Femoral Sheath Research Articles

Measuring CMAPs in addition to MEPs can distinguish peripheral ischemia from spinal cord ischemia during endovascular aortic repair

ObjectiveSpinal cord injury is a devastating complication after endovascular thoracic and thoracoabdominal aneurysm repair (EVAR). Motor evoked potentials (MEPs) can be monitored to detect spinal cord injury, but may also be affected by peripheral ischemia caused by femoral artery sheaths. We aimed to determine the incidence of peripheral ischemia during EVAR, and whether central and peripheral ischemia can be distinguished using compound muscle action potentials (CMAPs). MethodsWe retrospectively analyzed all EVAR procedures between March 1st 2015 and January 1st 2020 during which MEPs were monitored. Peripheral ischemia was defined as both a reduction in MEP amplitudes reversed by removing the femoral sheaths and no clinical signs of immediate post-procedural paraparesis. All other MEP decreases were defined as central ischemia. ResultsA significant MEP decrease occurred in 14/27 (52%) of all procedures. Simultaneous CMAP amplitude reduction was observed in 7/8 (88%) of procedures where peripheral ischemia occurred, and never in procedures with central ischemia. ConclusionsMEP reductions due to peripheral ischemia are common during EVAR. A MEP-reduction without a CMAP decrease indicates central ischemia. SignificanceCMAP measurements can help to distinguish central from peripheral ischemia, potentially reducing the chance of misinterpreting of MEP amplitude declines as centrally mediated, without affecting sensitivity.

Safeguard pressure assisted device for local femoral hemostasis in neuroendovascular procedures: A single center study of 879 patients

BackgroundVarious vascular closure devices (VCDs) are available for local hemostasis after percutaneous transfemoral approach for neuroendovascular procedures but they have been associated with an increased complication rate and limitations to a re-puncture of the artery. We evaluated the safety and efficacy of Safeguard® 24 cm pressure assisted device (Merit Medical, West Jordan, UT, USA) and the associated complications. MethodsFrom September 2016 to December 2019, 879 patients underwent neuroendovascular procedures via transfemoral approach using an introducer sheath ranging from 4 to 6-French and they were included in a prospective database. We registered the demographic characteristics and procedural factors. We evaluated the device failure and associated complications. ResultsThe Safeguard® was successful in 862 cases (98.1 %) with post-procedural local bleeding in 17 patients (1.9%). On univariate analysis, an association with local bleeding was observed with age >60 years (Odds ratio [OR] = 3.2, P = 0.04) and the use of an introducer sheath >4 F ([OR] = 3.1, P = 0.007). Female gender, antithrombotic medication and type of procedure (diagnostic or interventional) were not associated with local bleeding. On binary logistic regression analysis, there was association only for age >60 years ([OR] = 3, P = 0.04). ConclusionThe Safeguard® 24 cm is safe and efficient. It is simple to use and it can be applied independently from vessel anatomic characteristics. It should though be used with caution in case of a femoral introducer sheath larger than 4 Fr and patients older than 60 years.

Comparison of efficacy of different endovascular lead extraction techniques

Abstract Background Reports on lead extraction often concern a single technique, rendering direct comparison between techniques difficult. Purpose We compared efficacy and complications of consecutively used endovascular extraction techniques in a single centre. Methods Single centre observational study of consecutive lead extractions from 1997 to 2019. The preferential technique used over time was at first a laser sheath (LS), subsequently a femoral approach (FA) if feasible, and finally rotational mechanical sheaths (RMT). The FA remained the preferential initial technique for atrial and coronary sinus leads during the latter period. Extraction results are reported per lead for the initial technique before any alternative approach was initiated. Results A total of 1725 leads (including 222 ICD) leads were extracted in 775 patients. Primary endovascular extraction was attempted in 1703 leads (median implant time 6.0 yrs. [IQR 2.7–10.2]) with the remainder being surgically removed. Traction sufficed to remove 588 leads (median implant time 2.4 yrs. [IQR 1.2 - 4.7]). The table shows the radiological and procedural success of the initially used technique per lead. Including use as backup technique there were 7.4%, 0.5% and 1.2% major complications with respectively LS, FA, and RMT. Including backup approaches, clinical success (lead completely removed or only lead fragment <4cm left behind without mayor complication) for endovascular extraction of the 1703 leads was 94.8%. Conclusion The laser sheath has an inferior procedural outcome compared to rotational mechanical sheaths or a femoral approach which is largely the results of a higher complication rate. The femoral approach and mechanical rotational sheaths are seemingly equally effective, but the femoral approach is not suitable for many ICD leads and technically more demanding for ventricular leads. In current practice, the combination of a femoral approach and rotational mechanical sheaths yields optimal results. Funding Acknowledgement Type of funding source: None

