Jugular Access Research Articles

Transjugular balloon mitral valvotomy in a patient with severe kyphoscoliosis

Balloon mitral valvotomy (BMV) performed by the conventional transfemoral approach can be difficult or even impossible in the presence of structural impediments such as severe kyphoscoliosis, gross cardiac anatomic distortion and inferior vena caval anomalies. A 25-year-old woman with severe thoracolumbar kyphoscoliosis due to poliomyelitis presented with symptomatic rheumatic mitral valve stenosis. After the failure of transfemoral BMV, the procedure was attempted from the right jugular access, using a modified septal puncture technique. The left atrium was entered from the jugular access and the mitral valve was crossed and dilated successfully using over the wire balloon technique. Transjugular BMV is an effective alternative in patients with kyphoscoliotic spine that preclude transfemoral approach. The detailed technique used for the procedure, its advantages as well as the other percutaneous treatment options are also discussed.

External jugular venous access in children: A low cost and feasible route for emergency fluid resuscitation and inotropic therapy in resource poor clinical settings?

Introduction: The External Jugular Vein is superficial with a wide caliber and is also isolated from major neurovascular structures in neck. It can be simply cannulatedand used for fluid and inotrope administration without any major complications. Objectives: The goal of our retrospective pilot study is to demonstrate the feasibility of External Jugular Vein (EJV) access in the pediatric population in emergency settings. Methods: A total of seventy five childrenwere retrospectively evaluated after EJV cannulation. Results: EJV cannulation was successful in 63 children (84%) at the first attempt while 12 children (16%) required more than one attempt. All patients received vasoactive agents through the EJVcannula. Nineteen (25.33%) children had EJV cannulation related complications. Conclusions: As per our observations in this pilot study, vasoactive agents and intravenous fluids for resuscitation can be safely infused through the EJV in majority of children without any major complications. This route of administration could be considered especially in emergency and resource poor settings.

Percutaneous Cannulation in Predominantly Venoarterial Extracorporeal Membrane Oxygenation by Intensivists

Critical Care Medicine www.ccmjournal.org e595 The authors reply: The letter by Burrell et al (1) describing the percutaneous cannulation experience by intensivists at Alfred Hospital provides important information for intensivists involved in extracorporeal life support (ECLS) programs and nicely complements our reported experience (2). Our ECLS program has historically provided predominantly respiratory support, and our cardiac support experience is more limited. Our ECLS experience consists mostly of venovenous cannulation with a smaller venoarterial cohort. Burrell et al (1) describe their cannulation experience, which includes a large venoarterial cohort. Aspects of the Alfred Hospital experience deserve mention. The first is their success with arterial cannulation with a low complication rate. Arterial cannulation entails more inherent risk than venous because arterial injury can lead to substantial more morbidity than venous injury. The 8% arterial complication rate reported, although higher than their venous rate (2%), is not unexpected and would not be considered excessive. Some of their complications required surgical management, so the availability of surgical services would seem advisable. Another aspect is the larger number of intensivists (16) available to perform cannulations. Although this would seem to dilute the experience of each intensivist, the approach of having more than one intensivist cannulating a given patient (as we do) increases the exposure to the procedure and helps maintain cannulation skills. secured. A second patient’s internal jugular venous access cannula was accidentally dislodged and removed but was resecured without major consequence. Overall average ECMO duration was 4 ± 4 days for VA ECMO and 14 ± 4 days for VV ECMO. Survival to hospital discharge was 73 of 122 (60%) for VA ECMO (including extracorporeal CPR) and 32 of 45 (71%) for VV ECMO. In total, seven of 167 patients (4%) had hemorrhagic or ischemic stroke, and there was one blood stream infection, and one confirmed cannula related infection. In conclusion, intensivist-led cannulation is also possible for a predominantly VA ECMO service and is associated with an acceptable complication rate. The authors have disclosed that they do not have any potential conflicts of interest.

