Guidewire Insertion Research Articles

Wire-in-needle versus conventional syringe-on-needle technique for ultrasound-guided central venous catheter insertion in the internal jugular vein: the WIN randomized trial.

There are different techniques for ultrasound-guided central venous catheter (CVC) insertion. When using the conventional syringe-on-needle technique, the syringe needs to be removed from the needle after venous puncture to pass the guidewire through the needle into the vein. When, alternatively, using the wire-in-needle technique, the needle is preloaded with the guidewire, and the guidewire-after venous puncture-is advanced into the vein under real-time ultrasound guidance. We tested the hypothesis that the wire-in-needle technique reduces the time to successful guidewire insertion in the internal jugular vein compared with the syringe-on-needle technique in adults. We randomized 250 patients to the wire-in-needle or syringe-on-needle technique. Our primary endpoint was the time to successful guidewire insertion in the internal jugular vein. Two hundred and thirty eight patients were analyzed. The median (25th percentile, 75th percentile) time to successful guidewire insertion was 22 (16, 38) s in patients assigned to the wire-in-needle technique and 25 (19, 34) s in patients assigned to the syringe-on-needle technique (estimated location shift: 2s; 95%-confidence-interval: - 1 to 5s, p = 0.165). CVC insertion was successful on the first attempt in 103/116 patients (89%) assigned to the wire-in-needle technique and in 113/122 patients (93%) assigned to the syringe-on-needle technique. CVC insertion-related complications occurred in 8/116 patients (7%) assigned to the wire-in-needle technique and 19/122 patients (16%) assigned to the syringe-on-needle technique. The wire-in-needle technique-compared with the syringe-on-needle technique-did not reduce the time to successful guidewire insertion in the internal jugular vein. Clinicians can consider either technique for ultrasound-guided CVC insertion in adults.

Modified pendulum osteotomy to correct severe tibial varus deformity

Correction of asevere tibial varus deformity near the knee joint with only aslight influence on leg length and patella height. Medial osteoarthritis and/or cartilage damage with asevere varus deformity > 10° with amedial proximal tibial angle (MPTA) < 80°. Femoral varus deformity with lateral distal femoral angle > 91°, severe lateral cartilage damage, lateral osteoarthritis, lateral meniscus loss. Skin incision of approx. 8-10 cm between the tibial tuberosity and the head of the fibula. Exploration of the peroneal nerve. Detachment of the extensors. Insertion of an obliquely ascending guidewire ending approximately 10 mm below the medial articular surface. Insertion of asecond guidewire. This aims at the middle of the first wire (hemi wedge). Check the wire position under fluoroscopy. Osteotomy with an oscillating saw under cooling. Removal of the wedge and closure of the osteotomy. Percutaneous needling of the medial collateral ligament with acannula to carefully lengthen the ligament. Check the correction result with ametal rod. Osteosynthesis with lateral angle-stable plate. Partial weight-bearing with 10 kg for 6weeks postoperatively, free range of motion. Reports from the literature show that good clinical results can be achieved with this procedure for severe tibial varus deformities. Postoperative leg length discrepancies are less common with this procedure than with laterally closing osteotomy.

A generalized reduced-order model for trans-stenotic pressure drop with and without a guidewire

Guidewire-based pressure measurement is essential for diagnosing coronary artery disease. However, the impact of the guidewire on local hemodynamics and diagnostic outcomes is not fully understood. In this study, we propose a generalized reduced-order model (ROM) to accurately predict the trans-stenotic pressure drop in arteries. A key advantage of this model is that the viscous term does not rely on empirical parameters, making it applicable to both scenarios with and without guidewire insertion, and across varying stenosis severities. The proposed model demonstrates good accuracy compared to 3D idealized numerical models, achieving an average prediction error of 3.61% for cases without a guidewire and 4.53% for cases with a guidewire. Furthermore, when applied to a patient-specific model, it achieves comparable or better results than previously published ROMs. Finally, this ROM is employed to investigate the shifting relative importance of different components of the trans-stenotic pressure drop at various stenosis severities, and to provide further insights into the guidewire’s influence on FFR measurements.

