Guidewire Research Articles

Venolaryngeal Obstruction Syndrome (VLOS): Characterizing Airway Obstruction in Massive Thyroid Goiters.

Characterize the presentation of chronic airway obstruction for patients presenting with massive thyroid goiters. Demographic data acquisition was undertaken on 5 patients who presented with a compressive goiter and had pre-operative severe airway obstruction secondary to supraglottic and laryngeal edema. Each patient had a resolution of severe airway obstruction post-thyroidectomy. In all, 5 patients were diagnosed with severe airway obstruction due to chronic obstruction by a thyroid goiter. Several airway management interventions were pursued during definitive surgery (conventional or videolaryngoscopic intubation and a hybrid endoscopic approach incorporating the Seldinger technique). Successful thyroidectomy led to rapid resolution of laryngeal edema. Venolaryngeal obstruction syndrome is proposed as a term to describe the laryngeal findings in compressive goiters. The pathophysiological sequence resulting in chronic airway obstruction may have similar mechanisms to expanding neck hematomas after thyroid surgery.

2: Surgical Cutdown and Semi Seldinger Technique for Placement of Distal Perfusion Cannula after Percutaneous Cannulation in VA ECMO - Our Experience

2: Surgical Cutdown and Semi Seldinger Technique for Placement of Distal Perfusion Cannula after Percutaneous Cannulation in VA ECMO - Our Experience

Abstract TP251: The Use of Hydrophilic-Coated Introducer Sheaths for Reducing Radial Artery Spasm During Transradial Procedures: A Systematic Review and Meta-Analysis

Abstract TP251: The Use of Hydrophilic-Coated Introducer Sheaths for Reducing Radial Artery Spasm During Transradial Procedures: A Systematic Review and Meta-Analysis

Experience with the implementation of central venous catheters by medical oncologists in a non-surgical setting

Totally implantable central venous catheters (CVCs) are widely used in the management of patients with malignant diseases. Conventionally, port implantations were carried out by general surgeons and vascular radiologists. In recent years, the medical staff of the Medical Oncology department at the Central University Hospital of Asturias (HUCA) has developed a simplified methodology for the routine implantation of these devices. The aim of this study was to review our experience of CVCs and analyze the outcomes regarding catheter duration, complications, and cost comparison with respect to conventional port implantation by vascular radiologists. An observational epidemiological study was conducted, analyzing the methodology performed in a non-surgical, outpatient setting utilizing the Seldinger technique, without fluoroscopic control. A thorax X-ray was performed after each procedure and no prophylactic antibiotics were required. From January 2015 to March 2019, five hundred port systems were implanted, with a median age of 62 years (range 18–81), male 286/female 214. Most patients had a digestive tumor (79.4%). The right jugular vein was the most accessed in 345 patients (69%), followed by right subclavian in 144 (29%). Complications were observed in 49 patients (9.8%), immediate in 16 (3.2%), and late in 33 (6.6%). Thirty-nine devices were removed (7.8%). The cost incurred for port implantations by medical oncologists was lower (994.38 € cheaper for each device) compared to those implanted by vascular radiologists. Our experience suggests that implantation of port devices by medical oncologist in a non-surgical environment is safe and cost saving regarding conventional procedures.

Huscher modified technique for robotic pancreaticojejunostomy: a video report.

Pancreaticojejunostomy (PJ) is a critical step in pancreaticoduodenectomy (PD), often complicated by the risk of postoperative pancreatic fistula (POPF). This video report demonstrates a novel robotic PJ technique employing a self-expandable metallic stent. The method involves the use of the Da Vinci Xi robotic system and the WallFlex™ Biliary RX Stent for improved anastomotic support, particularly in high-risk cases defined by soft pancreatic texture and narrow duct diameter (<3 mm). Key steps include precise deployment of the self-expandable stent using a modified Seldinger technique and completion of the anastomosis with barbed sutures. The self-expandable stent dynamically adapts to the pancreatic duct, reducing tension and enhancing ductal drainage during the critical postoperative period, without requiring balloon expansion or fluoroscopy. This innovation addresses limitations associated with traditional stents and facilitates robotic procedures. Compared to Huscher's use of coronary artery stents (CAS), this technique offers simplicity and adaptability to minimally invasive settings. Outcomes of the robotic PJ approach highlight potential benefits, including reduced POPF rates and improved anastomotic precision. The integration of barbed sutures enhances efficiency and reproducibility, though considerations of pancreatic tissue fragility remain essential. This report underscores the feasibility and advantages of combining advanced robotic surgery with innovative stenting techniques to optimize outcomes in pancreatic surgery.