Device closure of patent ductus arteriosus in interrupted inferior vena cava

IntroductionA 3-year-old child, weighing 8kg, presented with patent ductus arteriosus (PDA) and interrupted inferior vena cava (IVC). The patient underwent successful PDA device closure via transjugular route after failing attempt at femoral venous route. Case summaryPDA device closure was attempted via femoral venous route but could not be accomplished due to difficult curves to negotiate. Following this, PDA could be closed by device from jugular venous route with ease. DiscussionInterrupted IVC poses challenges for PDA device closure and various alternative routes are described like internal jugular, transhepatic, or femoral venous – azygous route. Our case describes difficulties associated with femoral venous route and advantages of jugular venous route in such cases. ConclusionInternal jugular access is a safe and feasible method of PDA device closure in cases of interrupted IVC even in smaller children.

Rescue N-butyl-2 cyanoacrylate embolectomy using a Solitaire FR device after venous glue migration during arteriovenous malformation embolization: technical note

One of the procedural risks in arteriovenous malformation (AVM) embolization is possible migration of the embolic agent into the venous drainage with an incomplete nidus occlusion, which may lead to severe hemorrhagic complications. This report presents the case of a 29-year-old man who presented with a deep intraparenchymal hematoma on the left side secondary to the spontaneous rupture of a claustral AVM. Upon resorption of the hematoma, the patient underwent an initial therapeutic session of N-butyl-2 cyanoacrylate endovascular embolization, with the purpose of reducing the AVM volume and flow before performing Gamma Knife radiosurgery. After glue injection into one of the arterial feeders, the control angiography showed a partial migration of the glue cast into the straight sinus, with most of the nidus still visible. Because of the bleeding risk due to possible venous hypertension, it was decided to try to retrieve the glue from the vein by using a stent retriever via jugular access. This maneuver allowed a nearly complete removal of the glue cast, thereby restoring normal venous flow drainage. The patient showed no clinical worsening after the procedure. To the authors' knowledge, this is the first report of the use of the Solitaire FR device as a rescue glue retriever. This method should be considered by physicians in cases of unintended glue migration into the venous circulation during AVM embolization.

Surgical placement and management of jugular vascular access ports in dogs and cats: description of technique

Summary Background: vascular access ports (VAPs) are designed to allow repeated access to the vascular system with minimum patient distress. Objective: to describe the surgical technique, care and complications of jugular VAPs currently used at the Veterinary Oncology Service of the University of Florida Small Animal Hospital. Conclusion: the VAPs can remain in site for long terms (months) with minimum complications, and its placement is a reliable technique that should be considered by veterinarians, particularly for a longterm treatment. Keywords: chemotheraphy, intravenous access, medical oncology, vascular surgical procedures. Resumen Antecedentes: los cateteres venosos centrales (VAPs) estan disenados para permitir el acceso repetido al sistema vascular con las minimas molestias para el paciente. Objetivo: describir la tecnica quirurgica, atencion de mantenimiento y las complicaciones de los VAPs en vena yugular, que se utiliza actualmente en el Veterinary Oncology Service en la University of Florida Small Animal Hospital. Conclusion: el VAP puede permanecer en el lugar durante periodos largos (meses) con pocas complicaciones, y su implantacion quirurgica debe ser considerada por los veterinarios, en particular para el tratamiento a largo plazo. Palabras clave: acceso intravenoso, oncologia medica, procedimientos quirurgicos vasculares, quimioterapia. Resumo Antecedentes: os cateteres venosos centrais (VAPs) permitem acessos repetidos ao sistema vascular com minimo desconforto ao paciente. Objetivo: descrever a tecnica cirurgica, cuidados de manutencao e complicacoes dos VAPs de veia jugular utilizados atualmente no Servico de Oncologia Veterinaria do Hospital Veterinario de Pequenos Animais da Universidade da Florida. Conclusao: o VAP pode permanecer no local por longos periodos (meses) com poucas complicacoes. O implante cirurgico descrito no presente trabalho deve ser considerado pelos medicos veterinarios, particularmente para tratamentos de longa duracao. Palavras chave: acceso intravenoso, oncologia, procedimentos cirurgicos vasculares, quimioterapia .