CORRELATION BETWEEN POINT OF CARE ACTIVATED CLOTTING TIMES AND LABORATORY-DETERMINED ANTI-XA UNFRACTIONATED HEPARIN LEVELS TO GUIDE MANAGEMENT OF SHEATH REMOVAL

Femoral arterial access for coronary angiography is infrequent but still in use. Point-of-care (POC) activated clotting time (ACTs) analyzers to guide the timing of femoral sheath removal require increasingly disproportionate use of resources in ongoing maintenance and quality assurance for a low volume test. It is hypothesized that there is a strong correlation between POC ACTs and laboratory-determined anti-Xa unfractionated heparin (UFH) levels.

364 Feasibility Study of Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Medical Cardiac Arrest

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a hemorrhage control technique involving the intra-vascular occlusion of the thoracic aorta using a balloon catheter and may help to increase coronary and cerebral perfusion during out-of-hospital cardiac arrest (OHCA) by blocking blood flow to the lower body. Primary Objective: The primary objective of this study is to assess the feasibility of an emergency medicine (EM)-initiated multi-disciplinary protocol for REBOA in non-traumatic OHCA. Secondary Objectives: Secondary objectives are procedural outcomes (eg, attempts required for common femoral access), hemodynamic outcomes before and after aortic occlusion (end-tidal carbon dioxide, diastolic blood pressure), and rates of return of spontaneous circulation (ROSC) and survival to hospital discharge with a favorable neurologic outcome. This single-arm early feasibility study of REBOA initiated in the emergency department (ED) for OHCA uses an investigational device approval with a community exception from informed consent. Subjects under 80 years of age with witnessed OHCA and down time under 45 minutes are eligible. On arrival to the ED, an emergency physician obtains common femoral access using a 7Fr introducer sheath while the REBOA catheter is prepared and subsequently advanced by an interventional radiologist (IR). Two patients were enrolled between January and February 2020, with a temporary pause in enrollment due to the COVID pandemic from March - August 2020. To our knowledge, this is the first trial of ED-initiated REBOA involving emergency physicians for non-traumatic OHCA (two similar recent reports exist in the anesthesia and critical care literature). Our initial patient was a 77-year-old man who presented in refractory ventricular fibrillation. The emergency physician placed the common femoral sheath on the first attempt using ultrasound guidance under chest compressions and the REBOA catheter was then advanced by the interventional radiologist. After inflation of the aortic balloon, investigators noted immediate improvements in mean arterial pressure (MAP) (37 to 50 mmHg) and end-tidal carbon dioxide (ETCO2) (35 to 50 mmHg), with transient non-sustained ROSC. The second patient, a 63-year-old man, underwent successful REBOA placement with similar improvements in MAP (22 to 50 mmHg) and ETCO2 (33 to 43 mmHg). Unfortunately, both patients were in refractory ventricular fibrillation and despite multiple defibrillation attempts and antiarrhythmics they did not survive to hospital admission. REBOA has been hypothesized to improve outcomes in OHCA by blocking blood flow to the lower body and redirecting it towards the heart and brain, improving the perfusion of these vital organs. In both cases, REBOA was temporally associated with improved hemodynamics during chest compressions with transient ROSC in one case. Performance of REBOA by a multi-disciplinary team for OHCA in the ED was feasible in these initial two cases. Future research will examine the feasibility of REBOA catheter advancement by the emergency physician and further quantify the hemodynamic effects associated with aortic occlusion.

Protected complex percutaneous coronary intervention and transcatheter aortic valve replacement using extracorporeal membrane oxygenation in a high-risk frail patient: a case report

