Mean Access Time Research Articles

A Comparison of the Alken Metallic Telescopic Dilator and Amplatz Serial Dilator for Renal Access in Percutaneous Nephrolithotomy.

Access to the renal calyx is a challenging and crucial step for a successfulpercutaneousnephrolithotomy (PCNL). There are different methods of access tract dilatation, and there is no consensus on which method is the best. We conducteda comparative retrospective study on the safety and efficacy of the Alken metallicdilator and Amplatzdilator for renal access inPCNL. We retrospectively reviewed the medical records of80 patients who underwent PCNL between March 2023 and February 2024, and they were divided into two groups.Group A (n=42) comprised patients where Alken dilators were used, while group B (n=38) comprised patients where Amplatz dilators were used. Safety parameters, that is, perioperative bleeding, blood transfusion, access time, postoperative fever, and urosepsis, were compared between the groups. Efficacy in terms of successful renal access and stone clearance was also compared. The mean access time (mins) was longer in group B than group A (8.1 vs. 7.3, p=0.012).The intraoperative bleeding was more in group B (15.7% vs. 4.7%, p<0.001). Group B had more hemoglobin (g/dl) drop (1.3 vs. 0.7, p<0.001) and need for blood transfusion (18.4% vs. 7.14%, p<0.001) and VAS score (p<0.001) than group A.Postoperative urosepsis was more common in group B. Efficacy in terms of successful renal access and stone clearance was comparable. The Alken dilator group has a lower rate of blood transfusion and postoperative VAS score. The Amplatz dilator group had more incidences ofpostoperative urosepsis. The efficacy in both groups was comparable.

Comparison of radial artery occlusion between traditional radial access and distal radial access for coronary angiography and intervention: A prospective cohort study

BackgroundThe radial approach is now recommended as the default strategy in diagnostic coronary angiography and percutaneous coronary intervention. Radial artery occlusion (RAO) is the most common complication that limits subsequent angiographic procedures through this access. Recently, distal radial access (DRA) has been recommended as an alternative access site. Despite lower RAO rates in DRA in some recent clinical trials, concerns remain regarding possible complications and limitations due to the small size of the distal radial artery. ObjectiveThe present study aimed to compare traditional radial access (TRA) and DRA concerning RAO in percutaneous coronary procedures. MethodsIn the present prospective cohort study, percutaneous coronary procedures were performed via DRA or TRA in 2 study groups. All consecutive participants underwent DRA from September 2021 to March 2022 and TRA from April 2022 to June 2022. Ultrasonography was performed preprocedurally in the DRA group, and patients with small distal artery diameters (<2 mm) were excluded. The same 6-Fr sheaths and standard air-filled compression devices were used in both groups. The primary endpoint was RAO in ultrasound sonography on the first postprocedural day, and the secondary endpoints were the success rate, access time, angiography time, radial artery spasms, and vascular access complications. ResultsA total of 298 patients were assigned to the DRA group and 278 to the TRA group. The RAO rate was significantly higher in the TRA group than in the DRA group (10.1 % vs 0.9 %; P = 0.0001; OR, 0.08, 95 % CI, 0.01–0.27). The success rate was significantly higher in the TRA group (96 % vs 90.2 %; P = 0.009). Access crossovers were done on 12 patients (4.0 %) in the TRA group and 24 patients (9.8 %) in the DRA group (P < 0.001). The mean access time was significantly lower in the TRA group than in the DRA group (1.9 min vs 2.9 min; P < 0.001). The mean angiography time did not significantly differ between the groups (10.2 min in the TRA group vs 9.9 min in the DRA group). The rate of radial artery spasms was not significantly different between the 2 groups (13.8 % in the TRA group vs 14.5 % in the DRA group). The rates of access site hematoma (12.4 % vs 2.3 %; P < 0.001) and bleeding (10.7 % vs 4.1; P = 0.005) were significantly higher in the TRA group. ConclusionsDRA was safe and feasible with lower rates of RAO and access site complications than TRA. Thus, it could be used as an alternative approach in percutaneous coronary procedures. However, the trade-off for these advantages of DRA is an increase in cross-over rate, and a decrease in puncture success rate.

Current alternatives to traditional radial approach for coronary interventions: A randomized prospective study of the ulnar and distal radial approaches.

