Internal Jugular Access Research Articles

Internal jugular access using pocket ultrasound in a simulated model: comparison between biplane and monoplane visualization techniques

IntroductionUltrasound is the current standard for central venous access due to its advantages in efficiency and safety. In-plane and out-of-plane visualization techniques are commonly used, but there is no clear evidence showing an advantage of one technique over the other. The objective of this study was to compare the success and time required for biplane visualization vs. in-plane and out-of-plane techniques in simulated models.MethodologyTen emergency medicine specialists participated in 60 simulated events, with randomization of the visualization technique for each event. Each event required intravenous cannulation of a simulated model for jugular venous access, with a maximum of three attempts allowed. The number of attempts required for each event, success of puncture and venous cannulation, frequency of redirection and puncture of the posterior wall, time required to obtain an optimal window, visualize the needle inside the vessel, and passage of the guidewire were recorded. The success ratios and times required for each visualization technique (biplane, in-plane, and out-of-plane) were compared.ResultsCannulation success rate was 100% for all three techniques. Success on the first attempt was 95% for biplane visualization vs. 100% for in-plane and out-of-plane. The median total time for the procedure was higher for biplane visualization (29.9 s) compared to in-plane (25.2 s) and out-of-plane (29 s), but this difference was not statistically significant (p = 0.999). There were no significant differences in cannulation success, needle redirection, or posterior wall puncture frequency between biplane visualization and in-plane and out-of-plane techniques.ConclusionsThis study suggests that biplane visualization with the use of pocket ultrasound for internal jugular cannulation in simulated models did not demonstrate significant differences when compared with in-plane and out-of-plane visualization techniques. Further research with larger sample sizes may be needed to confirm these results.

The effect of the AN69 ST100 versus oXiris® membrane on filter life during CRRT for non-anticoagulated liver failure patients.

In patients with liver failure, continuous renal replacement therapy (CRRT) without anticoagulation may be necessary. A new heparin coated membrane (oXiris®) may prolong circuit life in this setting. In liver failure patients not receiving anticoagulation, to compare CRRT circuit life with the oXiris® versus the AN69 ST100 (usual care) membrane. Randomized single cross-over trial. We studied 20 patients and 39 circuits. Twenty-five treatments used femoral and 14 internal jugular access catheters. Median circuit life was 21 h (IQR: 8.25-35.5) with the AN69 versus 16.0 h (14-25) with the oXiris® membrane (p = 0.36). Median first circuit duration was 14 (11.25-23) h for the AN69 ST100 versus 16 (8 -26) for the oXiris® membrane. There was also no difference between the AN69 ST100 or oXiris® membrane circuits using femoral access at 13 (8 -22.5) versus 15.5 (12.5-21.5) h (p = 0.57) or internal jugular access at 28 (13-47) versus 23 (21-29) h (p = 0.79), respectively. The oXiris® heparin-grafted membrane does not appear to prolong circuit life in liver failure patients receiving CRRT without anticoagulation.

Increased Complication Rate of Ports Placed into the Subclavian versus Internal Jugular Vein

Purpose: Totally implantable venous access ports are commonly placed via subclavian or internal jugular (IJ) veins. The purpose of this study is to investigate the rate of radiographic abnormalities in clinically dysfunctional ports for subclavian versus IJ venous ports. Methods: This retrospective study included 152 ports in 150 patients placed by multiple operators in both surgery and interventional radiology departments. Contrast-based, fluoroscopically guided vascular access studies performed for clinically dysfunctional ports from January 2019 to September 2020 were included. The port studies were evaluated for subclavian versus IJ access and to determine if there were radiographic abnormalities present, including catheter fracture, fibrin sheath, or catheter malposition. Results: Of the 152 ports investigated, 30 were placed into the subclavian vein and 122 into the IJ vein. During vascular access checks, subclavian ports (n=23, 76.7%) demonstrated significantly more radiographic abnormalities compared to IJ ports (n=66, 54.1%, p=0.025). Of the dysfunctional ports with abnormal radiographic findings, subclavian ports were significantly more likely to have a major abnormality (n=15, 65.2%), defined as a malpositioned or fractured catheter, compared to IJ ports (n=21, 31.8%, p=0.005). The most common finding during vascular access checks for all ports investigated was no abnormality, with a well-functioning port and the catheter tip in an appropriate position (n=63; 41.4%). Conclusions: This study suggests that for patients undergoing implantable port evaluation, ports placed into the subclavian vein are more likely to demonstrate a radiographic abnormality, as well as having increased likelihood of catheter malposition or fracture, compared to those placed into the IJ vein. Additionally, this study suggests that a relatively high rate of clinically dysfunctional ports referred for IR port checks have no demonstrable abnormalities on fluoroscopic port evaluation.