Towards a reduced order model for EVAR planning and intra-operative navigation

IntroductionThe pre-operative planning and intra-operative navigation of the endovascular aneurysm repair (EVAR) procedure are currently challenged by the aortic deformations that occur due to the insertion of a stiff guidewire. Hence, a fast and accurate predictive tool may help clinicians in the decision-making process and during surgical navigation, potentially reducing the radiations and contrast dose. To this aim, we generated a reduced order model (ROM) trained on parametric finite element simulations of the aortic wall-guidewire interaction. MethodA Design of Experiments (DOE) consisting of 300 scenarios was created spanning over seven parameters. Radial basis functions were used to achieve a morphological parametrization of the aortic geometry. The ROM was built using 200 scenarios for training and the remaining 100 for validation. ResultsThe developed ROM estimated the displacement of aortic nodes with a relative error below 5.5% for all the considered validation cases. From a preliminary analysis, the aortic elasticity, the stiffness of the guidewire and the tortuosity of the cannulated iliac artery proved to be the most influential parameters. ConclusionsOnce built, the ROM provided almost real-time and accurate estimations of the guidewire-induced aortic displacement field, thus potentially being a promising pre- and intra-operative tool for clinicians.

Progression of Femoral Osteolytic Metastases after Intramedullary Nailing and Subsequent Salvage Techniques.

Intramedullary nailing insertion from the proximal-to-distal femur is frequently performed for impending and complete pathological femur fractures due to osteolytic metastases. After nailing through cancer-laden bone, residual chemotherapy- and/or radiation-resistant tumor may progress. Progression of osteolysis risks future nail failure or pathological fractures. This study assesses the incidence of cancer progression following intramedullary nailing in a femur-only cohort and describes a percutaneous rod-retaining salvage technique. A single-institution, retrospective study was conducted to identify adult patients who underwent intramedullary nailing for femoral osteolytic lesions for complete or impending nail failure from 2016 to 2023. Progression was defined as enlargement of the pre-existing lesion and/or appearance of new lesions on radiographs. Surgical outcomes were assessed with a combined pain and functional score. A total of 113 patients (median age 66.8 years (IQR = 16.4); median follow-up 6.0 months (IQR = 14.5)) underwent intramedullary nailing. Sixteen patients (14.2%) exhibited post-nailing cancer progression. Pre- and postoperative radiation and chemotherapy did not decrease the odds of cancer progression. Three patients underwent initial open surgical salvage consisting of proximal femur replacement arthroplasty, and six patients did not receive salvage due to poor surgical candidacy or patient choice. Seven patients (median follow-up 10.7 months (IQR = 12.9)) received percutaneous salvage. In this group, pain and functional scores improved by 4.0 points (p = 0.0078) at two-week postoperative follow-up and 2.0 points (p = 0.0312) at the most recent follow-up (mean follow-up 13.0 ± 9.4 months). All three nonambulatory patients became ambulatory, and six patients were able to ambulate independently without walking aids. No major complications were reported 30 days postoperatively. Progression of femoral osteolytic metastases may occur following intramedullary nailing. Continued monitoring of the entire femur is needed to maintain improved functional status and to prevent catastrophic progression of pre-existing lesions or appearance of new lesions. In patients with more proximal metastases only, the customary practice of bringing a long nail from the proximal femur to distal metaphysis should be reconsidered. Furthermore, there is concern of mechanical transport of cancer cells during guide wire insertion, reaming, and rod insertion through cancer laden bone to cancer free distal bone.

Risk factors for pancreatitis after endoscopic retrograde cholangiopancreatography in children

To investigate the application of endoscopic retrograde cholangiopancreatography (ERCP) in children and the risk factors for post-ERCP pancreatitis (PEP). A retrospective analysis was conducted on the clinical data of 66 children, aged ≤16 years, who underwent ERCP for pancreaticobiliary diseases at the Gastrointestinal Endoscopy Center of the Second Affiliated Hospital of Kunming Medical University from September 2013 to September 2023. The incidence rate of PEP and the risk factors for the development of PEP were analyzed. A total of 78 ERCP procedures were performed on 66 children, with 5 diagnostic ERCPs, 69 therapeutic ERCPs, and 4 failed procedures. The success rate of ERCP operations was 95% (74/78). There were 17 cases of PEP in total, with an incidence rate of 22%. In the PEP group, the proportion of children with normal preoperative bilirubin and the proportion of guidewire insertion into the pancreatic duct during surgery were higher than in the non-PEP group (P<0.05). The multivariate logistic regression analysis showed that guidewire insertion into the pancreatic duct was an independent risk factor for PEP (P<0.05). With the increasing application of ERCP in children with pancreaticobiliary diseases, it is important to select an appropriate intubation technique during surgery to avoid blindly entering the guidewire into the pancreatic duct and reduce the occurrence of PEP.