BackgroundTranscatheter aortic valve replacement has become a routine procedure for patients with severe symptomatic aortic stenosis at increased surgical risk. Not much is known about using prophylactic support with venoarterial extracorporeal membrane oxygenation in patients undergoing transcatheter aortic valve replacement and eventually concomitant complex percutaneous coronary intervention.Case presentationWe present a successful procedure of transcatheter aortic valve replacement and high-risk percutaneous coronary intervention utilizing venoarterial extracorporeal membrane oxygenation for hemodynamic support in a very frail 88-year-old Caucasian woman with severe symptomatic aortic stenosis and coronary bypass grafting in the past.Echocardiography revealed a “low-flow low-gradient” aortic stenosis (mean transvalvular gradient 30 mmHg, aortic valve area 0.4 cm2, significant calcification), a left ventricular ejection fraction of 35%, severe mitral regurgitation with moderate stenosis (mean transvalvular gradient 7 mmHg), with a systolic pulmonary artery pressure of 80 mmHg. Moreover, pre-interventional coronary angiography exposed a severe left main ostial stenosis and sequential subtotal heavily calcified stenosis of the left anterior descending artery . Computed tomographic angiography showed no heavy tortuosity but moderate calcification of the iliofemoral arteries.The procedure was performed under general anesthesia in our hybrid operating room. Extracorporeal membrane oxygenation was established by left femoral percutaneous cannulation using a 21-Fr venous and 15-Fr arterial cannula. Subsequently, complex percutaneous coronary intervention with implantation of two drug-eluting stents from the left main into the left anterior descending artery was performed via a right femoral arterial 7F sheath. Thereafter, a 23-mm Sapien 3 aortic valve prosthesis (Edwards, Irvine, CA, USA) was implanted via right femoral artery in the usual manner, whereby the arterial pigtail catheter for marking the aortic annulus during transcatheter aortic valve replacement was inserted over a Check-Flo® Hemostasis Assembly (Cook Medical, Bloomington, IN, USA) on a Y-adapter via the arterial extracorporeal membrane oxygenation cannula. After extracorporeal membrane oxygenation decannulation, vascular closure was easily performed using the MANTA vascular closure device in order to reduce procedural time and risk of access site complications.ConclusionsIn summary, we demonstrate the feasibility of elective prophylactic extracorporeal membrane oxygenation implementation in selected very high-risk and frail patients undergoing transcatheter aortic valve replacement and percutaneous coronary intervention in order to avoid intraprocedural complications.

1910-P: Effects of Glucagon Concentrations on Splanchnic and Leg Glucagon Extraction in Healthy Humans

We have recently developed a novel isotope dilution method using nonradioactive, stable human Glucagon (Phe 6 13C9, 15N; Phe 22 13C9, 15N) tracer to measure glucagon turnover. In this study we combined this method with organ catheterization technique to estimate the effects of increasing circulating glucagon concentrations, spanning the physiological range, on splanchnic and leg glucagon extraction. We present data from the first 6 healthy subjects (age 25±3.6 yrs; BMI 26.7±4.5 kg/m2; fasting glucose 4.6±0.5 mM; HbA1c 5.1±0.3%) completed thus far. After IRB approval and informed consent, subjects were admitted in the morning after an overnight fast to Interventional Radiology, where catheters were placed in the right femoral artery and vein under local anesthesia with aseptic precautions. Under fluoroscopic guidance, a hepatic venous catheter was positioned through the femoral vein. Glucagon tracer was infused intravenously and Indocyanine Green infused via the femoral artery sheath to measure splanchnic and femoral plasma flows. After a 90 min period for basal sampling, exogenous glucagon was infused at 0.65 ng/kg/min for 60 minutes (low) followed by 1.5 ng/kg/min (high) for another 60 minutes. Plasma samples were collected periodically from femoral artery, femoral vein and hepatic vein for concentrations of Glucagon tracer (Tandem Mass Spectrometry), glucagon, glucose and Indocyanine Green (Spectrophotometry) concentrations. Arterial glucagon concentrations were 45.2±9.6 pg/ml (basal), 56.3±13.3 pg/ml (low) and 81.4±15.5 pg/ml (high). While fractional splanchnic glucagon extraction remained relatively unchanged (24.0±12.5% vs. 27.7±15.6% vs. 23.5±10.1%: basal vs. low vs. high), fractional leg glucagon extraction tended to increase (13.5±3.8% vs. 16.0±7.2% vs. 18.5±9.4%: basal vs. low vs. high) with increasing glucagon concentrations. These initial data suggest differing mechanisms of glucagon clearance across the splanchnic and leg tissues in humans. Disclosure F. Ruchi: None. Y.R. Yadav: None. D. Romeres: None. S. Sawleh: None. L.M. Benson: None. K.L. Johnson: None. C. Dalla Man: Research Support; Self; Sanofi-Aventis Deutschland GmbH. C. Cobelli: None. D.J. McCormick: None. L.R. Wilkins: None. R. Basu: Consultant; Self; GENFIT. Research Support; Self; AstraZeneca. A. Basu: Consultant; Spouse/Partner; GENFIT. Research Support; Spouse/Partner; AstraZeneca. Funding National Institutes of Health (R01DK029953 to R.B.), (R01DK085516 to A.B.), (DK059637, DK020593)