Effect of access site choice on inferior vena cava filter angulation and outcomes

BackgroundIn the present study, we compared the outcomes of inferior vena cava (IVC) filter placement between the femoral vein (FV) and internal jugular (IJ) vein access sites. MethodsWe performed a retrospective study using the Vascular Quality Initiative database to assess patients who had undergone IVC filter placement from 2013 to 2019. The patients were placed into two groups according to the access site location: FV and IJ vein. The FV group included patients with access via the right and left FVs and other leg veins, and the IJ group included patients with access via the right or left IJ vein. The primary outcome was the rate of filter angulation. The secondary outcomes included access site complications such as deep vein thrombosis, hematoma, and bleeding requiring transfusion. ResultsOf 13,221 patients, 8214 (63%) had undergone IVC filter placement via FV access and 4789 (37%) via IJ access. The remaining 218 patients had had an unknown access site or were excluded. Within the IJ group, 4696 (98.0%) had undergone access via the right IJ and 93 (2%) via the left IJ. Within the FV (common femoral, femoral, or other infrainguinal veins) group, 7007 (85.3%) had undergone access via the right FV and 1207 (14.6%) via the left FV. The mean patient age was 63 ± 15.9 years, the mean body mass index was 30.9 ± 9.60 kg/m2, and 6788 of the patients were men (52.0%). The most common indication for filter placement was a contraindication to anticoagulation because of a recent or active bleeding episode (30%), followed by planned surgery (22%), new deep vein thrombosis/pulmonary embolism (7%), fall risk (5%), and trauma (4%). Infrarenal filters had been placed in 97.9% of the patients. Univariate analysis identified body mass index and suprarenal placement as independent risk factors for angulation. The final multivariate analysis showed a significant increase in angulation (0.9% vs 0.34%; odds ratio, 1.46; 95% confidence interval, 1.02-2.11; P = .04) and increased access site complications (0.25% vs 0.07%; odds ratio, 2.068; 95% confidence interval, 1.01-4.23; P = .048) in the FV access group. No significant correlation between the access site and retrieval rate was found (P = .9270). ConclusionsPlacement of IVC filters via IJ access showed a lower rate of filter angulation in the IVC and fewer access site complications compared with FV access.

Catheter-Related Bloodstream Infection With Femoral Central Access Versus Internal Jugular Access in Patients Admitting to Medical Intensive Care Unit.

BackgroundThe current research focused on studying the pattern of catheter-related bloodstream infections (CRBSI) with femoral central access versus internal jugular access in patients admitted to the medical intensive care unit (ICU).MethodsA cross-sectional study was conducted at the Department of Emergency Medicine, Shifa International Hospital, between March 4, 2022, and August 4, 2022. All individuals who presented to the ICU who needed a central venous catheter (CVC) for more than 48 hours were included. Catheter insertion was not permitted if the patient had a history of dermatitis or burns at the site of insertion or if the hemodialysis procedure necessitated the insertion of the catheter into a blood vessel. Three groups of patients were created: group A patients had been diagnosed with CRBSI; group B patients had catheter colonization (CC); and group C did not have CRBSI or CC. Standard microbiological methods were used to identify all of the bacteria collected from the cultures. All data was documented in a predefined pro forma.ResultsOverall, 20 (12.12%) patients had positive CRBSI, 68 (41.5%) had CC, and the remaining 46.3% of cultures were negative. Elderly populations were more prone to acquiring CRBSI showing a significant correlation between older age and CRBSI (p < 0.0001). CC was significantly associated with a longer duration of ICU stay, i.e., 30.3 ± 3.7 (p = 0.003). The absence of both CRBSI and CC was significantly associated with a lower duration of catheterization (11 ± 8.5 days in group C versus 22.1 ± 6.9 and 18.7 ± 7 days in groups A and B, respectively; p < 0.0001). Our study revealed a higher risk of CRBSI when the femoral access was compared to the internal jugular access (58.3% vs. 41.7%; p = 0.0008). The study did not find any significant association of CC with femoral or internal jugular access. Furthermore, a significantly higher rate of negative cultures was reported in patients with internal jugular access as compared to femoral vein access (85.8% vs. 14.2%; p = 0.007).ConclusionThe need for routinely monitoring and observing the microbiological spectrum in patients receiving care in intensive care units is highlighted by the current investigation. The patients with internal jugular vein access had a decreased incidence of CRBSI and CC, while those with femoral access experienced CRBSI more frequently. Escherichia coli and Pseudomonas aeruginosa were the most frequently isolated germs, and both were resistant to various drugs that are used today. It is essential to regularly monitor the epidemiology of CRBSI in order to adopt preventative measures for infection prevention and control, such as staff education, strict hygiene standards, and a higher nurse-to-patient ratio.