The radial artery is the standard access for coronary intervention; however, it is essential to have alternative accesses as it may be used as a conduit during coronary artery bypass grafting or for dialysis fistula. Ulnar and distal radial artery accesses have emerged as alternative accesses for traditional radial artery. To compare distal radial artery access and ulnar artery access as alternatives to traditional radial artery access regarding safety, efficacy, and success rate. Two-hundred patients were included (100 traditional radial [TRA], 50 distal radial [DRA] and 50 ulnar). Access artery follow up ultrasound was performed up to 28 days. Procedural success rate was 97%, 74%, and 92% in the TRA, DRA and ulnar groups, respectively (p < 0.001). Crossover occurred in 3 patients (3%) in TRA, 13 patients (26%) in DRA and 4 cases (8%) in ulnar group (p < 0.001). The most common cause of crossover was failure of artery cannulation. Regarding cannulation time, the mean access time in seconds was 80.19 ± 25.98, 148.4 ± 29.60, 90.5 ± 21.84 in TRA, DRA and ulnar groups, respectively (p < 0.001). Our study concluded that these new approaches proved to be potential alternatives to traditional radial approach; however, ulnar artery access proved to be superior to distal radial artery access as regards success rate and cannulation time.

Investigation of Factors Associated with Excessive Bleeding in Patients Undergoing Percutaneous Nephrolithotomy Surgery at Imam Khomeini Hospital in Urmia City during the period from October 2019 to October 2020

Introduction Bleeding during percutaneous nephrolithotomy (PCNL) surgery is a significant concern and a common surgical complication. This study aimed to identify factors associated with excessive bleeding in patients during or after PCNL surgery. Methods In this retrospective study, a total of 357 patients who underwent PCNL surgery were evaluated within the period from October 2019 to October 2020. Patient-related factors, kidney stones, and surgical details were recorded. The median drop in hemoglobin after PCNL was 5.1, and values exceeding this were considered as excessive bleeding. Results In this study, only 51.2% of patients experienced decreased hemoglobin levels. The average stone size in patients with and without reduced hemoglobin levels was 2.48 cm and 2.41 cm, respectively. The mean duration of surgery in patients with and without a decrease in hemoglobin levels was 58.69 minutes and 55.30 minutes, respectively. The mean access time for patients with and without reduced hemoglobin levels was 68.62 seconds and 65.71 seconds, respectively. The mean exposure time to radiation for patients with and without a decrease in hemoglobin levels was 74.11 seconds and 68.80 seconds, respectively. In this study, no significant relationship was found between patient gender, stone size, duration of surgery, access time, previous surgical history, and a decrease in hemoglobin levels. However, a significant association was observed between the access site and decreased hemoglobin levels. Conclusion Despite concerns regarding intraoperative complications, PCNL is an effective and safe treatment modality for patients with kidney stones, irrespective of their clinical treatment history. Furthermore, the advantages of this minimally invasive approach can be applied to all patients.

Comparison Between Closed and Open Methods for Creating Pneumoperitoneum in Laparoscopic Cholecystectomy.

Background: To study the efficacy of closed and open methods for creating pneumoperitoneum in laparoscopic cholecystectomy by comparing the two in terms of their outcome and complication. Study Design: Single-centre, prospective, observational study. Materials and study: Purposive sampling method where the inclusion criteria were all patients with cholelithiasis who were advised and consented to laparoscopic cholecystectomy of age 18-70 years were included in the study group. Exclusion criteria include patients with a paraumbilical hernia, a history of upper abdominal surgery, uncontrolled systemic illness, and local skin infection. Sixty cases of cholelithiasis satisfying exclusion and inclusion criteria who underwent elective cholecystectomy during the study period were included. Thirty-one of these cases underwent the closed method, while in the remaining 29 patients open method was adopted. Cases in which pneumoperitoneum created by closed technique were grouped as group A and those by open technique as group B. Parameters comparing the safety and efficacy of the two methods were studied. The parameters were access time, gas leak, visceral injury, vascular injury, need for conversion, umbilical port site hematoma, umbilical port site infection, and hernia. Patients were assessed on the first postoperative day, the seventh postoperative day, and then two months after surgery. Some follow-ups were done telephonically. Results: Out of 60 patients, 31 underwent the closed method, while 29 underwent the open method. Minor complications like gas leak during the procedure was observed more in the open method. The mean access time in the open-method group was less than in the closed-method group. Other complications like visceral injury, vascular injury, need for conversion, umbilical port site hematoma, umbilical port site infection, and hernia were not observed in either group during the allocated follow-up period in the study. Conclusion: Open technique for pneumoperitoneum is as safe and effective as the closed technique.

