the ill effects of fluid from an unhealthy lung, which may be blood, lavage fluid, or malignant or purulent secretions. Ensure correct placement, which is required and confirmed by a fiberoptic bronchoscope (FOB). The use of the DLT has been proven to be effective, but it has its challenges and drawbacks. This article proposes an alternative technique to the DLT in SLV without the use of a FOB. We have implemented this technique in 14 cases, however, we would like to discuss two challenging cases that have highlighted the advantages of this new technique.

Percutaneous Cavopulmonary Assist: From Design to 96 Hour Survival in Lethal Cavopulmonary Failure Sheep.

We are developing a clinically practical percutaneous double lumen cannula (DLC)-based cavopulmonary assist (CPA) system to support failing Fontan patients. In this study, our CPA DLC was redesigned for even blood flow, minimal recirculation, and easy insertion/deployment. After bench testing, this new CPA system was evaluated for 4 hours (n = 10) and 96 hours (n = 5) in our clinically relevant lethal cavopulmonary failure (CPF) sheep model for ease of cannulation/deployment, reversal of CPF hemodynamics/end-organ hypoperfusion, and durability/biocompatibility. Cavopulmonary failure was achieved in all sheep. All DLCs were successfully inserted/deployed into Fontan anatomy. Cavopulmonary assist reversed CPF with normalized central venous pressure and cardiac output. All survival sheep were ambulatory with normal eating/drinking. One sheep was euthanized after 6 hours from cannula kinking, and one sheep died of hypokalemia after 8 hours. Three sheep survived 96 hours with normal hemodynamics. Free hemoglobin was only 3.7 ± 1.2 mg/dl at 96 hours, indicating negligible hemolysis. Creatinine, blood urea nitrogen, and lactate increased from hypoperfusion but normalized by 72 hours CPA. Necropsy showed only a small, immobilized thrombus ring at umbrella attachment to DLC. Our DLC-based system provided total ambulatory CPA in a lethal CPF sheep model with 96 hour survival and complete reversal of hemodynamics and end-organ hypoperfusion.

Hemodynamic performance evaluation of neonatal ECMO double lumen cannula using fluid-structure interaction.

Extra corporeal membrane oxygenation (ECMO) is an artificial oxygenation facility, employed in situations of cardio-pulmonary failure. Some diseases i.e., acute respiratory distress syndrome, pulmonary hypertension, corona virus disease (COVID-19) etc. affect oxygenation performance of the lungs thus requiring the need of artificial oxygenation. Critical care teams used ECMO technique during the COVID-19 pandemic to support the heart and lungs of COVID-19 patients who had an acute respiratory or cardiac failure. Double Lumen Cannula (DLC) is one of the most critical components of ECMO as it resides inside the patient and, connects patient with external oxygenation circuit. DLC facilitates delivery and drainage of blood from the patient's body. DLC is characterized by delicate balance of internal and external flows inside a limited space of the right atrium (RA). An optimal performance of the DLC necessitates structural stability under biological and hemodynamic loads, a fact that has been overlooked by previously published studies. In the past, many researchers experimentally and computationally investigated the hemodynamic performance of DLC by employing Eulerian approach, which evaluate instantaneous blood damage without considering blood shear exposure history (qualitative assessment only). The present study is an attempt to address the aforementioned limitations of the previous studies by employing Lagrangian (quantitative assessment) and incorporating the effect of fluid-structure interaction (FSI) to study the hemodynamic performance of neonatal DLC. The study was performed by solving three-dimensional continuity, momentum, and structural mechanics equation(s) by numerical methods for the blood flow through neonatal DLC. A two-way coupled FSI analysis was performed to analyze the effect of DLC structural deformation on its hemodynamic performance. Results show that the return lumen was the most critical section with maximum pressure drop, velocity, shear stresses, and blood damage. Recirculation and residence time of blood in the right atrium (RA) increases with increasing blood flow rates. Considering the structural deformation hasled to higher blood damage inside the DLC-atrium system. Maximum Von-Mises stress was present on the side edges of the return lumen that showed direct proportionality with the blood flow rate.