Can inverse probability treatment weighting (IPTW) be used to assess differences of CRBSI rates between non-tunneled femoral and jugular CVCs in PICU patients?

BackgroundIn children in the ICU, catheter-related bloodstream infections (CRBSI) have also been linked to mortality, morbidity, and healthcare costs. Although CRBSI poses many potential risks, including the need to avoid femoral access, there is debate regarding whether jugular access is preferable to femoral access in adults. Study reports support both perspectives. There is no consensus in meta-analyses. Children have yet to be examined in depth. Based on compliance with the central line bundle check lists, we aim to determine CRBSI risk in pediatric intensive care units for patients with non-tunneled femoral and internal jugular venous access.MethodsA retrospective cohort study was conducted on patients with central venous catheters in the pediatric ICU of King Abdulaziz University Hospital between January 1st, 2017 and January 30th, 2018. For the post-match balance, we use a standardized mean difference of less than 0.1 after inverse probability treatment weighting for all baseline covariates, and then we draw causal conclusions. As a final step, the Rosenbaum sensitivity test was applied to see if any bias influenced the results.ResultsWe recorded 145 central lines and 1463 central line days with 49 femoral accesses (33.79%) and 96 internal jugular accesses (66.21%). CRBSI per 1000 central line days are 4.10, along with standardized infections of 3.16. CRBSI risk differed between non-tunneled femoral vein access and internal jugular vein access by 0.074 (− 0.021, 0.167), P-value 0.06, and relative risk was 4.67 (0.87–25.05). Using our model, the actual probability was 4.14% (0.01–0.074) and the counterfactual probability was 2.79% (− 0.006, 0.062). An unobserved confounding factor was not identified in the sensitivity analysis.ConclusionsSo long as the central line bundle is maintained, a femoral line does not increase the risk of CRBSI. Causation can be determined through propensity score weighting, as this is a trustworthy method of estimating causality. There is no better way to gain further insight in this regard than through the use of randomized, double-blinded, multicenter studies.

Utilization of Intra-arterial Contrast for Abdominal Computed Tomography in a Swine Model