Seldinger's technique: If resistance appears, brain over brawn.

Seldinger's technique: If resistance appears, brain over brawn.

A novel cerebral ischemia-reperfusion model using intraluminal filament in rabbit

Abstract Introduction Stroke models are based on permanent or transient occlusion of cerebral arteries. Despite transient occlusion model tends to produce more variable results, it can investigate reperfusion. Although ischemia-reperfusion model is well established in rat using a silicone-filament by exposition of carotid artery, the endovascular approach in large animal is still a challenge. The purpose was to develop a novel cerebral ischemia-reperfusion model in rabbit using an intraluminal wire by means of an endovascular approach and subsequent assessed by MRI. Methods Four New Zealand rabbits (4-5 kg) underwent cerebral ischaemia-reperfusion. A 4Fr introducer sheath was inserted into the femoral artery. Under fluoroscopy, a 4Fr Cobra catheter was placed into the common carotid artery. A 1.9Fr microcatheter was inserted coaxially into the internal carotid artery, and a 0.014” microwire was advanced into the middle cerebral artery (MCA). Alternatively, the posterior cerebral artery (PCA) was occluded through the vertebral artery when the above approach failed. After 1 hour, reperfusion was performed by withdrawing the microwire. MRI examinations were conducted from 1 to 3 hours later. Results Technical success was achieved in three out of four animals, with the MCA reached in two rabbits and the PCA in one. In the rabbit with technical failure, it was impossible to advance the microwire into either the MCA or PCA due to the tortuosity of the vessels and vasospasm. Conclusion Ischemia-reperfusion model in rabbit though an intraluminal wire may provide a new model using an endovascular approach for the earlier research of transient stroke.

Minimally Invasive Mitral Valve Surgery: Initial One-team Experience and Short Review.

Introduction: Minimally invasive mitral valve surgery (MIMVS) is now a widely accepted and more frequently utilized method for patients needing mitral valve surgery. The promoted advantages are less trauma, less bleeding, less pain, and fewer wound infections, allowing faster postoperative and decreased healthcare costs. Material and Methods: This is a single-center retrospective study. We have collected the records of patients who underwent MIMVS by one team at the Cardiac Surgery Service, UHC” Mother Theresa” Hospital. The patients' data regarding demographic, preoperative, operative, and post-operative variables were collected from the medical records in the hospital. All statistical analyses were performed using IBM SPSS version 24.0 software (SPSS, Inc., Chicago, IL, USA). Results: Surgical technique includes mitral valve repair or replacement through right lateral mini-thoracotomy, through a small 5-7cm incision in the 4th–5th right intercostal space under direct vision Seldinger technique under transesophageal echocardiogram guidance is used for cannulation, first 3 cases of MIMVS was performed with 2 venous cannulas – one percutaneous jugular cannula and femoral one, 8 cases underwent single two-stage femoral venous cannulation for venous drainage, femoral arterial cannulation and vacuum assisted cardiopulmonary by-pass(CPB). Conclusion: Minimal-invasive mitral valve surgery is as safe as the standard approach and allows faster recovery with a shorter length of hospitalization, resulting in decreased healthcare costs. We need a more extensive study to confirm the other advantages, but minimal-invasive should be pushed to become a standard approach for mitral valve surgery. An adequate learning curve is mandatory for all the operative teams to achieve all the benefits for the patients.

