Jugular Vein Research Articles

Coronary sinus reducer device for the treatment of refractory angina: a single center experience

Abstract Introduction The coronary sinus Reducer emerged as a complementary therapy in patients with angina refractory to optimal medical therapy and not amenable to revascularization. Aim The aim of this study was to assess the safety and efficacy of the Reducer in a real-world cohort of patients presenting with refractory angina. Methods and population Twenty-six patients with refractory angina, objective evidence of myocardial ischemia attributable to the left coronary artery and deemed unsuitable for revascularization were treated with Reducer at a single center between April 2018 and January 2023. Safety endpoints were procedural success and complications. Efficacy endpoints, assessed at 6-month, were a reduction in Canadian Cardiovascular Society angina (CCS) class and a reduction in pharmacological antianginal therapy. Results Twenty-one (81%) patients had end-stage coronary artery disease without targets for further revascularization (13 had previous CABG ± PCI and 8 had only PCI) and 5 patients had microvascular disease without epicardial stenosis. All procedures were performed via right jugular vein. The mean procedure and fluoroscopy duration were 66±29 and 19±8 minutes. Procedural success was achieved in all patients, with no device related complications. There was one cardiac tamponade, promptly treated with pericardiocentesis. Regarding the efficacy endpoint, 21 patients (81%) had at least 1 grade reduction in CCS class, 13 patients (50%) had at least 2 class reductions, and 7 patients (28 %) became asymptomatic, with a mean reduction of CCS class of 1.4±0.9, from 2.6±0.5 to 1.2±0.9 (p=0.001) at 6-month follow-up. During this time frame, twelve patients (46%) withdrew or reduced the dose of at least one anti-anginal drug. The mean reduction of anti-anginal drugs was 0.54 ±0.86, from 3.5±1.02 to 2.9±1.07 (p=0.04). Conclusion In this real-world, single-center experience, implantation of Reducer was safe and associated with improvement of angina and reduction of anti-anginal drugs intake in patients with refractory angina unsuitable for revascularization.

Multiparametric assessment of decongestion in patients admitted with acute heart failure: dynamic changes and correlation with natriuresis

Abstract Background Heart Failure (HF) is a major public health problem, expected to increase in the next few decades. The vast majority of acute HF (AHF) episodes are precipitated by congestion with volume overload and/or fluid redistribution. Current Guidelines stress on the importance of relieving congestion before discharge, recommending anyway only daily assessment of signs and symptoms. Lung ultrasound (LUS) B-lines and other ultrasound markers of congestion has emerged as valuable tools to improve diagnostic accuracy and help clinicians in fluid management. Purpose To assess the dynamic changes of B-lines and other markers of congestion and their relationship with the clinical evaluation, chest X-ray (CXR) and natriuretic peptides in patients admitted for AHF. Methods Fifty-eight patients (age 72±11 ys, 35% women) admitted with acute HF were enrolled. Patients underwent clinical evaluation (Clinical Congestion Score, CCS, including rales, pathological S3 heart sound, pedal oedema, jugular vein distension; range 0-4), and CXR (CXR score, including enlargement and loss of definition of hilar structures, peribronchial and perivascular cuffing, cardiomegaly, pleural effusion; range 0-4). An integrated multiorgan ultrasound exam including LUS B-lines, echocardiography, and venous excess ultrasound (VExUS) score was performed at admission (T0), between 24 and 48 hours from T0 (T1), and at discharge (T2). Follow-up data at 30 days were collected. Results Mean CCS was 1.52±0.99 at T0, with a reduction at T1 (0.86±0.66; p<0.01), and at T2 (0.34±0.66; p<0.01). Sixteen percent of patients with a CCS=0 at T0 showed, however, persistent B-lines on LUS (mean B-lines 19±6). The mean number of B-lines was 26±12 at T0 with a reduction at T1 (17±11; p<0.001), and at T2 (13±11; p<0.001). Other echocardiographic non-invasive hemodynamic parameters, such as pulmonary artery systolic pressure (PASP) and E/e’ showed a reduction only at T2, but not at T1 (figure). The number of B-lines correlated at all time points with CCS, CXR score, VExUS score, and NT-proBNP values (all p<0.05). We divided patients into two groups: "responders" (with ≥15 reduction of B-lines between T0 and T2) and "non-responders" (with <15 reduction of B-lines between T0 and T2). Responders had higher chlorine and sodium urinary excretion at T1 compared to non-responders. The number of B-lines at all time points was associated to 30-days cardiovascular mortality at univariable analysis. Neither CCS nor CXR score were associated with 30-day events. Conclusions In patients with acute HF, B-lines quantification is related to standard congestion assessment based on clinical evaluation, CXR and NT-proBNP, showing, however, a more dynamic behaviour in the assessment of decongestion. B-lines variations are also related to diuresis and chlorine urinary output, a recognized predictor of diuretic response. Persistent congestion is related to an increased risk of hospitalization and death.