Comparative Study of Transradial Versus Transfemoral Route Percutaneous Coronary Intervention in Acute ST-Elevation Myocardial Infarction.

Introduction Percutaneous coronary intervention (PCI) is the first choice of treatment for myocardial infarction (MI). However, entry site failure is still one of the major complications faced by the interventionist. Hence the present study compared the efficacy and complications of radial and femoral approaches in PCI in ST-elevation myocardial infarction (STEMI). Methods A hospital-based prospective study was conducted on patients with acute STEMI. A total of 100 patients were enrolled that were randomly divided into two groups of 50 each, i.e., patients that had undergone PCI by radial approach (N=50) and those who had undergone PCI by femoral approach (N=50). Results The male-to-female ratio was 1.5:1 and 1.6:1 in the transradial (TR) and transfemoral (TF) groups, respectively. With respect to age, both the groups were dominated by the age group of 50-60 years, with 42% in the TR group and 34% in the TF group having an age >60 years. The mean access time, fluoroscopy time, and procedural time in the TR group were 6.0 ± 0.7 minutes, 5.9 ± 0.6 minutes, and 29.55 ± 0.9 minutes, respectively. In the TF group, the mean access time, fluoroscopy time, and procedural time were 5.1 ± 0.5 minutes, 5.5 ± 0.7 minutes, and 26.7 ± 2.1 minutes, respectively. In the TR group, ecchymosis and loss of radial pulse were observed in 10% of the patients, thrombophlebitis in 4%, and bleeding complications in 2%. While in the TF group, ecchymosis was observed in 26%, followed by thrombophlebitis (24%), minor hematoma, and bleeding complications (14%). Conclusion The present study emphasizes the use of radial access in patients with ST-segment elevation acute coronary syndrome, as this approach was associated with significant clinical benefits. Moreover, bleeding complications were more in patients undergoing TF intervention.

Ant colony based optimization model for QoS-based task scheduling in cloud computing environment

Cloud computing has evolved with various techniques for satisfying the needs of users to reduce costs and offer better results. The users' needs may include sharing of resources like memories, processors, apps, information, data, applications, etc., whereas, performance should be in terms of improved DC processing period & response time. Apart from the above-said, there is also a requirement to manage the stability of the system and be flexible to make amendments to the system. Static data is used to optimize the project schedule. However, the traditional does not take into account the personnel allocation matrix when scheduling projects. The ACO model is not a suitable solution to the scheduling problem. The classic ACO methodology operates in two phases: the first phase uses an event-based scheduler to address the complex planning issue. Planning and allocating resources for a project are both constrained by these two approaches. The event-based ACO model was developed to match the resource restrictions and activity schedule to handle dynamic data allocation. When it comes to multi-objective scheduling, EBS with ACO is not an adequate approach. An updated ACO technique to optimum global search employing a neural network approach was presented to schedule many activities to tackle the difficulty of multiple objectives. Using the suggested multi-objective technique, an activity with a defined number of tasks and necessary resources may be optimally organized. The algorithm LBACO is the most effective one to apply for optimizing the objective function, according to the test results, as well as the fastest. An advantage of ACO over other techniques is its ability to provide better plans with higher statistics and mean access times, as well as more consistent job assignments.

A simple method of axillary venipuncture using single landmark for pacemaker leads implantation

Background Axillary venipuncture for pacemaker lead implantation has been demonstrated to be an effective method without fatal complications encountered with standard subclavian access approach, but the relatively high complexity limits its clinical practicability. Objective We are proposing a simple technique for axillary venipuncture using single point on clavicle as anatomical landmark with the possibility of alternative fluoroscopic assisted puncture as a backup. Methods Connecting point of medial to middle third of clavicle is located as the landmark. Deflected lateral 45°from sagittal line, an 18-guage needle tip is laid on the point and tangential to upper border of clavicle. Penetrated from the hub site, the needle is directed to the landmark at approximately 30–45° relative to body surface for venipuncture. If blind puncture failed, an alternative fluoroscopic method is performed. Upon successful venipuncture, a guide wire is positioned in inferior vena cava and a skin incision and subcutaneous pocket is made at the puncture site. Results Axillary vein puncture was successful for 106 of 113 patients (93.8%) in the study with mean access time of 3.6 ± 1.4 min. In 84 patients (74.3%), the vein was cannulated by blind puncture, and fluoroscopy guided method was required in other 22 patients (19.5%). The puncture of axillary artery occurred in one patient (0.09%) and no haemorrhage was observed after local pressure. No pneumothorax, hemothorax, or brachial plexus injury was found. Conclusions The approach of axillary vein puncture using single landmark on the clavicle is simple, effective and safe for pacemaker lead implantation.