Aortic roadmapping during EVAR: a combined FEM-EM tracking feasibility study.

Currently, the intra-operative visualization of vessels during endovascular aneurysm repair (EVAR) relies on contrast-based imaging modalities. Moreover, traditional image fusion techniques lack a continuous and automatic update of the vessel configuration, which changes due to the insertion of stiff guidewires. The purpose of this work is to develop and evaluate a novel approach to improve image fusion, that takes into account the deformations, combining electromagnetic (EM) tracking technology and finite element modeling (FEM). To assess whether EM tracking can improve the prediction of the numerical simulations, a patient-specific model of abdominal aorta was segmented and manufactured. A database of simulations with different insertion angles was created. Then, an ad hoc sensorized tool with three embedded EM sensors was designed, enabling tracking of the sensors' positions during the insertion phase. Finally, the corresponding cone beam computed tomography (CBCT) images were acquired and processed to obtain the ground truth aortic deformations of the manufactured model. Among the simulations in the database, the one minimizing the in silico versus in vitro discrepancy in terms of sensors' positions gave the most accurate aortic displacement results. The proposed approach suggests that the EM tracking technology could be used not only to follow the tool, but also to minimize the error in the predicted aortic roadmap, thus paving the way for a safer EVAR navigation.

Design and application of alaryngeal mask and monitoring device facilitating withdrawal of endotracheal tube

Percutaneous dilatational tracheostomy (PDT) is a surgical method for quickly establishing an artificial airway, which has been favored by clinicians because of its simple operation, small trauma and bedside operation. However, for patients with tracheal intubation in intensive care unit (ICU), the tip and balloon of the existing endotracheal tube will not only hinder percutaneous puncture, but also hinder insertion of guidewire and tracheotomy tube, and consequently affect the process of PDT. On the contrary, blind withdrawal of the existing endotracheal tube may cause the tracheal tube tipleave the glottis, leading to an emergency airway situation that endangers the patient's life. Therefore, the medical staff from intensive care medicine department of the First People's Hospital of Chenzhou designed a laryngeal mask and its monitoring device, which is convenient for withdrawal of endotracheal tube, and obtained the national utility model patent of China (patent number: ZL 2020 2 2795887.1). The device is composed of a laryngeal mask and a monitoring device. The laryngeal mask mainly includes a laryngeal mask body, a vent tube, a guidance tube and other components. The laryngeal mask body is mainly used to seal the throat and provide the air supply channel for the patient together with the ventilation tube. The main function of the guidance tube is to accommodate the tracheal tube and facilitate the withdrawal of the inserted tracheal tube. During percutaneous dilatation tracheotomy, this device can monitor the withdrawal of tracheal catheter in real time, and immediately ensure the airway patency of patients without re-intubation when the cuff of tracheal catheter exits the glottis. The utility model has the advantages of real-time monitoring, simple operation, safety and convenience, and is worthy of transformation and promotion.

A comparison of internal jugular vein cannulation versus supraclavicular brachiocephalic vein cannulation using ultrasound guidance