152-OR: Postabsorptive Splanchnic and Leg Glucagon Metabolism in Healthy Subjects: Use of 13C 15N Glucagon

Glucagon metabolism in humans is poorly understood and is currently under active investigation. We have recently developed a novel isotope dilution method using nonradioactive, stable human glucagon (Phe 6 13C9, 15N; Phe 22 13C9, 15N) tracer to measure glucagon turnover. In this study we combined this method with organ catheterization technique to estimate splanchnic and leg glucagon extraction and uptake. We present data from the first 6 healthy subjects (age 25±3.6 yrs; BMI 26.7±4.5 kg/m2; fasting glucose 4.6±0.5 mM; HbA1c 5.1±0.3%) completed thus far. After IRB approval and informed consent, subjects were admitted in the morning after an overnight fast to Interventional Radiology, where catheters were placed in the right femoral artery and vein under local anesthesia with aseptic precautions. Under fluoroscopic guidance, a hepatic venous catheter was positioned through the femoral vein. Glucagon tracer was infused intravenously and Indocyanine Green infused via the femoral artery sheath to measure splanchnic and femoral plasma flows. Plasma samples were collected periodically from femoral artery, femoral vein and hepatic vein for concentrations of glucagon tracer (Tandem Mass Spectrometry), glucagon, glucose and Indocyanine Green (Spectrophotometry) concentrations. Fractional splanchnic glucagon extraction was 24.0±12.5 % while total splanchnic glucagon uptake was 214.3±56.1 ng/kg total body weight/min. Net splanchnic glucagon balance was -34.4±10.0 ng/kg total body weight/min implying net splanchnic glucagon production. Fractional leg glucagon extraction was 13.5±3.8% while total leg glucagon uptake was 53.0±21.2 pg/kg total body weight/min. To the best of our knowledge, these initial data provide the first direct assessment of regional glucagon metabolism in healthy humans in the post absorptive fasting state. Disclosure F. Ruchi: None. Y.R. Yadav: None. D. Romeres: None. S. Sawleh: None. L.M. Benson: None. K.L. Johnson: None. C. Dalla Man: Research Support; Self; Sanofi-Aventis Deutschland GmbH. C. Cobelli: None. D.J. McCormick: None. L.R. Wilkins: None. R. Basu: Consultant; Self; GENFIT. Research Support; Self; AstraZeneca. A. Basu: Consultant; Spouse/Partner; GENFIT. Research Support; Spouse/Partner; AstraZeneca. Funding National Institutes of Health (R01DK029953 to R.B.), (R01DK085516 to A.B.), (DK059637, DK020593)

Retrograde Recanalization of the Celiac Artery via the Pancreaticoduodenal Arcade as a Safe and Valid Alternative to Antegrade Access.

The antegrade recanalization of an occlusion or high-grade stenosis of the celiac artery via the aorta often represents a technical challenge. A retrograde approach via the superior mesenteric artery and the pancreaticoduodenal arcade may be an alternative approach. Based on our experience, we assess the technical success and the short- and mid-term outcomes of this bailout procedure. We performed a retrospective analysis of all consecutive patients who underwent recanalization and stent implantation in the celiac artery between January 2010 and December 2018. Data on vascular access, the materials used including stents, as well as the length of the intervention, radiation exposure, and follow-up were assessed. Recanalization in combination with stent implantation into the celiac artery was performed in 43 patients. In 39 (91%) of 43 patients, the recanalization was successful with an antegrade approach via the aorta, whereas in 4 (9%) of 43 patients the passage of the stenosis was possible only through a retrograde approach through the superior mesenteric artery and the pancreaticoduodenal arcade followed be advancement of the microwire through the celiac artery into the aorta. The tip of the microwire was captured in the aorta with a snare and pulled out in the femoral introducer sheath and used as a guide for the antegrade implantation of a balloon-expandable stent. The retrograde recanalization of the celiac artery via the pancreaticoduodenal arcade may be technically challenging yet represents a feasible alternative in case of a failed antegrade approach.

Safety and Feasibility of Percutaneous Purse-String-Like Downsizing for Femoral Access During Complex Endovascular Aortic Repair.