Innovative use of a 3-Fr microcatheter for precision guidewire placement with digital single-operator cholangioscopy for pancreaticobiliary drainage (with video)

Biliary and pancreatic tract stenosis are hallmark symptoms in pancreaticobiliary diseases, transcending malignancy. Endoscopic techniques are pivotal for biliary/pancreatic drainage; however, challenging scenarios arise when attempting to pass a guidewire (GW) through obstruction. Cholangioscopy-assisted GW placement has proven valuable, but challenges persist in its execution, particularly in maneuvering the GW through cholangioscopy. Therefore, we explored the integration of a 3-Fr microcatheter into cholangioscopy with the aim of enhancing direct visualization and offering a super-selective approach. When GW manipulation under a digital single-operator cholangioscope (D-SOC) guidance was still unsuccessful in a resistant obstruction, the 3-Fr microcatheter was introduced. This technique was performed in 42 individuals for 37 biliary and 5 pancreatic duct drainages, among which there were 19 malignant, 18 benign, and 4 anastomotic obstructions. In all patients, contrast-filled cholangiography in the target area couldn’t be achieved at the pre-microcatheter insertion stage due to obstruction. The technical success rate was 85.7% overall, 89.5% in malignant strictures, 84.2% in benign strictures, and 75.0% in anastomotic obstructions, resulting in a clinical success rate of 78.6%. The use of a 3-Fr microcatheter appears effective for endoscopic drainage performed for obstruction. This technique could pave the way for improved outcomes in patients with pancreaticobiliary diseases.

A Randomized Non-Inferiority Clinical Trial of 14Fr Thal versus 28Fr Tube Thoracostomy for Traumatic Hemothorax.

The traditional treatment of traumatic hemothorax (HTX) is large bore chest tubes (CT) ≥28Fr. Recent evidence shows 14Fr pigtail catheters are as effective in drainage of HTX as larger CT. However, this has not been shown in 14Fr Thal tubes, a straight chest tube placed utilizing Seldinger technique. A single center, prospective randomized controlled trial was performed at an ACS verified Level 1 trauma center comparing 14Fr Thal CT (14CT) to 28Fr CT (28CT) between May 2017 and September 2021. The primary outcome was failure of drainage of hemothorax requiring additional intervention. Secondary outcomes included duration of chest tube placement, length of stay, tube-specific complications, and 90-day hospital readmission. Farrington-Manning approach was used for non-inferiority tests. Wilcoxon 2-samples test or t test was used for continuous variables, and Pearson chi-square or Fisher exact test was used for categorical variables. 109 patients were included in the randomized trial. There were 54 patients in the 14CT cohort, and 55 patients in the 28CT cohort. The primary outcome of drainage failure was similar between groups (8.3% 14CT vs 3.9% 28CT). Using a 15% non-inferiority margin 14CT is non-inferior to 28CT. No differences were identified in secondary outcomes. 14Fr Thal tubes have similar efficacy in drainage of traumatic hemothorax when compared with 28Fr chest tubes with similar complication rates (NCT03167723).

Recovery model for minimally invasive central cannulation, cardiopulmonary bypass, and cardioplegic arrest in quadrupeds.

Objectives: Sternotomy is rarely performed for veterinary therapeutic or recovery models in quadrupeds because of difficulties with breathing, ambulation, and pain control. Central cannulation for cardiopulmonary bypass (CPB) is infrequent and typically performed through full thoracotomies. Experienced clinical surgeons and perfusionists should provide guidance for new therapeutic interventions and translational research. We sought to develop, validate, and detail a contemporary model for minimally-invasive central cannulation, CPB, and cardioplegic arrest. Methods: After induction of anesthesia and sterile preparation, a right second-interspace parasternal mini-thoracotomy was performed, the ascending aorta was cannulated using Seldinger technique, and a cardioplegia needle was placed. A dual-stage cannula was introduced through the right atrial appendage and CPB commenced. The aorta was clamped and Buckberg 4:1 induction cardioplegia was administered. Arrest was maintained for 30minutes. CPB was discontinued after 2hours and the great vessels were decannulated. Hemostasis was achieved and the wound was closed. Initial recovery was accomplished in intensive care with subsequent transfer to the vivarium.Results: Ten consecutive Yorkshire swine (45 ± 5kg) were minimally invasively placed on CPB including cardioplegic arrest using central cannulation through a right parasternal mini-thoracotomy. There was no operative or late mortality. Morbidity appeared minimal. Planned euthanasia and scheduled necropsy were performed to exclude clinically-occult major complications. None were identified. Following initial supervision, veterinary and resident surgeons completed the procedures autonomously with excellent results.Conclusion: The described protocols should facilitate safe veterinary cardiac surgical care and humane translational research.