Intraoperative computed tomography (CT) imaging with endovascular catheter delivery of intra-arterial (IA) contrast could potentially provide higher signal attenuation in directed anatomic locations with lower contrast volumes. We compared image quality and attenuation timing of IA vs intravenous (IV) contrast protocols for abdominal imaging. Five anesthetized swine had internal jugular access and ascending aortic pigtails placed percutaneously via the brachial artery. The IV contrast protocol utilized 100 mL of iodinated contrast at 5 mL/sec over 20/sec. The IA protocol delivered 50 mL at 5 mL/sec over 10/sec. A 16-slice CT scanner with a 10 mm detector acquired static serial images at 1 image/sec for 45 seconds. Region-of-interest markers were used to select the aorta and portal vein to capture the arterial and portal venous phases of contrast administration via Hounsfield Units (HU) per second. Attenuation curves were plotted against time and assessed using a Pearson correlation. Adequate attenuation was defined as >100 HU a priori, and image quality was assessed using contrast-to-noise ratio (CNR). Both contrast protocols achieved adequate image attenuation with an aortic peak of 665 ± 226 (Mean HU ± standard deviation) for IA and 414 ± 141 for IV. IA contrast achieved faster peak aortic attenuation compared with IV contrast (8 vs 20 seconds; P < .001] (Figure 1). Portal values (attenuation and time to peak) were similar for IA vs IV (146 ± 46 vs 169 ± 39; 34 vs 42 seconds; P < .05) (Figure 2). IA administration achieved a superior CNR in less time compared with IV (10 vs 23 seconds; P < .001). All curves were modeled using non-linear least squares regression and achieved an R2 >0.94; P < .001. IA contrast achieves adequate opacification and a superior CNR compared with IV contrast, while using a smaller volume for organ directed imaging. It is likely that the contrast volume can be reduced further without impacting image quality. Although further work is required to optimize IA contrast CT and abdominal imaging, the incorporation of intraoperative CT with IA contrast could radically change imaging protocols in a variety of clinical settings.Fig 2Averaged Hounsfield units (HUs) over 45 seconds comparing intra-arterial (IA) vs intravenous (IV) contrast attenuation of the portal vein.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Extension of iliac vein stent into the profunda femoral vein for salvage

BackgroundThe extension of iliac vein stents into the common femoral vein is often required to correct stenoses found at or near the inguinal ligament. Very rarely, an extension of the iliac stent into the profunda femoris vein may be required because of severe disease at the femoral trijunction. Profunda extension of iliac vein stents is a rare but useful technique for salvage. Our experience with extensions of iliac vein stents into the profunda femoris vein is described. MethodsA search of our electronic medical records identified 20 limbs (0.75%) among a total of 2641 stented limbs (years 2006-2017) in whom the iliac vein stent was extended into the profunda femoris vein. Patients had been followed at 6 weeks, 3 months, 6 months, and yearly thereafter following the index procedure. Routine follow-up consisted of a detailed clinical evaluation, including the Venous Clinical Severity Score, visual analogue pain scale assessment, and edema grading by physical examination. Stent surveillance was performed at the follow-up visits. The iliac vein stent was declotted if needed and then extended into the profunda femoris vein at the same sitting. Antegrade access of the profunda femoris vein was preferred by direct puncture near the lesser trochanter or through a popliteal approach when a profunda-popliteal connection was present. An internal jugular access was used when an antegrade approach failed. ResultsStent extension into the profunda was a secondary procedure after the initial iliac-common femoral vein stent failed in 17 of 20 limbs (85%). In three limbs (15%), the profunda extension was carried out at the initial iliac vein stent procedure because there was severe stenosis at the femoral confluence. One or more reinterventions after profunda extension were required in 50% of the limbs to maintain secondary patency or functionality. Fifteen of 20 limbs (75%) with profunda extensions remained patent on long-term follow-up. The median duration of secondary patency of stents that remained patent and those that occluded, and overall were 23 months, 3 months, and 10 months, respectively. Thirty percent of stents remained patent at 5 years. ConclusionsThe extension of an iliac vein into the profunda femoris vein is a rarely required but useful procedure for stent salvage and symptom relief. Corrective reinterventions are often required but can result in long term patency extending to many years.

Abstract 289: Utilization Of Intra-Arterial Contrast For Computed Tomography Aortography In A Swine Model