Internal jugular vein catheterization: A comparison between ultrasound guided technique with landmark guided technique

Introduction: Central venous cannulation is frequently performed procedures to gain access to the central vein. With increased use of ultrasonography to guide cannulation, the success rate has improved and it has decreased the time required for cannulation and complications. The aim of the study was to compare ultrasound guided technique (USG) and landmark technique (LMG) in Internal jugular vein. Materials and Methods: This study was conducted in National Medical College and Teaching Hospital, Birgunj from July 2019 to July 2020. Ethical clearance (NMC/420/075/076) was obtained from institutional review committee of NMC Birgunj. Total of 60 patients were randomly allocated into two groups; ultrasound group (USG) landmark group (LMG) underwent landmark guided catheterization. Access time, number of attempts for successful cannulation and incidence of various complications were compared between groups. Data analysis was done with Statistical Package for Social Science version 22. Result: The study was conducted on 60 patients, divided randomly into two groups with 30 patients in each group. The mean age for LMG was 48.57±16.08 years and for USG was 50.03±13.36 years. Out of 60 patients, 61.7% were male and 38.3% were female. The mean of neck dimension for LMG and USG was 35.95±6.327 and 35.67±6.194 cm respectively. The mean distance under LMG and USG was 19.07±1.780 and 18.33±2.368 cm respectively. The mean access time taken for LMG and USG was 403.10±98.111 and 217.57±75.408 seconds respectively (p&lt;0.001). LMG technique showed total 5 cases (16.7%) of carotid artery puncture during procedure whereas there were no cases seen in USG (p value 0.05). Conclusion: This study has shown better result of ultrasound guided internal jugular cannulation when compared with landmark guided internal jugular vein cannulation technique by decreasing number of needle passes, access time, complication and giving least discomfort to the patient.

Comparison of Hasson (Open) and Veress Needle (Closed) Technique of Creating Pneumoperitonium in Laparoscopic Cholecystectomy

Objective: The purpose of this study is to compare the outcomes between hasson (open) and veress needle (closed) technique of creating pneumoperitonium in laparoscopic cholecystectomy. Study Design: Comparative/Randomized study Place and Duration: PHFMC (ZCD 417,Toba Tek Singh). Jun 2019-May 2020 Methods: Ninety patients of both genders with ages 20-75 years were presented in this study. All patients provided written informed consent before having their full demographic information collected, which included their age, gender, and body mass index. All the patients had symptomatic gall stones disease was underwent for laparoscopic cholecystectomy. Patients were categorized into two equal groups. Group I had 45 patients and received veress needle (closed) technique and group II received hasson (open) technique for creating pneumoperitoneum. Post-operatively outcomes in terms of access time , gas leak, visceral injury, vascular injury, need for conversion, umbilical port site hematoma, umbilical port site infection, umbilical port site hernia were assessed and compared among both groups. To analyze the entire set of data, we used the SPSS 24.0 edition. Results: Mean age of the patients in group I was 36.13 ±5.77 years with mean BMI 25.06 ±6.33 kg/m2 and in group II mean age was 37.23 ±6.55 years with mean BMI 25.16 ±4.45 kg/m2 . Majority of the patients 60 (30 in each group) were female. Mean access time in group II was lower 4.78 ±11.43 minutes as compared to group I 6.11±4.12 minutes. Mean closure time in group I was 7.33 ±7.23 minute and in group II mean closure time was 6.03±3.19 minutes. Frequency of gas leak in group I was higher found in 8 (17.8%) cases as compared to group II 3 (6.7%). Visceral injury was greater in group I 3 (6.7%) as compared to group II 1 (2.2%). Vascular injury among both groups was similar 2 (4.4%) and there is no any case found for conversion. Post-operatively complications hematoma, infection and umbilical hernia were greater in group II 4 (8.9%), 2 (4.4%) and 2 (4.4%) as compared to hasson (open) group. Conclusion: Pneumoperitonium was created more quickly and efficiently in laparoscopic cholecystectomy using the hasson (open) approach in this comparative analysis than any other method. When it comes to problems and injuries, the open approach (rather than the closed technique) was determined to be less risky overall. Keywords: Laparoscopic Cholecystectomy, Hasson (open) technique, Needle Veress, Outcomes, Pneumoperitonium

Robotic-assisted vertical sleeve gastrectomy in adolescents: Do BMI limits apply?

