Multipurpose Catheter Research Articles

Feasibility of Catheter Placement Under Ultrasound Guidance for Progressive Preoperative Pneumoperitoneum for Large Incisional Hernia with Loss of Domain.

Large incisional hernias with loss of domain (LIHLD) of the abdominal wall remain a therapeutic challenge due to the difficulty of replacing the contents of the hernia sac into the peritoneal cavity. Preoperative progressive pneumoperitoneum (PPP) is a valuable option. The purpose of this study was to evaluate the feasibility of peritoneal catheter insertion under ultrasound guidance for PPP and to compare the morbidity and mortality of this new technique to previously used techniques in our department. Medical records were reviewed retrospectively from February 1989 to April 2013 in a single institution. Three different techniques of PPP were evaluated: surgical subcutaneous implantable port (SIP), surgical peritoneal dialysis catheter (PDC), and radiologic multipurpose drainage catheter (MDC). Collected data included patients' age, sex, body mass index, medical and surgical history, hernia location, PPP technique, length of hospitalization, volume of air injected, morbidity and mortality linked to PPP, and the procedure of hernia repair. Thirty-seven patients with a mean age of 63.1 years were evaluated. Progressive preoperative pneumoperitoneum was performed using SIP, PDC, and MDC for 14, 11, and 12 patients, respectively. Overall morbidity related to the technique was seen in 36 % of SIP, 27 % of PDC, and 0 % of MDC. One patient from the SIP group died on the 3rd postoperative day due to septic shock following aspiration pneumonia. No postoperative mortality in the other groups was observed. The MDC is an interesting modification of the original technique and is a safe procedure. It is a minimally invasive technique with a very low risk of perforation of the viscera. Therefore, the use of a non-absorbable prosthesis with MDC technique can be offered for all patients undergoing PPP without increasing the risk of infection.

Use of Indigo Carmine Angiography to Qualitatively Assess Adequate Distal Perfusion After Endovascular Revascularization in Critical Limb Ischemia

Purpose: To report a novel technique to visualize the efficacy of revascularization in critical limb ischemia patients with ischemic foot ulcers. Technique: An 80-year-old man was admitted with nonhealing ulcers on his left second toe and lateral border of the foot owing to in-stent restenosis of the left popliteal artery. After dilation of the popliteal in-stent restenosis, below-the-knee angiography revealed that the anterior tibial artery (ATA) was occluded, the posterior tibial artery was hypoplastic, and the peroneal artery was enlarged, with 2 plantar arteries. To evaluate the foot circulation before performing additional procedures, a 4-F multipurpose catheter was advanced into the peroneal artery, and 5 mL of indigo carmine was injected. Immediately, the patient’s second toe and lateral border ulcers were dyed blue. We concluded that sufficient blood flow had been obtained to the ulcerated area by balloon angioplasty alone, so the procedure was terminated. The ulcers completely healed at 1 month. Conclusion: Indigo carmine angiography provides visual information on foot perfusion, yielding new insights into microcirculation and helping to determine the effectiveness of treatment and procedure endpoint.

A useful aid in navigating the tortuous ureter.

Navigating the tortuous ureter is challenging and could lead to perforation. Previously described techniques involve different types of guidewire and ureteric catheters.1 When routine techniques fail, we suggest using a 5Fr curved-tip multipurpose catheter (Tempo™ 5; Cordis, Bridgewater, NJ, US; £12.08). The curved tip combined with the ability to rotate on its axis facilitates the navigation through the tortuosity, and allows directing a hydrophilic guidewire in a more controlled and precise manner to gain access to the kidney (Fig 1). The catheter can then be advanced into the collecting system and the wire exchanged with a stiffer one for stenting or intervention.