Background: Intraoperative computed tomography (CT) imaging with endovascular catheter delivery of intra-arterial (IA) contrast could potentially provide higher signal attenuation in directed anatomic locations with lower contrast volumes. We compared image quality and attenuation timing of IA versus IV contrast protocols for abdominal imaging. Methods: Five anesthetized swine had internal jugular access and ascending aortic pigtails placed percutaneously via the brachial artery. The IV contrast protocol utilized 100 mL of iodinated contrast at 5 mL/sec over 20/sec. The IA protocol delivered 50 mL at 5 mL/sec over 10/sec. A 16-slice CT scanner with a 10 mm detector acquired static serial images at 1 image/second for 45 secs. Region-of-interest markers were used to select the aorta and portal vein to capture arterial and venous attenuation via Hounsfield Units (HU) per second. Attenuation curves were assessed using a Pearson’s correlation. Adequate attenuation was defined as &gt;100 HU a priori and image quality assessed using Contrast-to-Noise Ratio (CNR). Results: Both contrast protocols achieved adequate image attenuation with an aortic peak of 665 ± 226 (Mean HU ± SD) for IA and 414 ± 141 for IV. IA contrast achieved faster peak aortic attenuation compared to IV contrast [8 vs 20 sec; p&lt;0.001] (Fig 1). Portal values (attenuation and time to peak) were similar for IA vs IV: [146 ± 46 vs 169 ± 39; 34 vs 42 sec; p&lt;0.05]. IA administration achieved a superior CNR in less time compared to IV [10 vs 23 sec; p&lt;0.001]. All curves were modeled using non-linear least squares regression and achieved an R 2 &gt;0.94; p&lt;0.001. Conclusion: IA contrast achieves adequate opacification and a superior CNR compared to IV contrast, while using a smaller volume for intraoperative directed imaging. The incorporation of intraoperative CT with IA contrast could radically change imaging protocols for endovascular aortic repair.

Unguided temporary pacing via jugular/subclavian vein in an emergency department of a high-volume tertiary care hospital of India: its safety, efficacy, and practicability

BackgroundTemporary pacing is usually performed by cardiologists under fluoroscopic, echocardiographic, or ECG guidance. However, in the developing world, there are inadequate number of cardiologists, and C-arm, catheterization laboratories, or echocardiography are not available at primary or secondary healthcare facilities. In addition, in emergencies option of fluoroscopy and echocardiography is limited. So these patients are transferred to a facility where cardiologists and these facilities are available. Crucial time is lost in transit, which leads to increased mortality. In this study, we aimed to evaluate the safety, efficacy, and practicability of unguided temporary pacemaker insertion.ResultsA total of 1093 patients were enrolled in this study. After cannulating the internal jugular vein or subclavian vein, the pacing lead attached to the pulse generator was advanced blindly till ventricular pacing was achieved. Procedural success was taken as the primary endpoint. Secondary endpoints included the number of attempts taken for successful central venous puncture and procedural time. Complications and mortality were assessed for safety outcomes. Finally, the position of the pacing lead was assessed after the procedure on X-ray or fluoroscopy. The procedure was successful in all but one patient in whom a femoral vein approach was required because of brachiocephalic vein obstruction. Right internal jugular access was achieved in 981 (89.75%) patients. The mean number of attempts taken for achieving successful venous accesses was 1.54 ± 0.85; however, in 726 (66.42%) patients it was achieved in the first attempt. The mean procedural time was 11.5 ± 2.1 min. Overall, 117 (10.70%) patients developed complications; however, most of them were minor. Pneumothorax developed in 12 (1.1%) patients, of whom 2 needed an intercostal tube. Pericardial effusion was seen in 21 (1.92%) patients. Pacing lead tip was located in the right ventricular cavity abutting interventricular septum or free wall in 843 (77.20%) patients. No mortality attributable to procedure occurred.ConclusionsUnguided temporary pacing via jugular or subclavian venous approach in an emergency setting is possible with high success and a low complication rate. Thus, it is a safe and effective procedure, and clinicians working at primary and secondary healthcare levels should be encouraged to perform this procedure.Trial registration UMIN Clinical Trials Registry, UMIN000046771. Registered 28 January 2022—Retrospectively registered, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000053348

Abstract No. 222 Comparing apples to apples: the utility of intra-procedural CTPA during pulmonary artery thrombolysis

To describe a novel intra-procedural method of evaluating treatment response using hybrid CT-Angio imaging in catheter-directed thrombolysis (CDT) for intermediate-high risk pulmonary embolism (PE) A retrospective review was performed on 3 consecutive patients (1 female, age 40-73 years) who presented with acute, multisegment, intermediate-high risk PE from May-August 2020, and who were referred for intervention. All patients underwent second look thrombolysis evaluation within 24 hours from initiation of CDT. Intra-procedural CTPA was performed for all patients at the time of re-evaluation in a Siemens Nexaris Angio-CT hybrid suite with contrast injection via right internal jugular access sheath. Standard CTPA protocol with bolus tracking was utilized. Intra-procedural CTPA was found to be diagnostic to the proximal segmental level in all cases. One patient continued CDT at second look due to continued pulmonary hypertension, moderate residual clot burden, and need for repositioning of the infusion catheter. The remaining two patients completed thrombolysis at second look: one due to CT evidence of resolved abnormal RV:LV ratio and resolved saddle PE, the other due to CT evidence of improved RV:LV ratio and marked improvement in thrombus burden and pressures. Intra-procedural CTPA may provide evaluation of right heart strain, evaluating residual thrombus burden, and confirming intra-thrombus catheter position. This may allow for more information in determining the need for continued CDT and need for catheter repositioning.