Background: Ultrasound has become the standard of care for the insertion of central venous catheters (CVCs) in the intensive care unit. With the introduction of ultrasonography in CVC insertion, there has been an improvement in the success rate and a dramatic decrease in the rate of complications. Aims and Objectives: The aim of this study was to compare the safety and ease of insertion of ultrasonically guided cannulation of the internal jugular vein (IJV) with that of the supraclavicular subclavian vein (SCV) in adult patients undergoing various surgical procedures. Materials and Methods: All the patients in whom central venous cannulation was planned were assigned to two groups. Group I underwent ultrasound-guided IJV while as Group II underwent cannulation ultrasound-guided SCV cannulation. A comparison was made between the two groups, of the success rates, durations of procedure, number of attempts at needle redirections, difficulties if any during insertion of guidewires, and the complications encountered. Results: The IJV group had a higher proportion of first-attempt success (93.2% versus 62.7%). The IJV group had a lesser incidence (3.2%) of complications such as guidewire progression and needle redirections compared with SCV (15.2%). The frequency of adverse events did not differ between the two study groups with an incidence in 3.2% in IJV group and 9.6% in the subclavian group. Higher first-attempt success rates and fewer procedural complications were seen with ultrasound-guided IJV. Conclusion: IJV central venous catheterization is an easier and less invasive and less risky procedure for patients.

Comparing short-axis versus long-axis ultrasound-guided techniques for internal jugular vein cannulation: A meta-analysis of clinical outcomes and safety.

Central venous access plays a crucial role in various clinical settings, and ultrasound guidance has become increasingly popular for improving its safety and success rates. The aim of this meta-analysis was to compare the short-axis (SAX) and long-axis (LAX) ultrasound-guided techniques for internal jugular vein (IJV) cannulation in terms of first needle pass success rate, number of cannulation attempts, access time, guidewire insertion time, posterior IJV wall puncture, arterial puncture, haematoma and catheter-related bloodstream infection. A comprehensive literature search was conducted, and randomised controlled trials (RCTs) comparing SAX and LAX techniques for IJV cannulation on adults were included. A total of 11 RCTs involving 1183 patients were included in the meta-analysis. The SAX technique demonstrated a significantly greater first needle pass success rate and faster IJV access time compared to the LAX technique. However, more posterior IJV wall puncture was significantly associated with the SAX technique. There was no significant difference between the two techniques in terms of number of cannulation attempts, guidewire insertion time, arterial puncture, haematoma and catheter-related bloodstream infection. This meta-analysis suggests that the SAX technique may have advantages over the LAX technique in terms of first needle pass success rate and potentially reducing cannulation attempts and access time. However, the occurrence of posterior IJV wall puncture raises concerns. The decision on the choice of technique should be based on individual patient factors and operator proficiency.

Research on Locating Device for the Entry Point of Intramedullary Nail Based on Inertial Navigation

To introduce a locating device for the entry point of intramedullary nail based on the inertial navigation technology, which utilizes multi-dimensional angle information to assist in rapid and accurate positioning of the ideal direction of femoral anterograde intramedullary nails' entry point, and to verify its clinical value through clinical tests. After matching the locating module with the developing board, which are the two components of the locating device, they were placed on the skin surface of the proximal femur of the affected side. Anteroposterior fluoroscopy was performed. The developing angle corresponding to the ideal direction of entry point was selected based on the X-ray image, and then the yaw angle of the locating module was reset to zero. After resetting, the locating module was combined with the surgical instrument to guide the insertion angle of the guide wire. The ideal direction of entry point was accurately located based on the angle guidance. By setting up an experimental group and a control group for clinical surgical operations, the number of guide wire insertion times, surgical time, fluoroscopy frequency, and intraoperative blood loss with or without the locating device was recorded. Compared to the control group, the experimental group showed significant improvement in the number of guide wire insertion times, surgical time, fluoroscopy frequency, and intraoperative blood loss, with a statistically significant difference (P<0.01). The locating device can assist doctors in quickly locating the entry point of intramedullary nail, effectively reducing the fluoroscopy frequency and surgical time by improving the success rate of the guide wire insertion with one shot, improving surgical efficiency, and possessing certain clinical value.

Subclavian Vein Cannulation via Supraclavicular or Infraclavicular Route Which is Better? A Prospective Randomized Controlled Trial.