Fallopian tube recanalisation using dedicated radiographic tubal assessment set in angiography suite

Fallopian tube recanalisation (FTR) for proximal fallopian tube obstruction (PFTO) is considered a good treatment option for tubal infertility. The aim of this study was to assess the safety and the technical and clinical success rates of FTR using a dedicated radiographic tubal assessment set (FluoroSet(®) ) in the angiography suite. This study is a retrospective analysis of data prospectively collected between February 2007 and June 2011 at King Abdullah University Hospital, Irbid, Jordan. During this period, 61 patients affected by PFTO underwent FTR using FluoroSet(®) at our institution. The mean age of patients was 34 years (range 20-45 years), and the mean duration of infertility was 4 years (range 2-14 years). The procedure was performed with conscious sedation under fluoroscopic guidance in the angiography suite. The obstructed tube was accessed with a 5-Fr multipurpose catheter, and the obstruction was crossed with a 0.35-Fr hydrophilic guide wire until the wire coiled freely into the peritoneal cavity. Patency of the tube was then confirmed by selective salpingiogram. Technical success rate was recorded, and patients were followed up for evidence of pregnancy over 12 months. The procedure was technically successful in all patients. Minor bleeding and postprocedural pain occurred in most patients; however, there were no major complications encountered. Twenty-five patients (41%) became pregnant. Successful deliveries of full-term infants were reported in 21 patients (84%). Miscarriage was reported in four patients (16%). No ectopic pregnancies were detected, and all deliveries were full-term. The technical success rate was 100% and the clinical success rate was 41%. Selective salpingography and FTR using FluoroSet(®) is a safe and effective method. FTR is recommended as the first intervention in patients with PFTO. In experienced hands with dedicated equipment and in an appropriate setting, the success rate is high, and this treatment should be offered to infertile women with PFTO before other, more complex techniques are attempted.

Transarterial Coil Embolization of an Abdominal Aortocaval Fistula in a Dog

A 3-year-old, 5 kg, male Toy Poodle with a mast cell tumor on the left pelvic limb was referred to Tokyo University of Agriculture and Technology Animal Hospital for an oncologic evaluation. On physical examination, a continuous bruit was auscultated over the left inguinal region with a palpable thrill. Cardiac auscultation identified a grade II/VI systolic and a grade I/VI diastolic murmur over the mitral and the aortic valves, respectively. No signs of peripheral cyanosis or congestion were noted. On thoracic radiographs, moderate, generalized enlargement of the cardiac silhouette was observed without evidence of pulmonary edema or pleural effusion. Color Doppler echocardiography identified mild pulmonic, mitral, and aortic valve regurgitation. Measurements of the left ventricle (LV) indicated an increased internal diameter with normal LV wall and septal thicknesses, normal fractional shortening and mild left atrial (LA) enlargement, with normal sinus rhythm. Normal mean arterial blood pressure was obtained on the thoracic limb using the oscillometric method. Laboratory test results (complete blood count, serum biochemistry profile, electrolytes, coagulation profile) were within the normal reference ranges. Ultrasonography of the caudal abdomen showed a caudal vena cava (CVC) with a diameter of 24.6 mm (dog <10 kg, reference values 0.65 0.12 mm) at the site of shunt. Color Doppler with simultaneous electrocardiogram showed turbulent flow in the CVC during the arterial phase. Continuous-wave Doppler interrogation showed continuous low-velocity flow with a pulsatile pattern and spectral broadening of Doppler waveform and peak flow velocity of 3 m/s across the aortocaval shunt (Fig 1). Contrast-enhanced computed tomography (CT) was performed under general anesthesia for anatomic evaluation of the arteriovenous shunt. The contrast timing bolus method was used to synchronize image acquisition. Iodinated contrast medium (2 mL/kg of iodine) was injected into the cephalic vein at flow rate of 1 mL/s. After a 20-second delay, the entire abdomen was scanned with a dual-slice spiral CT scanner. Reconstruction was carried out using contiguous images with a slice thickness of 1.0 mm (total of 149 slices). Post imaging processing showed an aortocaval connection by an anomalous vessel (shunt) located caudal to the renal arteries and a saccular dilatation of the CVC elongating in the caudal direction. The major dilatation was observed caudal to the fistula, 2.6-fold greater than the dilatation observed cranial to the fistula (Fig 2A,B). Endovascular repair was performed under general anesthesia that was maintained with isoflurane. The dog was positioned in right lateral recumbency for a cervical left lateral approach and a small incision in the skin was made to access the left common carotid artery. A 4-Fr multipurpose catheter was inserted through a puncture in the artery and advanced over a guide wire. The catheter tip was positioned in the abdominal aorta, cranial to the fistula to perform aortography. A 5-mL bolus injection of iodinated contrast medium showed the contrast medium being diverted from the aorta into the CVC (Fig 3A). Blood flow in the renal arteries was preserved as observed by contrast filling of the arteries and renal excretion. The tip of the catheter then was repositioned into the AVF over a guide wire to deliver the embolization coil, because contrast injection showed that adequate coil deployment could be achieved through the aorta. An embolization coil of 6.5 mm diameter, 5 loops, and 10 cm in length was deployed along the fistula lumen under fluoroscopic guidance. Aortography a few minutes after coil deployment identified residual flow through the fistula (Fig 3B). Residual flow was also observed on Doppler ultrasonography, but the shunt flow velocity had decreased to 1.5 m/s. Recovery from the anesthesia was uneventful. Postoperative mean arterial blood pressure ranged from From the Department of Veterinary Medicine, Faculty of Agriculture, Tokyo University of Agriculture and Technology, Tokyo, Japan (Nakata, Tanaka, Hamabe, Yoshiyuki, Kim, Suzuki, Aytemiz, Huai-Che, Shimizu, Fukushima). Corresponding author: Ryou Tanaka, DVM, PhD, Department of Veterinary Surgery, Tokyo University of Agriculture and Technology, Saiwai-cho 3-5-8, Fuchu, Tokyo 183-8509, Japan; e-mail: ryo@vet.ne.jp. Submitted May 17, 2013; Revised November 19, 2013; Accepted December 16, 2013. Copyright © 2014 by the American College of Veterinary Internal Medicine 10.1111/jvim.12308 Abbreviations:

An Unusual Complication of a Transjugular Liver Biopsy

Question: A 28-year-old woman with hepatitis C presented for a liver biopsy. A transjugular approach was performed since the patient had thrombocytopenia with a platelet count of less than 50 × 103/μL. The right internal jugular vein was cannulated under ultrasound guidance and then, with fluoroscopy, a 5-french multipurpose angiographic catheter was directed via the inferior vena cava into the right hepatic vein. Three passes were made with a 19-gauge, spring-loaded needle for biopsy specimens.

Assessment of ventriculo-arterial interaction in pulmonary arterial hypertension using wave intensity analysis

To the Editor: Wave intensity analysis (WIA) is a recently described haemodynamic analysis methodology which enables assessment of ventriculo-arterial interactions via time-domain analysis of pressure and flow waveforms [1]. It enables quantification of wave energy, separation of waves into forward and backward components, and estimation of wave speed [2]. To date, WIA has not been applied to the pulmonary arterial circulation in humans. As WIA offers a potential novel approach for the study of pulmonary haemodynamics, the present study sought to evaluate the feasibility of invasive WIA of the pulmonary circulation during right heart catheterisation (RHC). The study was approved by the institutional review board (Sydney Local Health District Ethics Review Committee (RPA Zone)) and consent was obtained from seven controls (mean±sd age 69±9 years, three females) and six patients (age 56±13 years, four females) with pulmonary arterial hypertension (PAH). Control subjects presented to the cardiac catheterisation laboratory for investigation of possible coronary artery disease. Following standard pulmonary haemodynamic measurements (including thermodilution cardiac output), a combined dual-tipped pressure and Doppler wire (ComboWire; Volcano, Rancho Cordova, CA, USA) was positioned distal to the origin of the right or left lower lobe pulmonary artery via a 6 Fr multipurpose catheter (Mach 1; Boston Scientific, Natick, MA, USA) under angiographic guidance. Pressure and flow measurements were acquired simultaneously at a sampling frequency of 1000 Hz, once stable signals were obtained. Data were processed offline using customised MatLab software (MathWorks, Natick, MA, USA). Signals were ensemble-averaged with timing gated to the ECG R-wave and smoothed using a Savitzky–Golay filter [3]. Intrinsic hardware processing delays (between pressure and flow signals) were corrected by shifting signals to achieve a linear pressure–flow (P–U) relationship in early systole [4]. Wave speed (c) was derived from the P-U loop method …

Partial Anomalous Pulmonary Venous Connection in 2 Miniature Schnauzers

Partial Anomalous Pulmonary Venous Connection in 2 Miniature Schnauzers

Paravalvular leak closure for persisting aortic regurgitation after implantation of the corevalve transcatheter valve