Cervical Artery Dissection

Cervical artery dissection is a common cause of stroke in young adults. This article reviews the pathophysiology, etiology and risk factors, evaluation, management, and outcomes of spontaneous cervical artery dissection. Cervical artery dissection is believed to be a multifactorial disease, with environmental factors serving as possible triggers in patients who have a genetic predisposition to dissection formation. Cervical artery dissection can cause local symptoms or ischemic events, such as ischemic stroke or transient ischemic attack. Neuroimaging is used to confirm the diagnosis; classic findings include a long tapered arterial stenosis or occlusion, dissecting aneurysm, intimal flap, double lumen, or intramural hematoma. Patients with cervical artery dissection who present with an acute ischemic stroke should be evaluated for IV thrombolysis, endovascular therapy eligibility, or both. Antithrombotic therapy with either anticoagulation or antiplatelet treatment is used to prevent stroke from cervical artery dissection. The risk of recurrent ischemia appears low and is mostly limited to the first two weeks after symptom onset. Cervical artery dissection is a known cause of ischemic strokes. Current data show no difference between the benefits and risks of anticoagulation versus antiplatelet therapy in the acute phase of symptomatic extracranial cervical artery dissection, thereby supporting the recommendation that clinicians can prescribe either treatment. Further research is warranted to better understand the pathophysiology and long-term outcomes of cervical artery dissection.

A comment on 'An algorithm for difficult double lumen tube placement and troubleshooting a malpositioned double lumen tube harnessing A, B, Cs of lung isolation'.

A comment on 'An algorithm for difficult double lumen tube placement and troubleshooting a malpositioned double lumen tube harnessing A, B, Cs of lung isolation'.

MP74-18 DETRUSOR VOIDING CONTRACTION VELOCITY IS RELEVANT TO PATIENTS WITHOUT BLADDER OUTFLOW OBSTRUCTION

You have accessJournal of UrologyCME1 Apr 2023MP74-18 DETRUSOR VOIDING CONTRACTION VELOCITY IS RELEVANT TO PATIENTS WITHOUT BLADDER OUTFLOW OBSTRUCTION Peter F. W. M. Rosier Peter F. W. M. RosierPeter F. W. M. Rosier More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003348.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Bladder outflow obstruction (BOO) is prevalent in male patients >45 y with LUTS but much less in women. Detrusor voiding contraction underactivity (DVC-DU) is (equally?) prevalent in in both sex. BOO affects DVC through 'compensation'; muscle training, to gain force, which is represented in DVC-detrusor- pressure. DVC-muscle shortening velocity (muscle function Hill equation) is less known/studied and is potentially relevant as an element of DVC-DU. We analysed DVC parameters including contraction velocity in a large cohort of adult men and women without BOO. METHODS: Patients without relevant neurological or anatomical abnormalities, voiding (pressure flow studies PFS) >100 mL and <800 mL with PVR <500 mL, representative, after ICS (quality) standard UDS, for all usual/possible indications, with 7F double lumen water fill cystometry, were included. All known DVC parameters were analysed and DVC-velocity is calculated: (bladder circumference (based on mL) at begin voiding minus circumference at end) / voiding time (tQ>0). All patients had BOO<3 linPURR (ICS- noOBS). 2488 patients were 63.5 y (sd 16.8) men (n1511) 66.3 y (15.1) and women (n977) 59.2 y (18.3). They voided 359 mL with PVR 47 mL; void% 89.3. RESULTS: PFS-voided volumes were not different Void% was slightly lower in men (88.6 vs 90.4). Men's Qmax 12.5 mL/s; pdetQmax 43.3 cm H2O; BOOI 18.1; and Wmax 12.3 W/m2 differed signific. from women Qmax 19.9 mL/s; pdetQmax 25.7 cm H2O; BOOI -14.1; and Wmax 13.0 W/m2. DVC-velocity was 0.37 cm/s in men vs 0.56 cm/s (p.000). 58.4% of men had void%100 62.2% of women. The Figure 1 demonstrates the relevance of DVC-velocity to predict incomplete voiding, in absence of BOO. CONCLUSIONS: Men with LUTS have somewhat higher outflow resistance than women even when they are all within the no BOO -category. Anatomical differences likely the cause. Only a small percentage of all female patients has outflow obstruction (>grade 2) and diagnosing DVC especially in cohorts of female patients (but also in men without BOO) requires a parameter that includes detrusor contraction velocity. Most of the currently available parameters to represent the contraction force or -strength of the DVC include detrusor pressure -with a certain weight- in a mathematical product. If there is no or low grade outflow resistance however, not contraction power (≈pressure), but contraction speed (velocity or (flow)rate) is more important. This is now supported by this analysis showing that, in patients without BOO (<grade3) DVC-velocity, has the highest predictive value to predict incomplete micturition. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1077 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Peter F. W. M. Rosier More articles by this author Expand All Advertisement PDF downloadLoading ...