Abstract No. 188 Incidence of abnormalities and association with accessed vein on radiographic port evaluation

Totally implantable venous access ports are commonly placed via subclavian or internal jugular (IJ) veins. The purpose of this retrospective study is to investigate the rate of post-implantation, radiographic abnormalities in clinically dysfunctional ports for subclavian versus IJ venous ports. This retrospective study included 109 ports in 107 patients placed by multiple operators in both surgery and interventional radiology departments. Contrast-based, fluoroscopically guided vascular access studies performed for clinically dysfunctional ports from January 1, 2019, to July 31, 2020, were included. The port studies were evaluated for subclavian versus IJ access and to determine if there were radiographic abnormalities present, including catheter fracture, fibrin sheath, and catheter malposition. Of the 109 ports investigated, 27 were inserted via the subclavian vein and the remaining 82 via the IJ vein. The most common indications for port study referral were unspecified (n = 41, 37.6%), poor aspiration (n = 39; 35.8%), difficulty accessing (n = 12; 11.0%), and pain and/or swelling at the port site (n = 9; 8.3%). During vascular access checks, 20 of the 27 subclavian ports (74.1%) demonstrated radiographic abnormality compared to 42 of the 82 IJ ports (51.2%), which was significantly different using Chi-Squared testing (P = 0.038). The two most common findings during vascular access checks were well-functioning port with catheter tip in appropriate position (n = 47; 43.1%) and poorly aspirating port with fibrin sheath, but catheter tip in appropriate position (n = 37, 33.9%). Of the dysfunctional ports with abnormal radiographic findings, subclavian ports were significantly (P = 0.029) more likely to have a major abnormality (n = 12, 60.0%), defined as a malpositioned or fractured catheter, compared to IJ ports (n = 13, 31.0%). This study suggests that for patients undergoing implantable port evaluation, ports placed via subclavian vein are more likely to demonstrate a radiographic abnormality, as well as having increased likelihood of catheter malposition or fracture, compared to those placed via IJ vein. Additionally, this study suggests that a relatively high rate of clinically dysfunctional ports referred for port check will have no demonstrable abnormalities on fluoroscopic port evaluation.

Successful catheter ablation of atrial fibrillation from superior venous approach

Background: Trans-catheter ablation of drug refractory Atrial Fibrillation (AF) is an effective and safe treatment to avoid arrhythmia recurrences. However, some patients may present anatomic variant making impossible an inferior venous approach. We report a case of Pulmonary Veins Isolation (PVI) with cryoballoon technology via Right Internal Jugular Vein (RIJV) access. Methods: After the first transcatheter PVI attempt was failed due to Inferior Vena Cava (IVC) hypoplasia, cryoballoon ablation with a 28-mm cryoballoon (AFAPRO-Medtronic CryoCath LP, Quebec, Canada) via superior venous access was performed. A quadripolar electrode was inserted in coronary sinus from left basilic vein. The right internal jugular vein was accessed with Seldinger technique and Left Atrial (LA) catheterization was performed via single Trans-septal Puncture (TP) under Trans-esophageal Echocardiographic (TOE) and fluoroscopy guidance using an SL2 (St. Jude Medical) trans-septal sheath with a BRK2 (St. Jude Medical) needle. All Pulmonary Veins (PVs) were engaged. Cryothermal energy was delivered after checking the correct occlusion and PVI was successfully obtained for all PVs. The procedure lasted 210 min, fluoroscopy time was 55 min. During the 16-month follow-up no sustained atrial arrhythmia recurrence was detected. Conclusion: PVI with cryoballoon technology in patients with hypoplasia of IVC can be safely and successfully performed using right internal jugular access.