Surgical placement and management of jugular vascular access ports in dogs and cats: description of technique

Summary Background: vascular access ports (VAPs) are designed to allow repeated access to the vascular system with minimum patient distress. Objective: to describe the surgical technique, care and complications of jugular VAPs currently used at the Veterinary Oncology Service of the University of Florida Small Animal Hospital. Conclusion: the VAPs can remain in site for long terms (months) with minimum complications, and its placement is a reliable technique that should be considered by veterinarians, particularly for a longterm treatment. Keywords: chemotheraphy, intravenous access, medical oncology, vascular surgical procedures. Resumen Antecedentes: los catéteres venosos centrales (VAPs) están diseñados para permitir el acceso repetido al sistema vascular con las mínimas molestias para el paciente. Objetivo: describir la técnica quirúrgica, atención de mantenimiento y las complicaciones de los VAPs en vena yugular, que se utiliza actualmente en el Veterinary Oncology Service en la University of Florida Small Animal Hospital. Conclusión: el VAP puede permanecer en el lugar durante períodos largos (meses) con pocas complicaciones, y su implantación quirúrgica debe ser considerada por los veterinarios, en particular para el tratamiento a largo plazo. Palabras clave: acceso intravenoso, oncología médica, procedimientos quirúrgicos vasculares, quimioterapia. Resumo Antecedentes: os cateteres venosos centrais (VAPs) permitem acessos repetidos ao sistema vascular com mínimo desconforto ao paciente. Objetivo: descrever a técnica cirúrgica, cuidados de manutenção e complicações dos VAPs de veia jugular utilizados atualmente no Serviço de Oncologia Veterinária do Hospital Veterinário de Pequenos Animais da Universidade da Florida. Conclusão: o VAP pode permanecer no local por longos períodos (meses) com poucas complicações. O implante cirúrgico descrito no presente trabalho deve ser considerado pelos médicos veterinários, particularmente para tratamentos de longa duração. Palavras chave: acceso intravenoso, oncología, procedimentos cirúrgicos vasculares, quimioterapia.

Ultrasonography-guided central venous port placement with subclavian vein access in pediatric oncology patients

Background/PurposeTo evaluate the technical success and complications of image-guided central venous port (CVP) placement with subclavian vein (SCV) access in pediatric oncology population. Materials and methodsNinety-two children (52 boys, 40 girls; mean age, 8.5years) underwent CVP implantation under local anesthesia with conscious sedation. SCV access was firstly attempted under ultrasonographic guidance and CVP implantation was performed under fluoroscopic guidance. Technical success, peri-procedural (<24h) complication, and post-procedural (>24h) complication were assessed. ResultsIn total, 102 CVPs were implanted in 92 children with a mean catheter time of 364days (total, 38,224days; range, 14–1911days). In three small children, conversion of SCV access to internal jugular vein access yielded a primary technical success rate of 97.1% and overall technical success rate of 100%. Three minor peri-procedural complications were observed (2.9%) and seven post-procedural infectious complications occurred (infection rate, 6.7%; 0.18/1000 catheter days). No pneumothorax, catheter malposition, venous thrombosis, or mortality occurred. ConclusionImage-guided CVP placement with SCV access in a pediatric population was performed with high technical success and low complication rate without general anesthesia. This procedure can be taken into account as a choice of procedure when internal jugular venous access is not possible.

Retrospective analysis of incidence of complications of central venous catheterization at an intensive care unit

Objectives: To compare mechanical, infectious, and thrombotic complications of internal jugular; subclavian and femoral venous catheterization at an post surgical and medical intensive care unitsMethods: It is a retrospective study in which the data from the medical records was evaluated and analyzed. Data, such as sex, date of insertion and removal, failure to place, malposition, complications and site of central venous catheterization were recorded. Landmark-based central venous catheterization using seldinger technique was performed under all aseptic precautions in 597 patients in postsurgical and medicine intensive care units. Central venous catheterization by three different routes i.e. IJV, SV and femoral vein were performed in critically ill patients.Results: Incidence of mechanical, infectious, and thromboembolic complications of central venous catheterization was 8.71%, 7.37 %, and 2.68% respectively. Incidences of different mechanical complications are as follows, arterial puncture4.18%, hematoma 3.18%, pneumothorax 1 %, haemothorax 0.33% .Incidence of central venous catheter with failure to place at various sites were 11.72 %. Incidences of central venous catheter with malposition at various sites were 6.36%.Conclusion: We found that complication rates of CVC insertion at our hospital are similar to those reported previously. Based on our experience, internal jugular venous access is associated with a low rate of mechanical complications like arterial punctures, hematoma, pneumothorax, thrombosis. Incidence with infection was least with subclavian cannulation.