Importance of the left superior ganglionated plexus ablation for the denervation of atrioventricular node: the impact of patient gender and bradycardia phenotype

Abstract Background Cardioneuroablation has been proposed as a new therapeutic option in selected patients with symptomatic functional bradyarrhythmia including recurrent neurally-mediated syncope. The contribution of individual ganglionated plexi to cardiac autonomic regulations is not fully established. Purpose It appears that ablation of the left superior ganglionated plexus (LSGP) is inoperable for the denervation of the sinoatrial node (SAN) and infrequently required for the denervation of the atrioventricular node (AVN). We explored the conditions that are associated with the need for LSGP ablation. Methods The study included 177 otherwise healthy patients aged 41 ± 12 years; 55% of males; 36% with predominant AVN disorder (29% in males, 44% in females, P <0.05) who underwent their first cardioneuroablation for symptomatic bradyarrhythmias at our centre between 2019 – 2024. Anatomically-navigated radiofrequency ablation with a bi-atrial approach was performed. In all patients, we ablated first the superior paraseptal (former right superior) ganglionated plexus (SPSGP) and inferior paraseptal (former posteromedial left) ganglionated plexus (IPSGP). Extracardiac vagus nerve stimulation (ECVS) via right and left jugular vein in general anaesthesia was used to assess the residual parasympathetic modulation of the AVN. If AVN was not completely denervated after the SPSGP and IPSGP ablation, the LSGP was targeted. Results Ablation of SPSGP and IPSGP resulted in SAN and AVN denervation in the majority of patients. LSGP ablation was required in 39 / 177 (22%) patients; in 31% of females vs. 14% of males (P <0.01); in 41% vs. 12% (P <0.0001) of patients with predominant AVN vs. SAN disorder, respectively. The corresponding decomposition is provided in the Table. In multivariate analysis, both female gender (P <0.05) and AVN disorder (P <0.001) were independently associated with the need for LSGP ablation. When the population was dichotomized into early (September 2019 – December 2021) and recent period (January 2022 – February 2024), the need for LSGP ablation had a downward trend (28% vs. 16%, P <0.05). Conclusions LSGP ablation to finalize the AVN denervation is required in a minority of patients. This need is independently associated with the female gender and predominant AVN disorder. The ECVS guidance in the ablation of SPSGP and IPSGP contributes to the decreasing trend of LSGP ablation, i.e. minimizing the final lesion set.Rate of LSGP ablation

Severe cervical hematoma following central venous puncture under ultrasound guidance in a patient with acute myeloid leukemia: a rare case report

We report the case of a 56-year-old male diagnosed with acute myeloid leukemia who developed a severe cervical hematoma following an ultrasound-guided right internal jugular vein catheterization. Despite receiving platelet transfusions prior to the procedure, the patient experienced progressive hematoma enlargement, leading to respiratory distress. Further investigations, including carotid Computed Tomography Angiography (CTA), ruled out arterial injury, but thromboelastography revealed severe coagulation dysfunction. The patient subsequently developed cerebral hemorrhage and died despite intensive care interventions.

Hemodynamic effects of vericiguat in symptomaticHFrEF patients: insights from right heart catheterization study