The subclavian vein is frequently cannulated using ultrasound. There are two techniques of subclavian vein catheterization (SVC): Supraclavicular (SC) and infraclavicular (IC). Though the IC route is often preferred, the SC approach offers several distinct advantages. This study was planned to compare the technique of SVC using SC and IC approaches in terms of catheterization technique and complications in elective surgeries in adults. Sixty American Society of Anesthesiologists (ASA) 1, 2, or 3 adult patients posted for elective surgeries under general anesthesia were recruited. Patients were divided into SC or IC groups randomly. Right-sided subclavian vein was cannulated in both the groups (n = 30). Visualization time, Likert scale, subclavian vein diameter, skin-to-subclavian vein depth, number of attempts, puncture time, ease of guidewire insertion, catheter insertion time, and total procedural time were observed. A comparison of complications for each approach was noted. Total procedural time, time to visualization of the subclavian vein, and puncture time was lower for group SC and higher for group IC. Catheter insertion time was higher with the IC approach than with the SC approach. Better ultrasound view scores were seen in group SC than in group IC. The first attempt success rate was higher in group SC than in group IC. Comparatively, lower complications both during and after the procedure were noted in the SC approach than the IC approach. Ultrasonography (USG) guidance guided SC approach to access the subclavian vein is quicker, relatively secure, and a better technique than the IC approach. Additionally, the SC approach is associated with comparatively fewer immediate and delayed complications. Jaiswal P, Saini S, Chhabra PH. Subclavian Vein Cannulation via Supraclavicular or Infraclavicular Route Which is Better? A Prospective Randomized Controlled Trial. Indian J Crit Care Med 2024;28(4):375-380.

Balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography for hepatolithiasis in patients with hepaticojejunostomy.

Balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) is an emerging procedure for pancreatobiliary diseases in patients with surgically altered anatomy. However, data on BE-ERCP for hepatolithiasis after hepaticojejunostomy (HJS) are still limited. Stone removal success, adverse events and recurrence were retrospectively studied in consecutive patients who underwent BE-ERCP for hepatolithiasis after HJS between January 2011 and October 2022. Subgroup analysis was performed to compare clinical outcomes between patients who had undergone HJS over 10 years before (past HJS group) and within 10 years (recent HJS group). A total of 131 patients were included; 39% had undergone HJS for malignancy and 32% for congenital biliary dilation. Scope insertion and complete stone removal were successful in 89% and 73%, respectively. Early adverse events were observed in 9.9%. Four patients (3.1%) developed gastrointestinal perforation but could be managed conservatively. Hepatolithiasis recurrence rate was 17%, 20% and 31% in 1-year, 3-year, and 5-year after complete stone removal. The past HJS group was the only risk factor for failed stone removal (odds ratio 10.4, 95% confidence interval 2.99-36.5) in the multivariable analysis. Failed scope insertion (20%) and failed guidewire or device insertion to the bile duct (22%) were two major reasons for failed stone removal in the past HJS group. BE-ERCP for hepatolithiasis was effective and safe in cases with HJS but the complete stone removal rate was low in the past HJS group. Recurrent hepatolithiasis was common and careful follow up study is needed even after complete stone removal.

A novel method of bilateral biliary decompression by EUS-guided hepaticogastrostomy with bridging stenting using the partial stent-in-stent method for reintervention of multiple metal stent failure