Alternative Venous Outflow by Brachial to Jugular Vein Vascular Access for Hemodialysis in the Exhausted Upper Extremities

A shunt is usually created from the distal arm (wrist) to the proximal arm (axillary loop) as long as no central stenosis has occurred. Creating vascular access in a patient with central vein stenosis could induce venous hypertension in the upper extremities. In such patients, an ipsilateral internal jugular vein (IJV) as an arteriovenous (AV) outflow vein should be the last option for using a particular arm. Thirty-two patients who had AV hemodialysis access via a jugular vein were analyzed retrospectively from 2001 to 2011. All patients had an ipsilateral subclavian or axillary vein stenosis. The preserved IJV and innominate veins were preoperatively confirmed with Doppler echocardiography and contrast venography. Mean age of the patients was 57.6 ± 12.3 years, and the mean follow-up period was 43.5 ± 27.4 months. Primary patency was 74%, 54%, 32%, 15% and 5% at 6 months, 1, 2, 3 and 4 years, respectively. Secondary patency was 97%, 93%, 93%, 89%, 79% and 72% at 6 months, 1, 2, 3, 4, and 5 years, respectively. One case of steal syndrome, 2 of seroma, 1 hematoma, 3 swollen arm, 2 infections, 1 pseudoaneurysm, 1 bleeding from puncture site, 8 stenoses and 13 thrombosis cases were noted. A brachial-jugular AV graft showed satisfactory results in terms of patency and complication rate. The IJV could be a good outflow vein for an AV fistula if the IJV is preserved in patients with chronic renal failure who have subclavian or axillary vein stenosis or occlusion.

Complications of Central Venous Totally Implantable Access Port: Internal Jugular Versus Subclavian Access

Background: Totally implantable access port (TIAP) provides reliable, long term vascular access with minimal risk of infection and allows patients normal physical activity. With wide use of ports, new complications have been encountered. We analyzed TIAP related complications and evaluated the outcomes of two different percutaneous routes of access to superior vena cava. Methods: All 172 patients who underwent port insertion with internal jugular approach (Group 1, n = 92) and subclavian approach (Group 2, n = 79) between August 2011 and May 2013 in a single center were analyzed, retrospectively. Medical records were analyzed to compare the outcomes and the occurrence of port related complications between two different percutaneous routes of access to superior vena cava. Results: Median follow-up for TIAP was 278 days (range, 1-1868). Twenty four complications were occurred (14.0%), including pneumothorax (n = 1, 0.6%), migration/malposition (n = 4, 2.3%), pinch-off syndrome (n = 4, 2.3%), malfunction (n = 2, 1.1%), infection (n = 8, 4.7%), and venous thrombosis (n = 5, 2.9%). The overall incidence was 8.7% and 20.3% in each group (p = 0.030). Mechanical complications except infectious and thrombotic complications were more often occurred in group 2 (p = 0.033). The mechanical complication free probability is significantly higher in group 1 (p = 0.040). Conclusions: We suggest that the jugular access should be chosen in patients who need long term catheterization because of high incidence of mechanical complication, such as pinch-off syndrome.