Abstract Background Vericiguat is recommended in the guidelines as Class IIb for patients with heart failure with reduced ejection fraction (HFrEF) who continue to have persistent symptoms despite receiving standard therapy. However, the precise effects of vericiguat on pulmonary and systemic hemodynamics and cardiac performance remain unclear. Purpose This study aimed to investigate the hemodynamic impact of vericiguat in 12 symptomatic HFrEF patients who experienced worsening HF despite receiving standard therapy with the four foundational heart failure medications, using right heart catheterization (RHC). Methods On day 1, RHC was performed via the right internal jugular vein and a balloon-tripped pulmonary artery thermodilution catheter was placed. On day 2 and 3, RHC data were measured at 15min before and 30min, 1hr, 2hr, 3hr and 5hr after intake of 2.5mg vericiguat. RHC data on day 2 and 3 were averaged and the catheter was removed after the RHC measurements on day 3. RHC was repeated on a median day of 105(quartiles 37,168). The acute hemodynamic effects of vericiguat were assessed using a comparison of six RHC measures, including pulmonary artery wedge pressure (PAWP), mean pulmonary artery pressure (MPAP), mean arterial blood pressures (MABP), pulmonary (PVR) and systemic vascular resistances (SVR) and cardiac index (CI), at 15minutes before intake of vericiguat 2.5mg with those at 30minutes to 5hours after that. The chronic hemodynamic effects of vericiguat were evaluated by comparing the six RHC measures on day 1 with those on day 105(37,168). Results Participant characteristics on day 1 were age 63.5(53.5,70)yrs., 16.7%(N=2) women, height 164.3(155,171.3)cm, weight 64.6(54.8,75.1)kg, body mass index 23.8(20,26.3), systolic 101.5(90.5,111.5)mmHg and diastolic blood pressures 60.2(53.5,65)mmHg, heart rate 65.5(56,72)bpm, New York Heart Association functional class Ⅱ 50%(N=6), Ⅲ 16.7%(N=2) and Ⅳ 33.3%(N=4), estimated glomerular filtration rate 44.5(34.5,53.5)mL/min/1.73m2, left-ventricular ejection fraction 19.9(14.5,24.5)% and diastolic diameter 68(60.5,72.5)mm, left-atrial diameter 45(36.5,50.5)mm and brain natriuretic peptide level 419(254,479)pg/mL. Oral intake of vericiguat 2.5mg decreased PAWP (11[7.5,15]mmHg) and MPAP (19.3[14.3,26.8]mmHg) before the intake to PAWP (9.3[6.8,14]mmHg) and MPAP (17.5[12.5,24]mmHg) at 30min after that (both P<0.05[crude P<0.0017])(Figure A) while comparable changes in MABP, PVR, SVR and CI and the other timepoints (all P>0.05[crude P<0.0017]). Vericiguat was titrated to 2.5mg 25% (N=3), 5mg 50% (N=6) and 10mg 25% (N=3) on day 105 (37,168), in which PAWP (9.5[6.5,12.5]mmHg) was decreased from PAWP (14.5[9.5,19.5]mmHg) on day 1 (P<0.05[crude P<0.0083])(Figure B) while comparable changes in the other RHC parameters (all P>0.05[crude P<0.0083]). Conclusions The consistent reduction in PAWP underscores vericiguat's well-tolerated nature and potential to enhance cardiac performance in patients with HFrEF.

Scoring system for early detection in pulmonary hypertension type I based on clinical presentation, electrocardiography, and chest X-ray at RSUD dr. Saiful Anwar

Background: In Indonesia, pulmonary hypertension prevalence is 1:10.000 population. Due to its atypical symptoms, often PH patients come as a late presenters thus they have a worse prognosis. The golden standard to diagnose is Right Heart Catheterization (RHC) which is not widely available. Objectives: To generate a scoring system based on clinical presentation, electrocardiogram, and chest x-ray for early detection. Methods: A hospital-based cross-sectional survey was conducted in RSUD dr. Saiful Anwar, East Java from July 2020 – November 2023 with data from the medical record in which all variables are obtained at one period. Data were analyzed using bivariate analysis, multiple logistic regression, and Area Under Curve (AUC) from Receiver Operating Characteristic (ROC). Results: A total of 244 patients who were above 18 years old were conducted RHC at RSUD dr. Saiful Anwar East Java. We found a total score of 12 consisting of Dyspnea on Effort (DOE) score 2, Palpitation score 1, Increasaed P2 score 2, Increased JVP (Jugular vein pressure) score 2, RV (Right Ventricular) Heaves score 2, Right bundle branch block (RBBB) score 1, and Cardiomegaly (CTR >50%) score 2. With a 2 x 2 table, we found that a score of ⩾5 is likely for pulmonary hypertension diagnosis. Conclusion: Our study is a predictive model with a scoring system that has good sensitivity and specificity in selected populations where one of its limitations is sampling bias thus cannot yet be applied to the general population and needs further research for validation. Keyword: congenital heart disease, pulmonary hypertension, scoring for early detection