Echocardiogram Guided Endomyocardial Biopsy: An Analysis beyond Safety Outcomes

Fluoroscopy-guided endomyocardial biopsy (FGEB) of the right ventricle is the common method for myocardial sampling for rejection among heart transplant patients. Echocardiographic-guided endomyocardial biopsy (EGEB) is safe, but few studies have compared the procedures outside of safety outcomes. Our hypothesis is that EGEB lowers radiation time without prolonging the total procedure. We retrospectively collected data from adult heart transplant endomyocardial biopsies via the right internal jugular access from 2/1/15-2/28/19. Differences of target variables between EGEB and FGEB groups were assessed by t test or Kruskal-Wallis test as appropriate. For binary target variables, chi-square-test was used; p < 0.05 was significant. There were 100 patients, 544 biopsies, 99 (18%) performed via EGEB by 2 of 5 transplant cardiologists. The mean biopsy time of the EGEB was 29.9 ± 10.3 min (95% CI: 27.9 - 32.0 min) compared to FGEB time of 29.7 ± 10.0 min (95% CI: 28.7 - 30.7 min), p = 0.75. Mean fluoroscopy time for EGEB was 1.83 ± 1.80 min (95% CI: 1.4-2.2 min) vs 5.58 ± 1.98 min (95% CI: 5.27-5.89 min) for FGEB, p < 0.0001. A measured mixed model analysis of mean fluoroscopy time accounting for patients receiving multiple endomyocardial biopsies showed a difference of 1.89 mins less with EGEB than FGEB (p < 0.0001). There were minimal adverse events with no statistical difference between groups: one pneumothorax and three new pericardial effusions in the FGEB group, with one new pericardial effusion in the EGEB group; none requiring intervention. EGEB is safe, decreases radiation exposure to patients and staff without extending procedural time. While the reduction in radiation time may be minimal, the cumulative dose can add up with a minimum of 11 biopsies performed 1 year after heart transplant alone.

Severe hypoxemia due to intrapulmonary right-to-left shunt: AVM embolization through internal jugular access.

Severe hypoxemia due to intrapulmonary right-to-left shunt: AVM embolization through internal jugular access.

Over-the-wire deployment techniques of option elite inferior vena cava filter: 3D printing vena cava phantom study

PurposeTo compare filter tilt and filter jumping during Option inferior vena cava (IVC) filter deployment with 3 different wires techniques using a 3-dimensional (3D) printing vena cava phantom. Materials and methodsAn IVC 3D printed vena cava phantom was made from a healthy young male’s computed tomographic data. Option IVC filters were deployed with 3 different wires: i) original push wire, ii) hydrophilic stiff wire, and iii) bent stiff wire. Right internal jugular and right femoral access were used 5 times with each wire. Filter tilt angle, tilt ratio, jumping, and tip abutment to the IVC wall were analyzed. ResultsThe transfemoral approach with original push wire had significantly higher tilt angle than did the transjugular approach (6.1˚ ± 1.9 vs. 3.5˚ ± 1.3, p = 0.04). Mean tilt ratio was significantly lower with the bent wire with transfemoral access (0.49 ± 0.13 vs. 0.78 ± 0.18 [original push-wire] and 0.67 ± 0.08 [stiff wire], p = 0.019). The ratio was lower also with original push wire with transjugular access (0.34 ± 0.19 vs. 0.57 ±0.11 [stiff wire] and 0.58 ±0.17 [bent wire], p = 0.045). Filter jumping occurred more often with the transjugular approach with original push wire than with stiff or bent-wire delivery. Filter tip abutment to the IVC wall occurred only with the transfemoral approach. ConclusionsBent wire with transfemoral access and original push wire with transjugular access had lower filter tilt ratio at Option IVC filter deployment. However, filter jumping was common using the original push wire with transjugular access.