Proof-of-concept study of compartmentalized lung ventilation using system for asymmetric flow regulation (SAFR).

Asymmetrical distribution of acute lung injury in mechanically ventilated patients can result in a heterogeneity of gas distribution between different regions, potentially worsening ventilation-perfusion matching. Furthermore, overdistension of healthier, more compliant lung regions can lead to barotrauma and limit the effect of increased PEEP on lung recruitment. We propose a System for Asymmetric Flow Regulation (SAFR) which, combined with a novel double lumen endobronchial tube (DLT) may offer individualized lung ventilation to the left and right lungs, better matching each lung's mechanics and pathophysiology. In this preclinical experimental model, the performance of SAFR on gas distribution in a two-lung simulation system was tested. Our results indicate that SAFR may be a technically feasible and potentially clinically useful although further research is warranted.

Clinical study on the classification of renal artery involvement and comparison of renal function and prognosis of Stanford type B aortic dissection after thoracic aortic endovascular repair

Objective: To investigate the different types of renal artery involvement in Stanford type B aortic dissection (TBAD) and the comparison of clinical effecacy after thoracic endovascular aortic repair (TEVAR). Methods: This is a retrospective cohort study included 330 patients with TBAD and renal artery involvement treated with TEVAR from June 2002 to September 2021 in General Hospital of Northern Theater Command of the PLA. According to aortic CTA image, unilateral renal artery involvement conditions were divided into 5 types: the true lumen type (renal artery opening completely from the true lumen), false lumen type (renal artery opening completely from the false lumen), double lumen type (renal artery opening from the true and false double lumen), compression type (renal artery opening connected with the true lumen, but the renal artery opening was extremely squeezed by the inner membrane), open type (renal artery opening with intimal tear). There were seven types of bilateral renal artery involvement: true-true type (true lumen-true lumen type), true and false type (true lumen-false lumen type), true-double type (true lumen-double lumen type), true-opening type (true lumen-opening type), false-false type (false lumen-false lumen type), false-compression type (false lumen-compression type), double-double type (double lumen-double lumen type). The primary observation index of this study was the comparison of postoperative renal function and the incidence of clinical adverse events of different types of renal artery involvement. One-way ANOVA test, Kruskal-Wallis H test and paired sample rank sum test were used to compare postoperative renal function between different types of bilateral renal artery involvement. The Chi-square test or Fisher's exact probability test were used to compare the near and long term adverse events between different types of bilateral renal artery involvement. Kaplan-Meier method was used to compare the all-cause mortality of patients with severe renal functional injury and non-severe renal functional injury before surgery. Results: The average age of the patients included in this study was (53±11) years, including 276 males (83.6%) and 54 females (16.4%). There were statistical difference in the level of serum creatinine (preoperative:H=18.686, P=0.005, postoperative:H=18.101, P=0.006) and cystatin C (preoperative:H=17.566, P=0.007, postoperative:H=10.433, P=0.016), pre-and post-operative, between the seven groups of TBAD patients with different renal artery involvement types (P<0.05), and the false-false type group shown the worst kidney function. However, no statistically significant differences were shown when comparing their pre- and post-operative change values (P>0.05). The 30-day follow-up result showed that there were statistically significant differences in the incidence of postoperative acute kidney injury (χ2=15.623, P=0.007), aorta-related adverse events (χ2=15.523, P=0.010), and intraoperative endoleak (χ2=17.935, P=0.004) among the seven groups, and the false-false group was the highest (2/9, 5/9 and 5/9, respectively). In terms of long-term follow-up results, there were statistically significant differences in all-cause death (χ2=14.772, P=0.011) and non-aortic death (χ2=15.589,P=0.008) among the seven groups. Kaplan-Meier survival analysis showed that patients with worse pre-operative renal function showed higher long-term all cause death (17.7% vs. 4.8%, P=0.009). Conclusions: For TBAD patients with renal artery involvement, there were differences in renal function among different types, and TEVAR showed no significant effect on renal function in TBAD patients. The long-term all cause death was higher in patients with worse renal function pre-operative.