Phase-contrast MRI analysis of cerebral blood and CSF flow dynamic interactions

BackgroundFollowing the Monro-Kellie doctrine, the Cerebral Blood Volume Changes (CB_VC) should be mirrored by the Cerebrospinal Fluid Volume Changes (CSF_VC) at the spinal canal. Cervical level is often chosen to estimate CB_VC during the cardiac cycle. However, due to the heterogeneity in the anatomy of extracranial internal jugular veins and their high compliance, we hypothesize that the intracranial level could be a better choice to investigate blood and cerebrospinal fluid (CSF) interactions. This study aims to determine which level, intracranial or extracranial, is more suitable for measuring arterial and venous flows to study cerebral blood and CSF dynamics interactions.MethodsThe spinal CSF and cerebral blood flow measured at intracranial and extracranial levels were quantified using cine phase-contrast magnetic resonance imaging (PC-MRI) in 38 healthy young adults. Subsequently, CSF_VC and CB_VC were calculated, and by linear regression analysis (R2 and slope), the relationship between CB_VC at both levels and the spinal CSF_VC was compared. The differences between extracranial and intracranial measurements were assessed using either a paired Student’s t-test or Wilcoxon’s test, depending on the normality of the data distribution.ResultsThe CB_VC amplitude was significantly higher at the extracranial level (0.89 ± 0.28 ml/CC) compared to the intracranial level (0.73 ± 0.19 ml/CC; p < 0.001). CSF oscillations through the spinal canal do not completely balance blood volume changes. The R2 and the slope values obtained from the linear regression analysis between CSF and blood flows were significantly higher in magnitude for the intracranial CB_VC (R2: 0.82 ± 0.16; slope: − 0.74 ± 0.19) compared to the extracranial CB_VC (R2: 0.47 ± 0.37; slope: -0.36 ± 0.33; p < 0.001). Interestingly, extracranial CB_VC showed a greater variability compared to intracranial CB_VC.ConclusionOur results confirmed that CSF does not completely and instantaneously balance cerebral blood expansion during the cardiac cycle. Nevertheless, the resting volume is very small compared to the total intracranial volume. To our knowledge, this study is the first to demonstrate these findings using cerebral blood flow measured intracranially below the Circle of Willis. Additionally, our findings show that cerebral arterial and venous flow dynamic measurements during the cardiac cycle obtained by PC-MRI at the intracranial plane strongly correlate with CSF oscillations measured in the spinal canal. Therefore, the intracranial vascular plane is more relevant for analyzing cerebral blood and CSF interactions during the cardiac cycle compared to measurements taken at the cervical vascular level.

Single center experience of internal jugular vein as alternative access for implantation of a wireless pulmonary artery pressure sensor

Abstract This single-center study delves into the novel use of the internal jugular vein (IJ) as an alternative access pathway for the implantation of the CardioMEMS device, a wireless pulmonary artery pressure sensor. This approach is compared to the conventional femoral vein access in terms of procedural times, contrast volume, and patient outcomes. The study spans five years, from 2018 to 2023, evaluating the efficacy and safety of IJ access for CardioMEMS implantation. The analysis revealed a tendency towards shorter procedural times and reduced contrast volume with IJ access, although statistical significance was not reached due to the small sample size. Notably, IJ access provided a quicker needle-to-door time, suggesting benefits such as improved patient throughput and potentially shorter hospital stays, which are pivotal in a healthcare landscape that prioritizes efficiency and cost-effectiveness. In conclusion, this investigation offers initial evidence that IJ vein access is a feasible and potentially superior alternative for CardioMEMS device implantation. While the findings are preliminary due to the study's limited scale, they pave the way for future larger-scale, multicenter studies. Such research could confirm the benefits of IJ access and possibly influence clinical practices, enhancing the management of heart failure patients.

Internal Jugular Phlebectasia; A Challenging Neck Mass in Children

Cystic neck masses are uncommon in children, and a minority of them are soft. Internal jugular vein phlebectasia (IJVP) is a rare cause of soft neck cysts. It presents usually as a unilateral soft neck mass of changing size. In most cases it is unilateral, right sided and predominantly in males. Imaging study modalities are diagnostic and helpful for observation and follow up. In the vast majority of cases, it decreases in size with time requiring only conservative treatment. However, surgery might be necessary in large or complicated phlebectasia. IJVP is underdiagnosed or misdiagnosed especially in pediatrics, with few cases documented in medical literature. To improve awareness of presentation and management-plan of this rare case, the authors present an extremely rare case of huge left internal jugular phlebectasia in a 14 year-old boy worsened and complicated over years of wait and see approach that needed surgical treatment.