Adequacy of haemodialysis in two centres in Southwestern Nigeria: Determinants and clinical correlates

Background: Dialysis remains the most common modality of renal replacement therapy for managing end-stage kidney disease. Optimisation of various measures is needed for its efficient delivery. Inadequate dialysis is common in many low-income nations, and there could be inter-centre differences in the delivered dose.Aim: We assessed the dialysis adequacy and factors associated with inter-centre variation.Materials and Methods: This was a two-centre comparative study. Participants' sociodemographic and examination findings were documented and dialysis was prescribed. Pre- and post-dialysis blood for electrolytes, urea and creatinine were taken, and urea reduction ratio and fractional urea clearance as a function of its distribution volume (Kt/V) were calculated.Results: Two hundred and thirty-two participants had 1248 dialysis sessions. Participants' mean age was 49.9 ± 4.6 years. More males participated in the study, and males also received more sessions per participant. A greater proportion of the participants had tertiary education and had hypertensive nephropathy as the cause of kidney disease. The internal jugular access was used for dialysis in majority (60.6%) of the dialysis sessions. Dialysis dose (DD) was adequate in only 115 (9.2%) sessions. The mean DD was 1.02 ± 0.4; in the two centres, it was 0.86 ± 0.2 and 1.11 ± 0.5.Conclusion: DD is low in many low-income nations including Nigeria. The DD was directly related to the blood flow rate, dialysis duration and frequency of erythropoietin use. In addition to other factors, inability to afford prescribed dialysis regimen is a major contributor to the low DD in low-income settings.

(555) - Right Internal Jugular Access Is an Alternative to Femoral Access for CardioMEMS Implantation

(555) - Right Internal Jugular Access Is an Alternative to Femoral Access for CardioMEMS Implantation

Board #102 - Research Abstract Comparing Standard Vs. Video-Based Teaching For Ultrasound-Guided Internal Jugular Central Venous Catheter Access For 4th Year Medical Students (Submission #8825)

Hypothesis Small group instruction of procedural skills is faculty intensive, and presents challenges when multiple instructors are required to train large numbers of learners. At our institution, incoming residents who want vascular access privileges undergo a protocolized ultrasound guided central line training program. Senior medical students have requested similar training, but faculty resources are not adequate to accommodate the large number of interested students. To meet student needs, we developed a self-directed video-based learning module to teach the skill of ultrasound guided internal jugular access (US-IJ) to our institutional standards. The objective of this study is to evaluate the efficacy of teaching US-IJ using high quality video compared to standard faculty led US-IJ teaching. The video enables learners to self-pace with the ability to rewind, pause, and fast-forward individual video segments. Methods Randomized controlled trial in the simulation center of an academic center, during a four-week senior medical student capstone course in March 2014. Each student completed a peripheral US IV training session and an online module. Subjects were randomly assigned to either faculty-led (standard) or video-guided (intervention) three-hour teaching sessions using vascular access manikins and ultrasound machines. Intervention group used an interactive video detailing procedural steps, following a standard checklist (55 items) established by our institution. The intervention group had the chance to interact with a faculty at the end of their session to address specific questions only. At the conclusion of each session, all students independently completed a video-recorded performance station of US-IJ placement. Two faculty instructors scored videos based on the checklist. Scores were compared using t-test. An independent instructor scored 20% of each group to calculate inter-rater reliability. Results Thirty-two MS-IV were enrolled in the study, 16 in each group. Five students were excluded (four did not attend and one encountered ultrasound recording failure). Fourteen students in the video group and 13 students in the standard group were included. The intervention group performed significantly more checklist items correctly (90%, 95%CI 86.5-93%) than did the standard group (81%, 95% CI 77.6-84.2%). (P = 0.0003) Conclusion US-IJ training using self-directed high quality video guided instruction may be superior to standard, faculty-guided instruction. Use of video eliminates instructional variability, decreases the demand on faculty time, and enables individual learners to work at their own pace. Furthermore, a larger number of learners can be accommodated. This is crucial in places where having continuous, standard, and high-quality instruction is considered a challenging problem. We recommend a larger study of vascular access training using video guidance be conducted. Disclosures The CLASS Center has received support in the form of equipment loans from Karl Storz. Claudia Ranniger owns stock in Intuitive Surgical (manufacturer of DaVinci Robot).

319 Comparing Standard versus Video-Based Teaching for Ultrasound-Guided Internal Jugular Central Venous Catheter Access for Fourth-Year Medical Students

319 Comparing Standard versus Video-Based Teaching for Ultrasound-Guided Internal Jugular Central Venous Catheter Access for Fourth-Year Medical Students