Video 1A novel method of bilateral biliary decompression by EUS-guided hepaticogastrostomy with bridging stenting using the partial stent-in-stent method for reintervention of multiple metal stent failure.We report a case in which anterior and posterior drainage was performed using the partial stent-in-stent method via the transpapillary approach. The patient had a bismuth type IV biliary obstruction, but only the right hepatic lobe was drained due to obstruction of the left portal vein. For the recurrent stent dysfunction, the patient underwent placement of a plastic stent within an uncovered self-expanding metal stent to correct stent dysfunction. A 7F plastic stent inside a metal stent is shown.The patient later experienced stent failure and jaundice due to tumor progression and was admitted for plastic stent replacement. Neither imaging results nor symptoms suggested duodenal stenosis. The transpapillary approach was attempted first but was unsuccessful. Duodenoscopy was challenging to perform because of duodenal stenosis. Fluoroscopy confirmed the duodenal stenosis. The plastic stent was extracted using an upper endoscope. Multiple uncovered metal stents are shown (1 stent in the anterior bile duct and 2 stents in the posterior bile duct). Jaundice did not resolve despite plastic stent removal.The patient refused to undergo percutaneous biliary drainage, so a decision was made to perform an EUS-guided hepaticogastrostomy (HGS) instead. The left bile duct was observed in the stomach. The left bile duct was punctured with a 19-gauge FNA needle. A 0.025-inch hydrophilic guidewire was directed into the left bile duct. Enhancement of the bile duct showing malignant hilar biliary obstruction (bismuth IV) is seen. Insertion of the guide wire into the posterior bile duct is shown.The stent mesh was then dilated using a balloon dilator. However, there was difficulty inserting the catheter. Additional dilation was performed using a spiral dilator. This instrument is a tapered tip dilator that fits into 0.025-inch guidewires and is expandable to 7F. Insertion of a second guidewire with a larger caliber was done to straighten the bile duct and help stabilize stent insertion. A 0.035-inch hydrophilic guidewire into the posterior bile duct using a double-lumen cannula and insertion of a 0.025-inch hydrophilic guidewire into the anterior bile duct are shown.The stent mesh was then dilated using a spiral dilator. A metal stent was placed through the anterior bile duct at a steep angle. Insertion and deployment of the first uncovered self-expanding metal stent (8× 60mm) from the anterior bile duct into the left bile duct is shown. Multiple metal stents were implanted into the hilar area, and the new stent was placed using the partial stent-in-stent method to prevent overexpansion. Guidewire seeking the posterior bile duct from inside the deployed stent through the stent mesh is shown.The stent mesh was then dilated using a balloon dilator. Insertion and deployment of an uncovered self-expanding metal stent (8× 60mm) from the posterior bile duct to the left bile duct using the partial stent-in-stent method is shown. Enhancement of the bile duct shows drainage from the right bile duct. The fistula of the HGS was only dilated with the spiral dilator. The risk of bile leakage was low, so we decided to implant a plastic stent. A 7F× 15-cm plastic stent was placed from the posterior bile duct into the stomach. Anterior and posterior segment drainage by EUS-HGS with bridging stenting using the partial stent-in-stent method is shown, with left segment drainage by EUS-HGS with the plastic stent.We performed EUS-HGS on a patient with multiple metal stents in place. There were no adverse events, and total bilirubin levels were reduced by more than half within 2 weeks. Six months have passed without stent dysfunction.

Impact of Pressure Guidewire on Model-Based FFR Prediction

IntroductionFractional Flow Reserve (FFR) is used to characterize the functional significance of coronary artery stenoses. FFR is assessed under hyperemic conditions by invasive measurements of trans-stenotic pressure thanks to the insertion of a pressure guidewire across the coronary stenosis during catheterization. In order to overcome the potential risk related to the invasive procedure and to reduce the associated high costs, three-dimensional blood flow simulations that incorporate clinical imaging and patient-specific characteristics have been proposed.PurposeMost CCTA-derived FFR models neglect the potential influence of the guidewire on computed flow and pressure. Here we aim to quantify the impact of taking into account the presence of the guidewire in model-based FFR prediction.MethodsWe adopt a CCTA-derived FFR model and perform simulations with and without the guidewire for 18 patients with suspected stable CAD.ResultsPresented results show that the presence of the guidewire leads to a tendency to predict a lower FFR value. The FFR reduction is prominent in cases of severe stenoses, while the influence of the guidewire is less pronounced in cases of moderate stenoses.ConclusionFrom a clinical decision-making point of view, including of the pressure guidewire is potentially relevant only for intermediate stenosis cases.

Application of Freehand 3D Ultrasound Guidance in Percutaneous Transluminal Angioplasty for Autogenous Arteriovenous Fistula Stenosis