Factors that Predict Increased Catheter Tip Movement in Left Internal Jugular Vein Implantable Venous Access Ports upon Standing

To determine the characteristics that predict catheter tip movement with positional changes in patients with left-sided, internal jugular vein (IJV) implantable venous access ports. A retrospective review revealed 264 patients with left IJV ports placed at one academic institution from 2008 to 2013 with follow-up upright chest radiographs. Demographic information was recorded and anatomic measurements were made on both procedural fluoroscopic imaging and upright chest radiographs. Multivariate regression analysis was performed to determine which factors had statistically significant relationships with catheter tip movement distance. Mean catheter tip movement was 1.49 ± 1.97 cm. There was a statistically significant positive relationship between catheter tip movement distance and age (p = 0.03), body mass index (BMI) (p = 0.02), innominate vein angle (p<0.01) and dual- compared to single-lumen ports (p = 0.02). Port pocket location, venous access site and gender did not demonstrate statistical significance. The factors associated with increased positional catheter tip movement for left IJV ports include patient age, BMI, innominate vein angle and dual- vs single-lumen port. This information can be useful in determining initial placement position and avoiding complications associated with catheter malposition.

Inferior Vena Cava Thrombosis Related to Hypothermia Catheter: Report of 20 Consecutive Cases.

Temperature management using endovascular catheters is an established therapy in neurointensive care. Nonetheless, several case series have reported a high rate of thrombosis related to the use of endovascular hypothermia catheters. As a result of a pulmonary embolism that developed in a patient after removing an inferior vena cava hypothermia catheter, we designed a clinical protocol for managing and removing these devices. First, an invasive cavography was performed before the removal of the catheter. If there was a thrombus, a cava vein filter was inserted through jugular access. After that, the catheter was removed. The venography found inferior vena cava thrombi in 18 of 20 consecutive patients. A concomitant ultrasonography study showed vena cava thrombosis in only three patients. A vena cava filter was inserted in all patients where thrombi were found, without any significant complication. Anticoagulation was started in all patients. No symptomatic pulmonary embolism was diagnosed until the time of discharge. The frequency of thrombosis related to temperature management catheters is extremely high (90%). Furthermore, ultrasonography has a very low sensibility to detect cava vein thrombosis (16.7%). The real meaning of our findings is unknown, but other temperature control systems could be a safer option. More studies are needed to confirm our findings.

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).

Accesos venosos para hemodiálisis: abordaje yugular

It is not an uncommon event that patients with stabilized kidney failure or healthy individuals develop a sudden deterioration in their kidney function requiring dialysis, while lacking an adequate vascular access. In these situations, the implant of a double-lumen tunneled catheter within the internal jugular vein should be considered the best option to start hemodialysis.The vascular approach must be practiced preferentially on the right side, under ultrasound control and fluoroscopy guidance to verify the correct location of the tip of the catheter in the right atrium. Catheters with outer caliber between 13.5 and 15.5Fr can provide adequate blood flow for hemodialysis.As the use of different types of anticoagulants and antiplatelet drugs is so widely extended, it is necessary, before implanting the catheter, to check the coagulation parameters and platelet count; and, when required, the establishment of specific corrective actions to prevent hemorrhagic complications during the implant of the catheter should be undertaken.Gaining vascular access may involve complications. Infection or sepsis is not a rarity, and its prevention requires carrying out the procedure with strict adherence to the rules for an aseptic insertion of the implant, and performing an adequate care and cleaning after every use of the catheter. Anti-microbial solutions for sealing the lumen are also effective in this context, but if an infection develops, the catheter must be removed and an appropriate antibiotic regimen must be established. Other situations that may involve removal of the catheter are: malfunction, breaking, venous thrombosis and central venous stenosis or occlusion. However, there are cases of venous thrombosis in which, before removing the catheter, direct fibrinolysis may be tried. Similarly, in selected cases of central venous stenosis or occlusion, pneumatic dilatation with balloon catheter (angioplasty, APT) may be tried (once or more) to restore the venous caliber. Finally, in very infrequent situations in which APT fails, it is possible to implant a stent to resolve the stenosis; however, as it is frequently not effective in the medium term, it should only be considered as a last resort.In conclusion, jugular access for dialysis in patients without a competent internal arterio-venous fistula is an optimum choice. Although it presents a wide range of complications, if being expected, an effective and appropriate treatment may be safely established. As complications involving complex instrumentation, such as APT or stenting, show a low frequency (below 3%), jugular access can be considered a safe, comfortable and effective access for dialysis procedures.