Proof of concept testing of a vascular closure device for use in fetal surgery

Objective Prior clinical findings have demonstrated that maternal laparotomy with trans-amniotic trans-uterine suturing of the fetoscopic port site during in utero myelomeningocele repair reduces the risk of membrane rupture. However, due to laparotomy-associated morbidity, we aimed to explore the feasibility of using a vascular closure device for percutaneous trans-amniotic trans-uterine suturing. Methods This IRB and IACUC-exempt study utilized 2 strategies for proof-of-concept testing of using the Abbott Perclose™ ProStyle™ Device for suture placement; 1. Ultrasound guided application on a high fidelity maternal abdominal uterus model used for fetal procedures and 2. Placement under direct visualization with sheep undergoing cesarean delivery for other research purposes. In the high-fidelity uterus model, the Abbott Perclose™ ProStyle™ device was used to place a transuterine/transamniotic stitch with accompanying video recording of the approach (https://go.screenpal.com/watch/cZfhoDVsYvW password: perclose). Regarding the second approach, at the time of a cesarean section, 12 French Checkflo® cannulas were inserted into the sheep amniotic space via different approaches: (1) Seldinger technique, (2) Seldinger technique insertion of Checkflo® cannula and subsequent use of the Abbott Perclose™ ProStyle™ device to suture the port site after check flow removal, (3) Abbott Perclose™ ProStyle™ device utilized in what is described as a “pre-close” technique, where prior to cannula placement, trans-uterine trans-amniotic stitches are placed followed by the insertion of a 12 French Checkflo® cannula over the same guidewire. Samples of the sutured uterine wall were sent to pathology and H&E staining was performed to assess uterine hole closure and amnion-to-uterus fixation. Results The high-fidelity model confirmed that the Perclose™ ProStyle™ Device was easily visualized by ultrasound and suture deployment was without complication. In the animal model, the Perclose™ ProStyle™ device effectively sutured the amnion to the uterus in both the pre- and post-close approach. The pre-close technique achieved better amnion-to-uterus approximation and more appropriate uterine hole closure. H&E staining revealed that without suturing, amnion separation from the chorion layer occurred, and the uterine hole persisted. The post-close technique showed partial connection between the amnion and chorion, but inadequate uterine hole closure with amnion shift into the defect. Optimal closure, with secure amnion-to-chorion fixation and uterine closure, was achieved through the pre-close technique. Conclusion The Abbott Perclose™ ProStyle™ Device seems to be a feasible device for use of uterine port closure in maternal-fetal surgery, larger animal studies with mid-pregnancy application are needed to further validate or refute these findings.

Intravascular ultrasound-guided reentry wiring with tip-detection technique for chronic total occlusion of lower extremity artery disease

BackgroundEndovascular therapy is an effective method for revascularization in lower extremity artery disease, but treating chronic total occlusion (CTO) remains challenging. This is particularly true for patients with severe calcification, poor run-off in below-the-knee arteries, or limited access sites, where even guidewire (GW) passage can be difficult and bidirectional approaches are often not feasible. The tip-detection (TD) method has been reported as a useful technique in coronary artery CTO interventions, allowing real-time visualization of the GW tip direction. Here, we applied the TD technique for peripheral CTO intervention.Case presentationCase 1 involved a 71-year-old man with a right toe ulcer. Angiography revealed total occlusion from the right anterior tibial artery (ATA) to the proximal dorsalis pedis artery. While attempting IVUS-guided parallel wiring, the GW could not advance through the intraplaque route because of severe calcification. We intentionally advanced the GW and IVUS into the subintimal space of the ATA to bypass the calcified lesion and performed IVUS-guided reentry using the TD technique in the distal ATA, where calcification was less severe. The second GW successfully passed through the intraplaque of the distal ATA and into the true lumen of the dorsalis pedis artery. Case 2 involved a 60-year-old man with bilateral intermittent claudication. Angiography revealed severe stenosis of the right common iliac artery (CIA) and CTO of the left CIA. Because of anatomical limitations and access site challenges, the antegrade approach for the left CIA was unsuccessful, and retrograde intraluminal wiring was difficult because of flexion and calcification. We advanced the GW and IVUS into the subintimal space and performed IVUS-guided reentry using the TD technique to access the true lumen of the proximal CIA. Finally, bilateral VBX stent grafts were implanted using the kissing stent technique.ConclusionsIVUS-guided reentry wiring with the TD technique may offer a useful solution for passing complex peripheral CTO lesions in cases where only a uni-directional approach is feasible.