BackgroundRobotic-assisted vertical sleeve gastrectomy (VSG) in adolescent patients has been shown to have comparable outcomes to laparoscopic VSG. Recent data suggests that metabolic and bariatric surgery (performed using robotic and laparoscopic techniques) in patients with BMI ≥ 50 kg/m2 have a higher risk of adverse events compared to those with BMI < 50 kg/m2. The aim of this study was to compare the outcomes of robotic-assisted VSG in adolescents with a BMI above and below 50 kg/m2. MethodsA retrospective analysis of all adolescents undergoing robotic-assisted VSG between January 2014 and December 2020. Subjects were categorized based on preoperative BMI; Group 1 (BMI < 50 kg/m2) or Group 2 (BMI ≥ 50 kg/m2). Data collection included patient demographics, preoperative BMI, total operative time, access time (i.e., total time for port-placement), 30 day complications, and 30 day hospital readmissions. Analysis was performed using chi-square, Fisher's Exact, and student t-test. ResultsTotal of 115 subjects (Group 1 N = 64 and Group 2 N = 51) were included. No differences in age or ethnicity were detected; however, Group 2 had a higher percentage of male patients (27.5% vs. 4.7%, respectively, p = 0.001). Mean operative times (Group 1 = 122.2 min vs. Group 2 = 121.6 min) and access times (Group 1 = 19.1 min vs. Group 2 = 19.7 min) were similar between groups. Thirty day complication rates were similar between groups (p = 0.133); however, there was a higher rate of hospital readmission in Group 1. ConclusionWhile recent data demonstrate an increased likelihood of adverse events occurring among patients with BMI ≥ 50 kg/m2 undergoing robotic surgery, we observed no differences in intraoperative or early postoperative outcomes based on BMI in this robotic-assisted pediatric cohort.

Totally ultrasound-guided minimally invasive percutaneous nephrolithotomy in children: Is it safe?

Objective:The objective of the study was to assess the outcome and feasibility of ultrasonography (US)-guided minimally invasive percutaneous nephrolithotomy (mini-PCNL) in children.Materials and Methods:Twenty-five children with upper urinary tract stones who had undergone US-guided mini-PCNL from June 2017 to June 2020 were enrolled in this study. Patients’ demographic information and post-treatment results were retrospectively gathered and analysed. Pyelocaliceal system was punctured in prone position using US guidance, and the tract was dilated using single-shot dilation technique. All steps of renal access were done using only US. Mini-PCNL in all cases was done by using 15 Fr rigid nephroscope. Stones were fragmented with a pneumatic lithotripter and evacuated.Results:The patients’ mean age was 6.30 ± 3.25 years (range: 1.5–15). The mean stone size was 16.04 ± 3.93 mm (range: 10–30). The mean access time to the stone was 1.50 ± 0.62 min (range: 1–4). The mean operation time was 94.66 ± 3.05 min (range: 90–100 min). The final stone-free rate was 96%. Post-operation fever occurred in 4 (16%) patients who were treated successfully with an antibiotic. No major complications occurred.Conclusions:We recommend US-guided mini-PCNL as a harmless alternative treatment option, in children with renal calculi due to its excellent outcomes and little complications.

Feasibility and Safety of Chronic Total Occlusion Percutaneous Coronary Intervention via Distal Transradial Access.