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

Internal jugular and common femoral venous access for the removal of a long-term embedded vena cava filter

We describe an inferior vena cava filter retrieval technique requiring triple venous access performed in a 35-year-old male who was referred for filter removal 16 months after its insertion. The filter showed a right-sided tilt with endothelialization of the distal filter struts into the caval wall. Access was required via both internal jugular veins to straighten the filter using a snared-loop technique. Further 18 F right common femoral vein access was required to snare and remove the filter, which could not be completely collapsed distally due to endothelialized tissue, precluding normal removal via the jugular venous route.

E-036 Cadaveric Flow Model for Endovascular Simulated Interventions

Introduction/purposeThe benefits of learning on simulator have long been established across different areas of practice including medical industry. In particular recent technological advances have produced either flow models or simulators...

A personalized approach to interventional treatment of tricuspid regurgitation: experiences from an acute animal study.

Interventional treatment of tricuspid valve disease has so far received little attention due to the anatomical challenges in a thrombogenic surrounding. In the present study, we present an imaging-based, personalized interventional approach to the therapy of tricuspid regurgitation. In our porcine model, we used rapid prototyping to build a matrix reproducing the geometry of the right atrium that was previously derived from computer tomography (CT) scans. Over this matrix, a braided nitinol device fitting almost completely the right atrium was crafted. An additional tubular stent component was developed to carry a tissue valve prosthesis. This part was designed to be connectable to the annular portion of the main device. In our feasibility study, the crimped device was implanted via jugular access into the right atrium of 12 pigs and expanded subsequently. Following isolated implantation of the device without the valve-carrying component, further procedures included implantation of the whole composite device, including the mentioned tissue valve. Representing a only feasibility study, all implantations were performed under full bypass and direct sight. On-site visualization was performed by both echocardiography and fluoroscopy. Additional imaging was realized by postoperative CT scans. Following implantation, 9 of 12 animals were weaned from cardiopulmonary bypass. Correct positioning of the device and orthodromic blood flow as maintained by the valve prosthesis were demonstrated by echocardiography and fluoroscopy. Postoperative contrast CT evaluation demonstrated proper fitting of the device into the right-sided heart cavities without obstruction of the outflow tract. Autopsy additionally confirmed its correct positioning without major trauma to surrounding structures. We demonstrated the feasibility in principle of a personalized interventional treatment for tricuspid regurgitation using a braided stent, based on individual cardiac imaging, with anchoring forces mainly exerted on the venae cavae and on the inner surface of the right atrium. The design process of this device is a good indicator of the growing potential of an imaging-based personalized simulation and production approach for the treatment of tricuspid valve disease.

Cost effectiveness of different central venous approaches for port placement and use in adult oncology patients: evidence from a randomized three-arm trial.

No randomized trials have so far investigated the cost effectiveness of different methods for implantation and use of central venous ports in oncology patients. Overall, 403 patients eligible for receiving intravenous chemotherapy for solid tumours were randomly assigned to implantation of a single type of port, either through a percutaneous landmark access to the internal jugular vein, an ultrasound (US)-guided access to the subclavian vein, or a surgical cut-down access through the cephalic vein at the deltoid-pectoralis groove. Insertion and maintenance costs were estimated by obtaining the charges for an average implant and use, while the costs of the management of complications were analytically assessed. The total cost was defined as the purchase cost plus the insertion cost plus the maintenance cost plus the cost of treatment of the complications, if any. A total of 401 patients were evaluable-132 with the internal jugular vein, 136 with the subclavian vein and 133 with the cephalic vein access. No differences were found for the rate of early complications. The US-guided subclavian insertion site had significantly lower failures. Infections occurred in 1, 3, and 3 patients (internal jugular, subclavian, and cephalic access, respectively; p=0.464), whereas venous thrombosis was observed in 15, 8, and 11 patients, respectively (p=0.272). Mean cost for purchase, implantation, diagnosis and treatment of complications in each patient was <euro>2,167.85 for subclavian US-guided, <euro>2,335.87 for cephalic, and <euro>2,384.10 for internal jugular access, respectively (p=0.0001). US real-time guidance to the subclavian vein resulted in the most cost-effective method of central venous port placement and use.