Objective: Using freehand three dimensional (3D) ultrasound imaging to evaluate arteriovenous fistula stenosis. Comparing the value of freehand 3D ultrasound and Doppler ultrasound in the application of percutaneous transluminal angioplasty (PTA) treatment for stenosis of an arteriovenous fistula. Methods: A retrospective analysis was conducted on 34 patients with arteriovenous fistula (AVF) stenosis who were treated at the 903RD Hospital of PLA and the Kidney Center of Zhejiang Provincial People's Hospital from August 2021 to August 2022. Based on the different types of surgical assistance, the patients were divided into two groups: the Doppler ultrasound group (Group A, n = 17) and the freehand 3D ultrasound imaging group (Group B, n = 17). Freehand 3D ultrasound and Doppler ultrasound were used to assess the narrowing of arteriovenous fistulas, and images and relevant data were collected before and after the PTA procedure. The differences in the time of puncture and sheath placement, guidewire insertion time, the duration of the procedure, complications, and methods to measure stenosis were compared between the two groups of patients, as well as the technical success rate, the initial patency rate, and the primary patency rates at 1, 3, 6 and 9 months post-surgery. This study discusses the clinical efficacy of using these two types of ultrasound to assist in the PTA treatment of arteriovenous fistula stenosis. Results: The differences in baseline demographics between the conventional ultrasound group (Group A) and the 3D ultrasound group (Group B) were not statistically significant (p &gt; 0.05). The intraoperative guidewire insertion time (4.647 ± 1.347 min vs. 2.824 ± 0.326 min) and the operating times (75.941 ± 7.557 min vs. 59.824 ± 8.175 min) between the two groups were statistically significant (t = 2.788, 3.069, p &lt; 0.01). The technical success rates for the two groups were 94.1% vs. 100%, not statistically significant (t = 1.03, p = 0.31). The first-time patency rates were 88.2% vs. 94.1%, with no statistically significant difference (t = 0.366, p = 0.545). No complications occurred in Group A, while one case of hematoma occurred postoperatively in Group B, with an incidence of 5.9% (1/17), which was not statistically significant (t = 1.03, p &gt; 0.05). Comparing the primary patency rates at 1, 3, 6 and 9 months post-surgery between Groups A and B, there were no statistically significant differences (p &gt; 0.05). However, the patency rates at different time points for Group B were consistently higher than Group A (94.1%, 82.4%, 82.4%, 82.4% vs. 88.2%, 82.4%, 76.5%, 76.5%). Conclusion: Freehand 3D ultrasound imaging can provide more intuitive, high-resolution, and high-definition three-dimensional images, clearly defining the lesion site and vascular structures. Its accuracy in assessing complications of arteriovenous fistulas is similar to that with conventional ultrasound. When used as an adjunct to PTA treatment, its efficacy is equivalent. It can significantly reduce guidewire insertion time and operation time, decrease postoperative recovery time, and alleviate the patients' concerns regarding surgical risks. It can be considered a new method for diagnosing, treating, and patients with AVF stenosis.

The Study of the Feasibility of Ultrasound-guided Catheterization of the Right Brachiocephalic Vein in Adult Patients: A Prospective Observational Study.

The brachiocephalic vein (BCV) is a feasible option for central venous access in the pediatric population and is rapidly developing as an alternative site for insertion of the central line in young children with faster insertion times, fewer attempts, and lower rates of complications. However, studies demonstrating the feasibility of BCV catheterization in adult patients are insufficient. The current study sought to assess the safety and effectiveness of ultrasound-guided supraclavicular right BCV cannulations in adults. A linear array Ultrasound (US) probe was used to obtain a longitudinal picture of the BCV beginning at the junction of the internal jugular vein and the subclavian vein in the supraclavicular region. Under US supervision, the needle was guided into the BCV using the in-plane approach. A prospective study was performed on 80 adult patients scheduled for elective and emergency operative procedures under general anesthesia requiring a central venous catheter (CVC). Success rates and complications that occurred during catheter insertion were analyzed. CVC placement was successful in all adults. The procedure was successful at the first attempt in 74 cases (92.5%) and after 2 attempts in six patients (7.5%). The time to guide wire insertion was 31.26 s (19-58 s), and catheter insertion took 88.44 s (63-145 s). The mean length of catheter insertion was 10.46 cm. No complications were noted. Ultrasound-guided supraclavicular BCV catheterization offers a new and safe method for central venous line catheterization in adults. However, larger trials and meta-analyses are needed to confirm these findings and evaluate the safety of this technique.