To describe a percutaneous "purse-string-like" technique to downsize the femoral access sheath achieving early pelvis and limb reperfusion during complex endovascular aortic repair, while maintaining a sheath in place. After ultrasound-guided femoral catheterization, two Perclose ProGlide vascular closure devices (VCD) are employed with the pre-close technique. When the deployment of aortic components is complete, the large delivery sheath is exchanged for a smaller non-occlusive one (≤ 10 F) and the rail suture of both VCDs is pulled to achieve hemostasis. At the end of the procedure, the access is closed according to standard technique. Fifty-eight femoral accesses were downsized achieving hemostasis with a completion percutaneous closure success of 95% (55/58). The median ischemic time to the limb was 66min (IQR 31-131) for the main access and 65min (IQR 30-100) for the contralateral one. When compared to a 1:2 propensity score-matched cohort who did not undergo access downsizing, no differences in closure success were recorded (95% vs. 89%, p = 0.19). However, hemostasis required more frequently an additional ProGlide in the downsizing group (26 cases, 45% vs. 17 cases, 15%; p < .001). Percutaneous purse-string-like sheath downsizing to restore perfusion to limbs and pelvis during complex endovascular aortic repair is feasible with high closure success rates, although a third ProGlide is more frequently needed to achieve hemostasis. The impact of this practice on SCI rates requires further evaluation in larger series as part of a multimodal approach for spinal cord protection.

Endovascular Embolization Techniques in a Novel Swine Model of Fatal Uncontrolled Solid Organ Hemorrhage and Coagulopathy

Endovascular embolization is increasingly used in treating traumatic hemorrhage and other applications. No endovascular-capable translational large animal models exist and coagulopathy's effect on embolization techniques is unknown. We developed a coagulation-adaptable solid organ hemorrhage model in swine for investigation of embolization techniques. Anesthetized swine (n=26, 45±3kg) had laparotomy and splenic externalization. Half underwent 50% isovolemic hemodilution with 6% hetastarch and cooling to 33-35°C (COAG group). All had controlled 20mL/kg hemorrhage and endovascular access to the proximal splenic artery with a 4F catheter via a right femoral sheath. Splenic transection and 5min free bleeding were followed by treatment (n=5/group) with 5mL gelfoam slurry, three 6-mm coils, or no treatment (n=3, control). Animals received 15mL/kg plasma resuscitation and were monitored for 6hr. Splenic blood loss was continuously measured and angiograms were performed at specified times. Coagulopathy was successfully established in COAG animals. Pre-treatment blood loss was greater in COAG (11±6mL/kg) than non-COAG (7±3mL/kg, P=0.04) animals. Splenic hemorrhage was universally fatal without treatment. Non-COAG coil survival was 4/5 (326±75min) and non-COAG Gelfoam 3/5 (311±67min) versus non-COAG Control 0/3 (82±18min, P<0.05 for both). Neither COAG Coil (0/5, 195±117min) nor COAG Gelfoam (0/5, 125±32min) treatment improved survival over COAG Control (0/3, 56±19min). Post-treatment blood loss was 4.6±3.4mL/kg in non-COAG Coil and 4.6±2.9mL/kg in non-COAG Gelfoam, both lower than non-COAG Control (18±1.3mL/kg, P=0.05). Neither COAG Coil (8.4±5.4mL/kg) nor COAG Gelfoam (15±11ml/kg) had significantly less blood loss than COAG Control (20±1.2mL/kg). Both non-COAG treatment groups had minimal blood loss during observation, while COAG groups had ongoing slow blood loss. In the COAG Gelfoam group, there was an increase in hemorrhage between 30 and 60min following treatment. A swine model of coagulation-adaptable fatal splenic hemorrhage suitable for endovascular treatment was developed. Coagulopathy had profound negative effects on coil and gelfoam efficacy in controlling bleeding, with implications for trauma and elective embolization procedures.

Direct autotransfusion following emergency pericardiocentesis in patients undergoing cardiac electrophysiology procedures.

Acute hemopericardium during cardiac electrophysiology (EP) procedures may result in significant blood loss and is the most common cause of procedure-related death. Matched allogeneic blood is often not immediately available. The feasibility and safety of direct autotransfusion in cardiac electrophysiology patients requiring emergency pericardiocentesis is unknown. We retrospectively analyzed records of patients undergoing EP procedures at a single, tertiary care medical center who had procedure-related acute hemopericardium requiring emergency pericardiocentesis during a 3-year period. Procedure details, transfusion volumes, and clinical outcomes of patients who received direct autotransfusion of aspirated pericardial blood via a femoral venous sheath were compared to those of patients who did not receive direct autotransfusion. During the study period, 10 patients received direct autotransfusion (group 1) and outcomes were compared with those of 14 control patients who did not receive direct autotransfusion (group 2). The volume of aspirated pericardial blood was similar in groups 1 and 2 (1.6 ± 0.7 L vs 1.3 ± 1.0 L, respectively; P = .52). Amongst patients with aspirated volumes <1 L, group 1 patients (n = 4) were less likely than group 2 patients (n = 8) to require allotransfusion (0% vs 75%, P = .02). Amongst patients with aspirated volume ≥1 L, group 1 patients (n = 6) required fewer units of red cell allotransfusion than group 2 patients (n = 6) (1.5 ± 0.8 units vs 4.3 ± 2.0 units, P = .01). No procedural complications related to direct autotransfusion occurred. Direct autotransfusion following emergency pericardiocentesis during electrophysiology procedures requiring systemic anticoagulation is feasible and safe. The utilization of direct autotransfusion may eliminate or reduce the need for allotransfusion.