Mid-term efficacy of single anastomosis duodenal-ileal bypass with sleeve gastrectomy in the treatment of obesity and type 2 diabetes mellitus

Objective: To evaluate the mid-term efficacy of single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) in the treatment of obesity and type 2 diabetes mellitus. Methods: The cohort of this retrospective observational study comprised 118 obese patients with body mass index (BMI) ≥40 kg/m2 with or without other related metabolic diseases and BMI of (27.5-40.0) kg/m2 with type 2 diabetes mellitus (T2DM) who had been treated with SADI-S. Patients who had undergone modified surgery or been followed up for less than 1 year were excluded. Clinical data of the included patients [56 men and 62 women aged (34.5±9.7) years], who had undergone SADI-S in China-Japan Union Hospital, Jilin University from October 2018 to August 2022, were collected. Their mean preoperative body mass was (125.9±25.0) kg and BMI (42.8±6.8) kg/m2. The 60 patients with T2DM had a mean fasting blood glucose of (9.9±3.2) mmol/L and HBA1c of (8.4±1.7) % before surgery. The main outcome measures were mid-term weight loss after surgery (body mass, BMI, excess weight loss, and total weight loss) 1, 2, 3, and 4 years after surgery and efficacy regarding diabetes mellitus (fasting blood glucose, glycated hemoglobin and diabetes remission rate at 1, 2, and 3 years after surgery). Outcomes were defined as follows. Complete remission: HbA1c <6% or fasting blood glucose <6 mmol/L without hypoglycemic medication; partial remission: HBA1c <6.5% or fasting blood glucose <7 mmol/L without hypoglycemic medication; significant improvement: HBA1c <7.0%, stable decrease of at least 1% compared with preoperative HBA1c, and postoperative dose of hypoglycemic medication significantly less; ineffective: no change in HBA1c and no reduction in dosage of hypoglycemic medication. Other outcome measures included intraoperative and postoperative adverse effects and postoperative nutritional indexes. Results: SADI-S was successful in all patients. There was no significant bleeding, conversion to open surgery, or perioperative death. The operation time was (186.1±41.5) minutes, and the postoperative hospital stay 6 (5-7) days. Surgical complications occurred in four patients, comprising peritoneal effusion, internal jugular vein thrombosis, anastomotic leakage, and gastric fistula. Body weight and BMI 1, 2, 3 and 4 years were significantly lower post- than pre-operatively (all P<0.05). Excess weight loss was (81.9±16.2) %, (82.2±15.5) %, (88.3±20.1) %, and (83.2±18.1) % at 1, 2, 3, and 4 years postoperatively, respectively. Total weight loss was (39.7±8.7) %, (40.6±10.6) %, (42.2±11.5) % and (45.4±10.2) %, respectively. The mean fasting blood glucose concentrations of the 60 patients with T2DM were (5.1±1.0) mmol/L, (5.0±0.7) mmol/L, and (5.4±0.9) mmol/L 1, 2 and 3 years postoperatively, respectively. The values for glycosylated hemoglobin were (4.9±0.6) %, (4.8±0.5) %, and (5.1±0.8) %, respectively, all of which are significantly lower than preoperatively (all P<0.05). The complete remission rate of diabetes was 95.0% (38/40), 90.0% (36/40), and 9/13 1, 2, and 3 years postoperatively, respectively. Additionally, the partial remission rate and significant improvement rate were both 100%. Two years postoperatively, the incidence of anemia was 27.8% (10/36), of hypoproteinemia 11.8% (4/34), and of ferritin deficiency 25.8% (8/31), all of which were improved by conservative treatment such as blood transfusion, iron supplementation, and adjustment of diet. Conclusion: SADI-S has a significant mid-term beneficial effect on weight loss and diabetes remission status in patients with obesity and type 2 diabetes.

A case report on the choice of venous access after ectopic peripherally inserted central catheter in an upper limb of a patient with a second recurrence of right-side breast cancer.

Intravenous catheter placement in the healthy upper extremity is preferred for chemotherapy in patients with breast cancer. Common venous accesses are peripherally inserted central catheters (PICCs) and totally implantable intravenous port catheters (TIVPs). In this case, a patient with breast cancer had a history of infusion port placement through the left internal jugular vein, with ipsilateral innominate vein stenosis after placement. The patient was re-treated with a PICC placed ectopically through the left upper limb into the intrathoracic vein. After multidisciplinary consultation, a transfemoral PICC combined with intracavitary electrocardiography (IC-ECG) was performed to establish venous access. This case can assist PICC catheterization nurses in developing optimal venous access strategies tailored to the specific situations of patients in similar situations. Through adequate evaluations and optimal selection of venous access, the success rate of disposable catheterization can be improved, and the risk of complications reduced. A 53-year-old female with breast cancer had a history of infusion port, with ipsilateral innominate vein stenosis after placement. The patient was re-treated with a PICC placed ectopically through the left upper limb into the intrathoracic vein. An axial computed tomography (CT) image before totally implantable venous access port (TIVP) placement and An axial CT 103 days after TIVP placement shows diffuse stenosis of the left innominate vein, associated with infusion port placement through the left internal jugular vein. After multidisciplinary consultation, a transfemoral PICC combined with intracavitary electrocardiography (IC-ECG) was performed to establish venous access. The patient's lower limb PICC was left in place for 201 days with no complications, completing the full treatment cycle. This case presents a rare and insightful clinical scenario. For patients with a history of infusion port placement, particularly via the left internal jugular vein, careful analysis of the innominate vena cava and examination of chest wall vein exposure are essential to determining the optimal vascular access strategy.