INTRA-ARTERIAL MIGRATION OF A BLUNT GUIDEWIRE DURING FEMORAL VENOUS CATHETERIZATION: A CLINICAL CASE REPORT

The use of a central venous catheter in an intensive care unit is a common practice. The femoral line is the emergency venous access of choice because it is quickly accessible and easily identifiable by the operator. However, the complications associated with this procedure remain quite considerable. The accidental migration of the guidewire during the Seldinger technique is exceptional but potentially dangerous complications given the risk of vascular and cardiac perforation. We report a rare case of an accidental intra-arterial femoral migration of a blunt guidewire when the venous central line passed mistakenly over the guidewire in the femoral artery. The removal of the guidewire by interventional radiology remains the solution of choice in such a situation, which could not be achieve due to the impossibility of moving the patient to radiology service because of her unstable hemodynamic conditions.

Open Seldinger Technique for Peripheral Cannulation Strategy for Minimally Invasive Cardiac Surgery

Open Seldinger Technique for Peripheral Cannulation Strategy for Minimally Invasive Cardiac Surgery

Transradial Stent Angioplasty Using Double Guide Wires for Severe Stenosis of Vertebral Artery Ostium at a Lower Location

To investigate the effect and safety of transradial stent angioplasty using double guide wires for severe stenosis of vertebral artery ostium at a lower location. Patients with severe stenosis of the vertebral artery ostium at a lower location treated with transradial stent angioplasty were retrospectively enrolled. All the clinical and endovascular treatment data were analyzed. Thirty-nine patients were enrolled. A low location of the vertebral artery ostium was present in 33 (84.6%) patients and an ultra-low location in 6 (15.4%). Transradial stent angioplasty was performed in all patients. In one patient who had a tortuous radial artery, the transradial access was failed. In the other 38 (97.4%) patients, transradial stent angioplasty was all successful. The sharp angle formed between the vertebral artery and the subclavian artery was significantly (P < 0.0001) increased from 15° to 65° (36° ± 11°) before to 70-125° (90° ± 17°) after insertion of a support guide wire. No damage was found in all support guide wires. Thirty-nine stents were deployed, and the preoperative stenosis rate of 70%-98% (85% ± 13%) was significantly (P < 0.0001) decreased to 0-25% (16%) immediately after stenting. Six-12months after surgery, 29 (74.4% or 29/39) patients were followed up with imaging, and 9 (31.0%) patients experienced in-stent restenosis, with endovascular retreatment being performed in 3 (33.3%) patients. Transradial stent angioplasty using double guide wires is safe and effective for the treatment of severe stenosis of the vertebral artery ostium at a lower location even though more studies are necessary to confirm this.

Safety and effectiveness of ultrasound-guided percutaneous versus open brachial artery access: results of the multicenter prospective ARCHIBAL study Percutaneous/open brachial artery access

Although brachial access (BA) has become increasingly used in percutaneous endovascular procedures, results from head-to-head comparisons between open brachial access (OBA) and ultrasound-guided percutaneous brachial access (PBA) are limited in the literature. The objective of our multicenter, prospective, noninterventional ARCHIv BrachiAL study was to compare the safety and efficacy of OBA and PBA to perform peripheral arterial interventions. From July 2019 to January 2021, all patients needing peripheral endovascular procedures with brachial artery access were consecutively included in the study by 15 surgeons in 14 centers. Procedures were done with 4F-8F (French gauge) introducer sheaths. Arterial closure was done by conventional arterial sutures for OBA and compression or vascular closure devices for PBA. The primary endpoint was the rate of access site complications occurring up to 30days postoperatively. Secondary endpoints were the occurrence of adverse events and the overall rates of clinical success of BA cannulation and technical success. Among the 251 included patients (mean age, 69.9years; males 70.5%), 122 (48.6%) had an OBA and 129 (51.4%) had a PBA, without significant differences in baseline demographic and clinical characteristics. 38.6% of the patients had the procedure for more than one indication. Clinical success was achieved in all patients and technical success in 244 patients (97.2%). No death, cerebral, cardiac, or embolic complications were reported. Access site complications (primarily hematomas) were significantly (P=0.02) more frequent in the PBA (8/129; 6.2%) than the OBA group (1/122; 0.8%) or when using introducer sheaths >6F for OBA or vascular closure devices for PBA. Our prospective study confirmed the safety and effectiveness of BA and showed the benefit in terms of safety of OBA versus PBA even when PBA was ultrasound-guided and performed by trained surgeons. It encourages the use of OBA and ultrasound guidance when using PBA. Large and/or randomized studies should be performed to support these results.