Effect of guidewire on the accuracy of trans-stenotic pressure measurement—A computational study

Accurate measurement of trans-stenotic pressure drop is vital for risk stratification in coronary artery disease. Currently, in vivo pressure measurement relies mostly on a pressure guidewire inserted into the artery, which inevitably alters local hemodynamics. To precisely assess the impact of guidewire insertion on the accuracy of pressure measurement, this study conducts numerical simulations with both an idealized straight-tube model and a patient-specific model. Results with and without a guidewire model are compared and analyzed. Results from the idealized model reveal that the insertion of a guidewire shifts velocity distribution, increases resistance, and amplifies the pressure drop across the stenosis. The patient-specific model also demonstrates that the guidewire causes non-negligible flow redistribution among the arterial branches, but the influence on pressure drop remains mostly localized. An analytical model for trans-stenotic pressure drop that takes the guidewire into consideration is also proposed and validated against the 3D simulation results. It is observed that the maximum relative error is around 3.0% in the patient-specific model, indicating the effectiveness of the analytical model in physiologically accurate settings. The proposed model can be used to align computed tomography-derived fractional flow reserve values with clinically recognized FFR standards established through guidewire measurements.

A Novel Dry Simulator Model for Learning Comprehensive Endoscopic Retrograde Cholangiopancreatography/Endoscopic Sphincterotomy Procedures while Minimizing Adverse Bleeding Events (with Video).

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) are essential skills for performing endoscopic cholangiopancreatic procedures. However, these procedures have a high incidence of adverse events, and current training predominantly relies on patient-based approaches. Herein, we aimed to develop an ERCP/EST simulator model to address the need for safer training alternatives, especially for learners with limited ERCP experience. The model was designed to facilitate the use of actual endoscopic devices, supporting learning objectives that align with the components of the validated Bethesda ERCP Skill Assessment Tool (BESAT). BESAT focuses on skills, such as papillary alignment, maintenance of duodenoscope position, gentle and efficient cannulation, controlled sphincterotomy in the correct trajectory, and guidewire manipulation. Thirty gastroenterology trainees used the simulator between May 2022 and March 2023, and their satisfaction was assessed using a visual analog scale (VAS) and pre- and post-training questionnaires. The novel simulator model comprised a disposable duodenal papillary section, suitable for incision with an electrosurgical knife, alongside washable upper gastrointestinal tract and bile duct sections for repeated use. The duodenal papillary section enabled reproduction of a realistic endoscope position and the adverse bleeding events due to improper incisions. The bile duct section allowed for the reproduction of fluoroscopic-like images, enabling learners to practice guidewire guidance and insertion of other devices. Following training, the median VAS score reflecting the expectation for model learning significantly increased from 69.5 (interquartile range [IQR]: 55.5-76.5) to 85.5 (IQR: 78.0-92.0) (p &lt; 0.01). All participants expressed a desire for repeated simulator training sessions. This innovative simulator could serve as a practical educational tool, particularly beneficial for novices in ERCP. It could facilitate hands-on practice with actual devices, enhancing procedural fluency and understanding of precise incisions to minimize the risk of bleeding complications during EST.

Comparison of Three Different Approaches to Ultrasound Guided Internal Jugular Vein Cannulation: A Randomised Clinical Study

Introduction: The standard approaches to ultrasound-guided central line insertion by Short Axis (SAX) and Long Axis (LAX) have limitations. The Medial Oblique Axis (M-OAX) approach allows visualisation of the length of the needle in real-time along with both the artery and vein. Aim: To compare the three approaches for ultrasound-guided right Internal Jugular Vein (IJV) cannulation with respect to ease of access and complications. Materials and Methods: A total of 171 patients scheduled to undergo right IJV cannulation were divided equally into three groups-SAX (Group-1), LAX (Group-2), and M-OAX (Group-3). They were compared with respect to first pass success, Venous Access Time (VAT), guide wire insertion time, catheterisation time, and complications. Continuous variables were compared with Analysis of Variance (ANOVA) test. Categorical variables were analysed using the Chi-square test. The p-value &lt;0.05 was considered significant. Results: First pass success was 55 (96.49%), 53(92.98%), and 54 (94.74%) in groups 1, 2, and 3, respectively. The VAT, guidewire insertion time, and catheterisation time were significantly lesser in Groups 1 and 3 compared to 2 (p&lt;0.001). Two cases of carotid artery puncture were noted in Group-2, though statistically not significant (p&gt;0.05). Conclusion: The medial oblique approach to IJV cannulation combines the advantages of both LAX and SAX and is a safer alternative with easier and faster venous access.