COMPARISON OF NEUTROPHILAND LYMPHOCYTE (N/L) RATIO IN SAPERAAND CROSSBRED ETAWAH GOATS IN SAYEGAN, SLEMAN, YOGYAKARTA AND ITSSOROUNDING AREA

Neutrophil and lymphocyte ratio (N/L) can be used as a chronic stress indicator inanimal. Increase of N/L ratio indicates stress in animal that marked by neutrophilia and lymphopenia. The study was aimed to determine the comparison of N/L ratio in Sapera an Ettawah crossbreed goats.The samples of this study were obtained from 126 Sapera goats and 99 Ettawah cross breed goats with various physiological condition status (rams, pregnant ewes, nanny goats, ewes, young rams, young ewes, and lactating goats)that are clinically healthy from farm in Seyegan, Sleman, and its surrounding. Blood samples were taken through jugular vein in the morning, the blood smear were made to calculate leukogram. The average calculation results of N/L ratio in Sapera goat group is 0.55±0.,57and Ettawah crossbreed goat group is 0.47±0.44.The results of the statistical analysis using the One-Way Analysis of Variance test showed an insignifi cant difference in the N/L ratio (p &gt; 0.05) between groups of Sapera and Ettawah crossbreed goats. It can be concluded there was no significant influence of the breed and physiological status difference in Sapera and Ettawah crossbreed goat's blood N/L ratio.

Development of a Porcine Model of Arteriovenous Fistula Venous Stenosis Treated with Percutaneous Transluminal Angioplasty

To develop a porcine model for arteriovenous fistula (AVF) venous stenosis treated with percutaneous transluminal angioplasty (PTA) and compare outcomes of plain balloon angioplasty (POBA) to IN.PACT paclitaxel drug-coated balloons (DCB). Twelve castrated male Yorkshire pigs (4-5 months, 35-45kg) underwent renal artery embolization to induce chronic kidney disease (CKD). Twenty-eight days later, AVF was created by anastomosing the left external jugular vein to left common carotid artery. The pigs were divided into a pilot group (n=6) for optimizing the AVF technique (euthanized at day 4) and a definitive group (n=6) for validating PTA outcomes (euthanized at day 42). Stenosis developed at juxta-anastomosis 28 days later and was treated with POBA [pilot group (n=6), definitive group (n=3)] or DCB [definitive group only (n=3)]. Definitive group underwent biweekly 4D Flow MRI scans. All animals developed CKD, with significant increases in BUN (median increase: 2.6 to 3.2 mmol/L, P<0.001) and creatinine (median increase: 100 to 187 μmol/L, P<0.001). In the pilot group, one animal had an infected fistula, and AVF patency was 1/5. In the definitive group, the patency was 5/6 because the AVF technique was modified by resecting the sternomastoid muscle and increasing the spatulation. At day 42 post PTA, DCB treated AVF outflow vein showed increasing blood flow compared to POBA (DCB 209.8 ± 64.42 mm2 vs POBA 170.9 ± 95.52 mm2 p = 0.934). A porcine model of AVF venous stenosis treated with PTA was developed, with blood flow trends favoring DCB over POBA.

Revisiting Virchow’s triad: exploring the cellular and molecular alterations in cerebral venous congestion

BackgroundCerebral venous thrombosis (CVT) is a rare but serious condition that can lead to significant morbidity and mortality. Virchow’s triad elucidates the role of blood hypercoagulability, blood flow dynamics, and endothelial damage in the pathogenesis of CVT. Cerebral venous congestion (CVC) increases the risk of cerebral venous sinus thrombosis and can lead to recurrent episodes and residual symptoms. However, the precise mechanism by which blood congestion leads to thrombosis remains unclear. Our objective was to investigate the cellular and molecular alterations linked to CVC through analysis of the pathological morphology of venous sinus endothelial cells and transcriptomic profiling.ResultsThis study demonstrated a remarkable correlation between CVC and the phenotypic transformation of endothelial cells from an anticoagulant to a procoagulant state. The findings revealed that cerebral venous stasis results in tortuous dilatation of the venous sinuses, with slow blood flow and elevated pressure in the sinuses and damaged endothelial cells of the retroglenoid and internal jugular vein ligation (JVL) rat model. Mechanistically, analysis of transcriptomic results of cerebral venous sinus endothelial cells showed significant activation of platelet activation, complement and coagulation cascades pathway in the JVL rats. Furthermore, the expression of von Willebrand factor (vWF) and coagulation factor VIII (F8) in the complement and coagulation cascades and Fgg and F2 in the platelet activation was increased in the cerebral venous sinuses of JVL rats than in sham rats, suggesting that endothelial cell injury in the venous sinus induced by CVC has a prothrombotic effect. In addition, endothelial cell damage accelerates coagulation and promotes platelet activation. Significantly, the concentrations of vWF, F2 and F8 in venous sinus blood of patients with internal jugular vein stenosis were higher than in their peripheral blood.ConclusionCollectively, our data suggest that CVC can induce endothelial cell damage, which then exhibits a procoagulant phenotype and ultimately increases the risk of CVT. This research contributes to our understanding of the pathophysiology of CVC associated with procoagulant factors and reexamines the components of Virchow’s triad in the context of CVC.