Nitrates and risk of vasovagal reaction in femoral sheath removal after percutaneous intervention : Aretrospective observational study.

The aim of this study was to analyze the risk factors for vasovagal reaction (VVR) in manual femoral sheath removal after percutaneous coronary intervention and to discuss methods for the prevention and control of VVR. The data of 455 patients who underwent percutaneous intervention in four interventional centers during a period of 30months were retrospectively analyzed. Patients were divided into a VVR group and a control group according to whether VVR developed. The clinical data of all patients were analyzed using univariate and multivariate logistic regression analysis to examine VVR -related factors. Atotal of 455 patients underwent 464 manual femoral sheath removal operations, of whom 12developed VVR (2.59%). Of these 12VVR patients, one had VVR during and 11 had VVR after the intervention. There were no statistically significant differences between the two groups in age, body mass index, gender, time of sheath removal, proportions of patients with hypertension, diabetes, and hyperlipemia, laboratory values of hemoglobin a1c, and ejection fraction (p > 0.05). Compared with the control group, use of nitrates was the only risk factor with a significant correlation with VVR (p = 0.012). In manual femoral sheath removal, the use of nitrates is the most important risk factor for the occurrence of VVR after percutaneous intervention.

Safety and effectiveness of single ProGlide vascular access in patients undergoing endovascular aneurysm repair

ObjectiveThe objective of this study was to evaluate the safety and effectiveness of single ProGlide use per bilateral access site for endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms. MethodsA retrospective cohort study was performed for all elective percutaneous EVARs from November 2015 to December 2017 at the QEII Health Sciences Centre (Halifax, Nova Scotia, Canada). Exposure of interest was number of ProGlides used per access site, dichotomized into bilateral single ProGlide closure vs nonsingle ProGlide closure on at least one femoral arteriotomy. Outcomes included Valve Academic Research Consortium (VARC)-2 and Bleeding Academic Research Consortium (BARC) criteria. Groups were compared with Fisher exact test, analysis of variance, or Wilcoxon rank sum, as appropriate. Logistic regression was used to compare the effect of single ProGlide use on VARC-2 and BARC criteria. ResultsA total of 131 cases were included, of which 116 had bilateral single ProGlide use for access closure. Baseline characteristics including comorbidities and smoking status were compared between groups. Groups were similar for all characteristics except smoking status, with an increased proportion of former smokers in the nonsingle ProGlide group. There were 119 (90.8%) patients who had single ProGlide use on the right femoral artery and 121 (92.4%) on the left; 16 (12.2%) patients had ProGlide deployment issues. Median maximal right and left femoral sheath diameters were 16F (interquartile range [IQR], 16F-18F) and 14F (IQR, 14F-16F), respectively. Median length of stay was 1 day (IQR, 1-1 day). VARC-2 criteria occurred in 8 of 131 (6.11%) patients, 6 of 116 (5.17%) with bilateral single ProGlides and 2 of 15 (13.3%) with nonsingle ProGlides. BARC criteria occurred in 6 of 131 (4.58%) patients, 5 of 116 (4.31%) with bilateral single ProGlides and 1 of 15 (6.67%) with nonsingle ProGlides. Single ProGlide use was not associated with a difference in VARC-2 (odds ratio, 0.35; 95% confidence interval, 0.64-1.94) or BARC (odds ratio, 0.63; 95% confidence interval, 0.07-6.79) criteria. No patients developed pseudoaneurysms or required repeated intervention for bleeding. ConclusionsSingle ProGlide use per vascular access site in patients undergoing EVAR is a safe and effective method for access closure with sheath diameters up to and including 16F.