Aims: The current study aims to verify the feasibility and safety of chronic total occlusion (CTO)-percutaneous coronary intervention (PCI) via the distal transradial access (dTRA).Methods: Between April 2017 and December 2019, 298 patients who underwent CTO PCI via dTRA were enrolled in this study. The baseline demographic and procedural characteristics were listed and compared between groups. The incidences of access-site vascular complications and procedural complications and mortality were recorded.Results: The mean J-CTO (Japanese chronic total occlusion) score was 2.6 ± 0.9 points. The mean access time was 4.6 ± 2.9 min, and the mean procedure time was 115.9 ± 55.6 min. Left radial snuffbox access was performed successfully in 286 patients (96.5%), and right radial snuffbox access was performed successfully in 133 patients (97.7%). Bilateral radial snuffbox access was performed in 107 patients (35.9%). 400 dTRA (95.5%) received glidesheath for CTO intervention. Two patients (0.7%) developed severe access-site vascular complications. None of the patients experienced severe radial artery spasm and only 2 patients (0.5%) developed radial artery occlusion during the follow-up period. The overall procedural success rate was 93.5%. The procedural success rate was 96.5% in patients with antegrade approach and 87.7% in patients with retrograde approach.Conclusions: It is both safe and feasible to use dTRA plus Glidesheath for complex CTO intervention. The incidences of procedure-related complications and severe access-site vascular complications, and distal radial artery occlusion were low.

The Learning Curves for Transradial and Ultrasound-Guided Arterial Access: An Analysis of the SURF Trial

Historically, coronary angiography and percutaneous coronary intervention involved accessing the femoral artery via palpation. However, recently there has been a trend towards using a transradial approach and ultrasound guidance for arterial access. Studies have shown that these techniques respectively improve major bleeding rates and access outcomes. There have been no studies conducted that assess the time it takes to train operators to attain proficiency. This sub-analysis of the Standard versus Ultrasound-guided Radial and Femoral access in coronary angiography and intervention (SURF) trial aims to assess the number of procedures required to attain proficiency in ultrasound-guided transradial and transfemoral access. The SURF trial randomised 1,388 patients undergoing coronary angiography and/or percutaneous coronary intervention into standard or ultrasound-guidance and radial or femoral access in a 2×2 factorial design. Operators who participated in this trial were required to have performed at least 50 standard and 10 ultrasound-guided punctures for each of transradial and transfemoral access. Cases were then chronologically ordered and stratified into groups of five, from which the primary endpoint measured was a progression in mean access time and first-pass success rates. Across all operators, there was a reduction in mean access time between procedures one to five and six to 10 with ultrasound-guided femoral punctures (60.5 secs-51.5 secs, p=0.029) and between procedures 11 to 15 and 16 to 20 ultrasound-guided radial punctures (74s to 62.5 secs, p=0.082). This trend was more obvious in trainees, with significant reductions in mean access time between procedures one to five and six to 10 from 73.5 to 53.5 seconds (p<0.001) for ultrasound-guided femoral access and from 99.5 seconds to 60 seconds (p=0.024) for ultrasound-guided radial access. There were no trends with standard transradial access. The numbers required to attain competency in ultrasound-guided femoral and radial access are 15 and 25 punctures, respectively. Fifty (50) punctures appear adequate for proficiency in a standard transradial approach. These numbers are useful in incorporating into training program for advanced trainees and interventionalists.

Comparison of standard versus ultrasound guidance in radial and femoral access: a subanalysis of the randomised SURF trial