Central Venous Catheter Migration Into Pleura Diagnosed by Transesophageal Echocardiography.

Central venous catheter (CVC) tip migration is a well reported delayed complication of these vascular access devices with left-sided internal jugular or subclavian vein placement being the primary risk factor for this complication. We report a case of left internal jugular CVC migration and its diagnosis made by the heretofore unreported use of intraoperative transesophageal echocardiography in this context. Moreover, we describe risk factors for CVC migration along with its diagnosis and management.

Connecting the dots: Linking superior ophthalmic vein and internal jugular vein diameter to carotid cavernous fistula type and location.

The specific objectives of this study are to identify the carotid cavernous fistula (CCF) type based on computerized tomography angiography (CTA) results, determine the cut-off diameter of the superior ophthalmic vein (SOV) and internal jugular vein (IJV) in CCF patients, and to evaluate the correlation between diameters of the right and left SOV and IJV with CCF type and location. A retrospective analysis of data from 35 CCF patients at our institution was conducted between January 2016 and October 2022. The analysis separated the vascular diameters of the right and left SOV and IJV, which were compared to 35 non-CCF patients. The non-CCF group consisted of individuals who underwent CTA for conditions unrelated to vascular abnormalities. In 35 CCF patients, the dilatation of the left SOV was significantly correlated with direct CCF type with a cutoff of >0.5 cm and significantly associated with indirect CCF type with a cutoff of <0.5 cm (P = 0.017), while the right SOV was not significantly correlated (P = 0.187). There was no significant correlation between the right and left IJV with CCF type or location (right IJV, P = 0.996 and left IJV, P = 0.558). However, the analysis indicated that IJV size differences between CCF and non-CCF patients were significant. Dilation of the left SOV correlates with both direct and indirect CCF types, while the right SOV and IJV (both sides) do not show a significant correlation with CCF type or location. This suggests that left SOV dilation may serve as an early indicator of CCF type, particularly in cases involving the left side.

Carotid Endarterectomy with Twisted Internal Jugular Vein Located Anterior to the Common Carotid Artery

AbstractThe knowledge of both normal and abnormal anatomy of the veins of the neck may be important for surgeons performing carotid endarterectomy (CEA), to avoid inadvertent injury to vascular structures. We present three cases of abnormal course of the internal jugular vein (IJV) which run anterior to the common carotid artery, named twisted IJV, that usually run posterolateral to the common carotid artery in patients undergoing CEA. These twisted IJV cases were detected by preoperative multidetector computed tomography angiography evaluation. During the CEA procedure, before identifying the common carotid artery, we dissected the retromandibular space to find the common facial vein. Then, dissection proceeded along the common facial vein caudally to find the IJV. After ligation and cutting of the common facial vein, a carotid sheath with the IJV turned laterally revealed the common carotid artery safely, and CEA was accomplished. Our clinical experience shows that knowledge of the anatomical anomaly of the IJV allows safe dissection of the carotid triangle avoiding inadvertent injury to the vasculature and vagus nerve.