Perforated retroperitoneal appendicitis presented with right thigh abscess: case report and literature review

The typical clinical presentation of acute appendicitis is initial diffuse abdominal pain that shifts to right iliac fossa, nausea, vomiting supported with elevated white blood cell count [3]. It is reported that there are atypical presentation of acute appendicitis approximately 20%-30%. Retroperitoneal perforated appendix can cause retroperitoneal and psoas abscess. After abscess formation, inflammation and pus may extend to pelvis and extra-abdominal compartments through certain routes and tissue plains. Reported routes in literature such as deep to inguinal ligament (through psoas sheath, femoral sheath and femoral canal), fibro-osseus canals (through sacrosciatic notch and Obturator foramen). We report a 67 years old patient with initial presentation of right thigh abscess and psoas abscess caused by perforated retroperitoneal appendicitis. He was managed with vertical drainage of the thigh abscess and laparoscopic appendectomy with psoas abscess drainage. There are several reports that diagnostic modalities such as CT of the abdomen and pelvis or MRI could direct the management to surgical or non-surgical plans. The early surgical intervention to the intra-abdomen pathology with sufficient drainage of the psoas and thigh abscess is the definite treatment. It is suggested that in unexplained thigh or groin pain/soft tissue infection with fever and leukocytosis a gastrointestinal pathology should not be overlooked.

Combining On-Table Embolization With Immediate Resection To Safely Excise Giant Hepatic Hemangiomas

Presenter: Ajay Maker MD | University of Illinois at Chicago Background: The management of symptomatic giant hepatic hemangiomas varies in the literature. Multiple approaches have been described, and surgical resection is often used as a last resort due to the risk of major hemorrhage. One of the major difficulties in approaching massive hemangiomas is safe control of the substantial arterial inflow since the porta, feeding vessels, and outflow may be inaccessible to due to tumor size and immobility. Preoperative arterial embolization is an option, however, many patients will experience severe pain, fever, transaminitis, acidosis, recanalization, and collateral inflow that limit its utility. Furthermore, patients will require post-procedure inpatient observation that extends hospital costs and length of stay, and there is no consensus on the appropriate time interval between procedures. We endeavored to approach this clinical situation with on-table angiogram and embolization followed by immediate resection in a hybrid operating room. Methods: Under general anesthesia in a hybrid operating room with on-table angiogram capabilities, the patient underwent a celiac and SMA angiogram followed by hemangioma inflow embolization and immediate hepatic resection. Results: Two large branches of the left hepatic artery were feeding a >20cm hemangioma. The mass replaced the left hepatic lobe and displaced the middle hepatic vein. After coil embolization of the arterial inflow to the tumor, the femoral sheath was removed and the patient was immediately prepped and draped for hepatic resection on the same table. Tumor size was substantially reduced and the hemangioma was compressible, allowing mobilization of the tumor and access to the porta hepatis. Left hepatic arterial and portal inflow were ligated, outflow was controlled, and the parenchyma was divided combining formal resection planes with enucleation of the tumor off the middle hepatic vein at its origin. Blood loss was minimal ( < 150mL) and the patient was discharged home on no pain medicine and free of preoperative symptoms on post-operative day 4. Conclusion: Combining on-table embolization with immediate resection avoids post-procedure pain and many of the pitfalls of preoperative embolization. It is an efficient use of hospital resources and reduces an intervening hospital admission. We have found it to be a preferred approach to enhance the safety and feasibility of resection for massive hepatic hemangiomas with minimal intraoperative blood loss and reduced risk.

A081 Percutaneous Closure of a Rapid Deployment Aortic Valve Paravalvular Leak Using Intracardiac Echocardiography

Paravalvular leak (PVL) is associated with poor outcomes and may be more common following rapid deployment valves. We present the first reported percutaneous closure of such a PVL using intracardiac echocardiography (ICE). A 76 year-old man underwent aortic valve replacement with 27mm Edwards Intuity rapid deployment valve in October 2018 for severe aortic stenosis. During follow-up, he developed worsening breathlessness (NYHA Class III) and diastolic murmur. Blood tests revealed elevated brain natriuretic peptide (189pmol/L) and evidence of haemolysis (haemoglobin 95g/L, bilirubin 34mmol/L, lactate dehydrogenase 800U/L, haptoglobin <0.07g/L). Transoesophageal echocardiogram confirmed moderate-severe paravalvular aortic regurgitation through a crescent-shaped defect. His case was discussed at the heart team meeting and percutaneous closure was recommended. The procedure was performed under local anaesthetic using fluoroscopic and ICE guidance. Two 8Fr femoral arterial and one 10Fr femoral venous sheath were used for access. The ICE catheter (10Fr Siemens AcuNav) was positioned in the right atrium to localise and measure the defect size at 20x3mm. This was closed using two overlapping 12x5mm Amplatzer Vascular Plug-III (Abbott, USA) devices, deployed simultaneously. Excellent result was confirmed on ICE, with stable device position and trivial residual leak. Arterial sites were closed using Terumo Angio-Seals and femoral vein by manual compression. There were no procedural complications. The patient had significant clinical and biochemical improvement. Percutaneous closure of rapid deployment aortic valve paravalvular leak with ICE guidance appears safe and effective; and may obviate the need for general anaesthesia.