Abstract Background Ultrasound (US) guidance in facilitating arterial access may reduce vascular complications and possible bleeding. There are still limited trials assessing real-time US guidance for coronary angiography. The SURF (Standard versus ultrasound-guided radial and femoral access in coronary angiography and intervention) trial showed no difference in primary outcome when the combined radial and femoral ultrasound analysis compared with standard (SD) technique, but significantly improved access efficiency and success rate. Purpose This subanalysis compared clinical and procedural outcomes of the individual radial and femoral access with US guidance versus standard technique. Methods Patients (n=1388) undergoing coronary angiography and percutaneous coronary intervention were randomised (1:1) into radial or femoral access, and (1:1) to SD or US guidance. The primary outcome was a composite of ACUITY (Acute Catheterisation and Urgent Intervention Triage strategY) major bleeding, MACE (death, stroke, myocardial infarction or urgent target lesion revascularisation) and vascular complications at 30 days. Secondary outcomes were access time, number of attempts, venepuncture, difficult accesses and first-pass success. Results Compared to standard, US guidance produced no difference in composite endpoint for both radial (1.4% vs 1.2%, p=0.78) and femoral (3.1% vs 3.8%, p=0.65) accesses. ACUITY major bleeding (radial: 0.9% US vs 0.6% SD, p=0.69; femoral: 1.9% US vs 2.3% SD, p=0.69), vascular complications (radial: 0.3% US vs 0.3% SD, p=0.98; femoral: 1.3% US vs 0.9% SD, p=0.63) and MACE (radial: 0.6% US vs 0.3% SD, p=0.59; femoral: 0.9% US vs 1.2% SD, p=0.78) were similar in the US and SD approaches, respectively. However, US guidance resulted in improved procedural outcomes for both accesses. Femoral access derived the most benefit from US, with reduced mean access time (73 sec vs 97 sec, p=0.006), attempts (1.35 vs 1.84, p≤0.0001), difficult accesses (1.8% vs 6.2%, p=0.004), venepuncture (5.8% vs 12.6%, p=0.002) and improved first-pass success (77.2% vs 58.8%, p≤0.0001). For radial, US reduced attempts (1.59 vs 1.97, p=0.0007), difficult accesses (6.9% vs 12.3%, p=0.02), venepuncture (2.5% vs 5.6%, p=0.04) and improved first-pass success (69.2% vs 60.7%, p=0.02). There was no difference in radial mean access time (111 sec vs 126 sec, p=0.18). Conclusions US guidance in radial and femoral access did not reduce primary outcome compared to standard technique. The use of US significantly improved the efficiency and success rate of arterial cannulation, with femoral access derived the most benefit. Funding Acknowledgement Type of funding source: None

Comparison Between Supraclavicular and Infraclavicular Approach in Subclavian Vein Catheterization in Tertiary Center of Nepal

Introduction: Central vein catheterization can be introduced in subclavian vein (SCV), internal jugular vein or femoral vein for volume resuscitation and invasive monitoring technique. Due to anatomical advantage and lesser risk of infection subclavian vein is preferred. Either supraclavicular (SC) or infraclavicular (IC) approach could be used for subclavian vein catheterization. The aim of the study was to compare SC and IC approach in ease of catheterization of SCV and record the complications present if any.&#x0D; Methods and materials: This was a hospital based comparative, interventional study conducted from November 2016 to October 2017 in Operation Theater in Bir Hospital. In this study, 70 patients for elective surgical cases meeting the inclusion criteria were randomly enrolled. Then samples were equally divided by lottery into either supraclavicular or infraclavicular approach groups. The Access time, cannulation success rate, attempts made for successful cannulation of vein, easy insertion of catheter and guide wire, approximate inserted length of catheter and associated complications in both groups were recorded. Data was entered in statistical software SPSS 16. Chi-square test was used. P value &lt; 0.05 was considered significant.&#x0D; Results: The mean access time in group SC for SCV catheterization was 2.12 ± 0.81 min compared to 2.83 ± 0.99 min in group IC (p-value= 0.002). The overall success rate in catheterization of the right SCV using SC approach (34 / 35) was better as compared with group IC (33 / 35) using IC approach. First successful attempt in the SC group was 74.28% as compared with 57.14% in the IC group.&#x0D; Conclusion: The SC approach of SCV catheterization can be considered alternative to IC approach in terms of landmark accessibility, success rate and rate of complications.

Real-time ultrasound-guided internal jugular vein cannulation by oblique-axis in-plane: Practice at the Fourth Hospital of Hebei Medical University.

We aimed to evaluate oblique-axis in-plane (OA-IP) techniques for real-time ultrasound-guided internal jugular vein (IJV) cannulation. We retrospectively analysed 1065 patients who underwent ultrasound (US)-guided IJV cannulation. We recorded demographic characteristics of patients, success rate, access time, cannulation time, number of attempts and the incidence of acute complications. The overall success rate of the procedure was 100% (n=1605). In total, 1594 cases (99.3%) were successful at the first attempt, and 11 (0.7%) were successful at the second attempt; no patient required three or more attempts. The mean access time was 18.7±19.3seconds. The mean cannulation time was 349.0±103.8seconds. There were 54 (3.4%) acute complications out of the total 1605 cannulations: 23 cases of puncture site bleeding (1.4%), 20 cases allergic to dressing (1.3%), 10 cases of local cervical hematomas (0.6%), and one catheter misplacement (0.1%). There were no major complications 12hours following the procedure. The results of our study suggest that OA-IP techniques can improve ultrasound-guided IJV cannulation with a high success rate and safety in clinical practice. Clinicians should consider adopting these methods.