Abstract 123: Microcatheter Guided Blood Patch for Treatment of Cervical Cerebrospinal Fluid Leak

Introduction Epidural blood patch (EBP) remains the therapy of choice in treating refractory headaches due to low cerebrospinal fluid (CSF) pressure. If a CSF leakage source is detected, targeted fluoroscopy‐guided EBP should be considered over non‐targeted (blind) technique. Cervical CSF leakage can be challenging to treat with targeted EBP given the high‐risk site. Methods We present a case of microcatheter‐guided targeted cervical EBP. A 44‐year‐old male with no significant past medical history presented with 4 weeks history of refractory headaches upon sitting and standing up. MRI brain showed bilateral subdural hygromas alongside diffuse pachymeningeal enhancement. A spinal myelogram showed evidence of a CSF leak at C4‐C5 level. Results The patient was placed in prone position to access the space between the spinous processes of L2 and L3 vertebrae. A 14‐gauge 6‐inch needle was then inserted at the interlaminar space, and CSF was observed. The needle was then exchanged over a microwire with a 4F introducer sheath under fluoroscopic guidance. Once the sheath was confirmed to be in the epidural space, a 0.014‐inch microwire was introduced and advanced into the cervical region. A 0.021‐inch ID microcatheter was advanced over the wire and parked at the C5‐C6 level. Then, 10cc of autologous blood mixed with Omni opaque contrast was injected through the microcatheter into the epidural space at the C5‐C6 level. Dyna CT demonstrated blood layering in the epidural space both anteriorly and posteriorly to the Dural sac, covering the entirety of the cervical region. Patient reported an instant relief of headache during the EBP and continued to be headache‐free by the time he was discharged. Conclusion We illustrated fluoroscopy‐guided microcatheter‐assisted EBP as an effective treatment of intracranial hypotension due to cervical CSF leak.

Feasibility and Safety of the Distal Transradial Access for Noncardiac Intervention

Distal transradial access through the anatomical snuffbox has been highlighted in recent research because it provides extremely low invasiveness. It has demonstrated its feasibility and safety for cardiac intervention. However, its characteristics for noncardiac intervention are not well known. This report aims to demonstrate the feasibility and safety of noncardiac intervention with distal transradial access, with identification of practical devices for procedures. This retrospective study was conducted from May 2021 to December 2021 with consecutive patients who underwent distal transradial access for noncardiac intervention. This study analyzed patient physical information, procedural details, technical success rates, and distal transradial access-associated complications. Nine patients (7 females, 2 males) aged 48-69 years (median: 57) were enrolled in this study. This study assessed 11 noncardiac procedures, such as transarterial infusion chemotherapy for head and neck malignancies (n = 4), embolization of visceral artery aneurysm (n = 2), embolization of renal angiomyolipoma (n = 2), percutaneous transluminal renal angioplasty (n = 1), bronchial artery embolization (n = 1), and diagnostic angiography (n = 1). The introducer sheath size was 4-6 French. Catheters respectively having nine tip shapes were used. Reverse curve catheters were used only in two cervical procedures. The technical success rate was 91% (10/11). Of the 11 procedures, only 1 (bronchial artery embolization) required conversion to transfemoral access. There was no complication associated with distal transradial access. Ultrasound evaluation after treatments revealed patent radial arteries in all patients. Results revealed that distal transradial access is feasible with commercially available catheters and is safe for various noncardiac interventions.

Abstract 431: The Use of Hydrophilic‐Coated Introducer Sheaths for Reducing Radial Artery Spasm During Transradial Procedures: A Systematic Review and Meta‐Analysis

Abstract 431: The Use of Hydrophilic‐Coated Introducer Sheaths for Reducing Radial Artery Spasm During Transradial Procedures: A Systematic Review and Meta‐Analysis