Management of acute cardiac tamponade by direct autologous blood transfusion in interventional electrophysiology

Acute cardiac tamponade (ACT) is the most common life-threatening complication of interventional electrophysiology. Urgent drainage by percutaneous pericardiocentesis and anticoagulation reversal are required. Immediate direct transfusion of the blood volume aspirated from the pericardial space to the patient has been rarely described. This study was designed to assess the efficacy and safety of immediate direct autologous blood transfusion (AutoBT). A retrospective case series of direct AutoBT performed for ACT was collected. Urgent drainage by percutaneous pericardiocentesis and immediate direct AutoBT into the femoral sheath of the blood volume aspirated from the pericardial space, were performed to achieve hemodynamic stabilization. Twenty-two electrophysiology centers were contacted to participate to the case series. Fourteen centers reported not to use direct AutoBT. Fourteen cases of immediate direct AutoBT were included from the five remaining centers. Electrophysiological procedures were performed for ventricular tachycardia ( n = 5), atrial fibrillation ( n = 5), atrial tachycardia ( n = 2), left accessory pathway ( n = 1) and premature ventricular contraction ( n = 1) with transseptal ( n = 9), retroaortic ( n = 4) and/or epicardial access ( n = 4). Pericardial drainage was performed by percutaneous pericardiocentesis for 13 patients and via the transseptal sheath for one patient. Surgical hemostasis was required for 7 patients. The mean volume of autologous blood directly transfused was 1207 ± 963 ml Direct AutoBT permitted to resume the procedure in 4 patients. 13 patients (93%) were discharged with a hospital stay of 12.3 ± 17.1 days. No major complication related to the use of AutoBT occurred ( table 1 ). Direct AutoBT without cell-saver system is a feasible and useful technique for salvage therapy in acute cardiac tamponade in interventional electrophysiology.

Management of Patients With Femoral Arterial Sheaths Following Percutaneous Coronary Intervention.

Management of Patients With Femoral Arterial Sheaths Following Percutaneous Coronary Intervention.

Unusual Suspect Causing Myocardial Infarction

An 84-year-old man with New York Heart Association functional class III/IV, due to prolapse of segment 2 of the anterior mitral valve leaflet with severe regurgitation as a result, was admitted for elective percutaneous edge-to-edge mitral valve repair. Significant coronary artery disease was ruled out previously. The left ventricular systolic function was normal with moderate concomitant aortic regurgitation. Mitral valve surgery was not considered a suitable option by the heart team due to frailty and a prohibitive surgical risk profile. The patient had an indication for transcatheter mitral-leaflet approximation, using the MitraClip-NT device (Abbott Vascular, Abbott Park, IL, USA). Implantation of the first clip resulted in insufficient reduction of mitral regurgitation. Therefore, a second device was positioned. Within minutes after release, transesophageal ultrasonography showed single leaflet device attachment of the second device, necessitating the deployment of a third device in order to stabilize the flailing clip (Figure 1a). Although regurgitation was reduced to moderate hereafter, flailing of the second device persisted. Two days later, the patient developed severe chest pain and cardiogenic shock. Electrocardiography showed ST-elevation in the inferior leads, corresponding to acute inferior wall myocardial infarction. Coronary angiography showed a dislodged clip seated in the right coronary ostium (Figure 1b). A 24Fr sheath was placed in the right femoral artery. After several attempts, a 35-mm Amplatz gooseneck snare was successfully positioned around the clip (Figure 1c). Subsequently, the device was retracted across the thoracic and abdominal aorta into the femoral sheath, which was successfully removed thereafter (Figure 1d). After the procedure, the patient was hemodynamically stable with normalization of the electrocardiogram. Transcatheter mitral-leaflet approximation using the MitraClip-NT device is used in high-risk patients with symptomatic mitral valve regurgitation. This unique case demonstrates an extremely rare complication of this procedure with a successful percutaneous solution. No potential conflict of interest was reported by the authors.