Computer-assisted needle navigation for pediatric internal jugular central venous cannulation: A feasibility study.

Vascular access for central venous catheter placement is technically challenging in children. Ultrasound guidance is recommended for pediatric central venous catheter placement, yet many practitioners rely on imprecise anatomic landmark techniques risking procedure failure due to difficulty mastering ultrasound guidance. A novel navigation system provides a visual overlay on real-time ultrasound images to depict needle trajectory and tip location during cannulation. We report the first pediatric study assessing feasibility and preliminary safety of using a computer-assisted needle navigation system to aid in central venous access. A prospective, institutional review board-approved feasibility study was performed. All participants provided written informed consent. Ten patients (mean age: 11.4 years, five males) underwent central venous catheter placement with ultrasound and navigation system guidance. All procedures were performed by interventional radiologists expert in vascular access. Feasibility was measured through binary (yes/no) responses from participating users assessing device usability and feasibility. The number of needle passes and procedure time measures were also recorded. Internal jugular veins (seven right sided, three left sided) were cannulated in all patients with no complications. Users confirmed navigation system feasibility in all 10 participants. Mean vein diameter and depth was 13.3 × 9.8 ± 3.4 × 2.1 and 7.0 ± 1.7 mm, respectively. Successful cannulation occurred in all patients and required only a single needle pass in 9 of 10 patients. Mean device set-up and vascular access times were 5:31 ± 2:28 and 1:48 ± 2:35 min, respectively. This pilot study suggests that it is feasible to use a novel computer-assisted needle navigation system to safely obtain central venous access under ultrasound guidance in pediatric patients.

Adopting for Supine Percutaneous Nephrolithotomy: Analyzing the Learning Curve of Tertiary Academic Center Urology Team

To evaluate the effect of learning curve on supine mini-percutaneous nephrolithotomy (PNL) outcomes. The aim of the study was to include a total of 75 patients. All of the patients were operated on by the same team, which had experience of at least 100 prone mini-PNL cases. The team was led by a surgeon who had observed 40 supine conventional PNL procedures (sheath size 24 Fr) over a period of 3 months at an endourology center with experience in supine PNL and surgeries were performed by the same primary surgeon. Patients were divided equally into 5 groups, as first 15 cases in Group 1, and final 15 in Group 5. Groups were compared according to preoperative characteristic, intraoperative result, complication rate, and success rate. The mean access time was 14 minutes in group 1. It decreased to mean of 10.3 minutes for cases 31 through 45, and afterward significant decrease occurred up to a mean of 6.5 minutes for cases 61 through 75 (P ≤.001). According to the Clavien-Dindo classification system, complications were assessed, and a decrease was observed from group 1 to group 5 (40%, 20%, 26.6%, 6.7%, and 13.3%, respectively). The stone free rate increased from the mean of 66.7% for the first two groups to 80% for group 3 and increase up to the 93.3% for group 4 and 5 (P=.128). The present study showed that considering the decrease in access time and operation time 60 patients could be enough for surgical competency as well as the complications and stone-free rates reached satisfactory levels after 45 patients.

A framework for assessing the capability of maritime search and rescue in the south China sea

Maritime search and rescue (SAR) services are critical for the safety of humans and property in marine environments. This paper proposes a comprehensive framework to assess the capability of maritime SAR in the South China Sea (SCS). The framework comprises three steps. First, rescue vessel response times are estimated by a geographic information system-based response time model. Second, maritime SAR services demand is calculated by combining ship location data and marine incident data. Third, three assessment criteria, namely primary coverage, weighted coverage, and mean access time, are determined to quantitatively assess the capability of maritime SAR. This framework was then applied to the SCS in the analysis of three scenarios in which the SAR response system was defined according to the rescue mechanism (e.g., noncooperation vs. cooperation between countries bordering the SCS). The results showed that only a limited area near the coasts can be reached in a short response time when countries do not cooperate. It was also determined it is difficult for a single country to implement SAR missions effectively while covering the whole SCS; a joint SAR mechanism would allow for better outcomes regarding the performance of maritime SAR services. Furthermore, maritime SAR capacity can be significantly improved when island rescue bases are built. The study offers insights to help policy makers take actions concerning strategic planning to develop effective risk reduction measures and improve maritime SAR capacity in the SCS.