Cervical heterotopic heart transplantation in mice using a novel suture technique

BackgroundVascularized transplantation models in mice are critical to understand mechanisms that mediate rejection and to develop new therapeutics. Standard abdominal heterotopic heart transplantation techniques employ an end-to-side suture technique and are the workhouse of transplant immunology research laboratories. Recently, cervical heterotopic heart transplantation in mice has emerged as an alternative due to several advantages but is conventionally performed by suture or cuff techniques in an end-to-end fashion. Therefore, we introduce an end-to-side anastomosis technique. MethodsThe donor pulmonary artery is end-to-side anastomosed to the recipient right external jugular vein, using a continuous 10-0 nylon suture. Vascular suturing is accomplished inside the vessel on the posterior wall, and then outside the vessel on the anterior wall. Finally, the donor ascending aorta is end-to-side anastomosed to the recipient common carotid artery with an identical suture technique. ResultsThe median times for the donor heart harvest, recipient preparation, anastomoses of the pulmonary artery to the external jugular vein, and the ascending aorta to the common carotid artery were 12, 10, 12 and 11 min, respectively. The survival rate was 100% (n=20). ConclusionsWe provide a detailed description of how to perform end-to-side anastomoses using a suture technique in the mouse cervical heart transplantation model. This procedure reconstitutes coronary blood flow in the heart graft with minimal interruption to recipient anatomy and provides an experimental platform to study transplant immunology.

Evaluation of the Safety and Effectiveness of Ultrasound-guided Internal Jugular Vein Catheterization in Critically Ill Patients

Background:Central venous catheterization is a frequently performed procedure in intensive care units (ICU) for diagnostic and therapeutic purpose. As an invasive procedure it carries some risk and should be performed with few attempts. Traditionally this procedure is performed blindly by considering body surface landmark, but this procedure can be done with the help of ultrasound machine as an alternative of landmark procedure. Objectives: Evaluation of the safety and effectiveness of USG-guided internal jugular vein(IJV) catheterization in critically ill patients. Methods: This prospective observational study was conducted in the ICU of Dhaka Medical College Hospital, from May 2017 to October 2018. Patients scheduled for central venous catheterization via the IJV were included based on selection criteria and randomly allocated into two groups of 50 patients each using card sampling. Group A received ultrasound-guided catheterization, while the landmark technique was used in Group B. Results: The analysis revealed that in the ultrasound group 49 out of 50 (98.0%) patients were successfully catheterized while the landmark method was successful in 45 out of 50 (90.0%) patients. Successful catheterization by first attempt was possible in 29 patients of group A, where as it was 5 in group B. The average number of attempts for successful catheterization in Group A was 1.7 (SD=0.2) and in the landmark group it was 2.8 (SD=0.1). On the average, 4.9 minutes (SD=1.3) were needed for catheterization in ultrasound group. The time was significantly increased in the landmark group 11.4 (SD=5.8). Total number of complication was 2 in Group A and it was 8 in Group B. After considered all the above parameter, by using four points safety and effectiveness rating scale, safety and effectiveness mean score was 10.3 for Group A and 8.2 for Group B. Conclusion: Two-dimensional ultrasound offers improved safety and quality when compared with an anatomical landmark technique for IJV catheterization. Bangladesh Crit Care J September 2024; 12 (2): 96-104

Rat Model of Menopausal/Andropausal Hypertension with Different Sensitivities to Non-Genomic Antihypertensive Responses of Female and Male Sex Steroids

Introduction: Hypertension is prevalent in older women and men, but the impact of sex differences is unclear. Methods: Blood pressure (BP) was evaluated weekly for 15 weeks using tail-cuff plethysmography in intact or gonadectomized female and male rats. Similarly, gonadectomized rats were subcutaneously treated daily for 15 weeks with estradiol in females or testosterone in males. Treatment with estrogen in males and androgen in females for BP was also examined. The non-genomic antihypertensive potency and efficacy of different sex steroids were determined; catheters were implanted in the carotid artery of hypertensive rats for BP recording with bolus injections in the jugular vein at cumulative doses (1 × 10−7−1 × 10−4M kg−1 min−1) of dehydroepiandrosterone (DHEA), estradiol, testosterone, or 5β-dihydrotestosterone (5β-DHT). Results: Data showed a time-dependent increase in BP after gonadectomy in female and male rats until hypertension values were reached. Males are more sensitive to the development of hypertension than females. The increases in BP in females and males were completely prevented by estradiol or testosterone, respectively. Testosterone completely prevented hypertension in females, whereas estradiol only partially in males. Antihypertensive potencies in conscious hypertensive rats were DHEA = 5β-DHT = testosterone >> estradiol, in females and DHEA = 5β-DHT >> testosterone >> estradiol in males. The efficacy was DHEA = 5β-DHT = testosterone >> estradiol in females and 5β-DHT = DHEA >> testosterone >> estradiol in males. Conclusion: Gonadectomized males developed hypertension faster than females, suggesting that androgen deficiency plays an important role in BP reduction. Antihypertensive responses of steroids are structure-dependent; estradiol demonstrated the lowest potency, whereas 5β-DHT was a potent antihypertensive without estrogenic and androgenic actions, suggesting it is as a therapeutic candidate for controlling hypertension in both sexes.