Significant aortic regurgitation after TAVI results in lack of symptomatic and prognostic benefit from the procedure and generally requires intervention. While most of the regurgitations can be successfully targeted with standard techniques, occasional patients have restrictive calcification resistant to post-dilatation and significant regurgitation persists. We present a case of refractory aortic regurgitation successfully treated with percutaneous paravalvular leak closure. An 81-year-old man with symptomatic severe aortic stenosis underwent a transfemoral CoreValve TAVI in December 2009. He had significant aortic regurgitation refractory to medical and interventional therapy including balloon post-dilatation, valve repositioning and valve-in-valve reimplantation. Aortic regurgitation remained severe and therefore in early 2013, we proceeded with an attempted percutaneous closure of the residual paraprosthetic leak. Using 6-French femoral access and a Terumo wire, the defect was successfully crossed with a 4-French Multipurpose catheter and an 8 mm Amplatzer Vascular Plug 4 device (St. Jude Medical) was deployed through this catheter, resulting in abolition of aortic regurgitation on aortography and TOE, with associated excellent clinical response. Refractory paravalvular aortic regurgitation post CoreValve implantation can be successfully treated using the Amplatzer Vascular Plug 4 device.

Native atretic coarctation of the aorta in a 37-year-old hypertensive woman, treated with a low-profile covered stent

We report on a 37-year-old woman with essential systemic hypertension. An MRI was performed because of weak femoral pulses, depicting a severe almost atretic coarctation of the aorta (Fig. 1). Angiography of the proximal distal thoracic aorta was simultaneously performed (Fig. 2a). The transverse arch was narrow (16 mm), as was the diameter of the terminal aortic arch distal to the left subclavian artery (10 mm). Distal of the coarctation the diameter of the descending aorta was 11 mm. A trajectory of 2 mm in length seemed atretic. The atretic segment could be crossed in an antegrade fashion with a straight 0,014 in. coronary wire and balloon pre-dilatation was performed with a 5 mm coronary balloon. Thereafter, a multi-purpose catheter could be advanced retrogradely across the coarctation segment. A 9 French Mullins sheath (Cook) was advanced to the transverse aortic arch. A 41 mm long Advanta V12 premounted covered stent (Atrium, Hudson, USA) on a 12 mm high pressure balloon was implanted. Consecutive angiography revealed complete expansion of the stent up to 12 mm without residual stenosis, and no aneurysm formation (Fig. 2b). Fig. 1 MRI imaging of the left ventricle (LV), ascending aorta (AAo). The left subclavian artery (LSA) is dilated and the descending aorta (DAo) is hypoplastic. The coarctation imposes as atresia. There are numerous collaterals. RV: right ventricle Fig. 2 a Simultaneous angiography of the proximal and distal descending aorta; anterior projection. Atretic coarctation (CoA). Some small collaterals can be seen right of the coarctation. Abbreviations: Cath: catheter, DAo: descending aorta, LSA: left subclavian ... In conclusion, treatment with placement of a low-profile covered stent, using a simultaneous radial and femoral approach and pre-dilatation, delivered an excellent result without complications and a short hospital stay. The patient’s blood pressure returned to normal and her antihypertensive medication could be stopped within 3 weeks after stent implantation. We emphasise that in so-called ‘unexplained’ systemic hypertension, especially in young adults, coarctation of the aorta has to be excluded [1, 2]. When coarctation is confirmed primary stenting is the first choice therapeutic option [3–5].

Simultaneous Thrombolysis and Venous Angioplasty in Acute Ilio-femoral Thrombosis after IVC filter Insertion and Novel Balloon Catheter Models

Four patients with extensive acute iliofemoral and popliteal vein thrombosis and partially extending into the inferior venacava (IVC) with diffuse swelling of lower limb and gluteal region were studied. Initially, Gunther Tulip (Cook) IVC filter was placed in all patients. A 5F multipurpose catheter with side holes was placed in common iliac vein bifurcation and thrombolysis was done for 18 hours with diluted streptokinase infusion at 50,000 U/hr. Thereafter, a 5 mm × 4 cm peripheral balloon was advanced through the clots to mid or lower femoral vein level and thrombolysis was done for 18 hours with streptokinase infusion through the balloon’s 035 wire port. The balloon was pulled back and multiple serial dilatations were done in all four procedures. Post procedure the venous channels were opened and were draining adequately. Limb edema subsided in 4 to 5 days and there were no bleeding or embolic complications in all patients. The first two patients are on follow up for 18 months, the third patient for 5 months, and the fourth patient for 2 weeks. Based on these observations, two novel balloon models for thrombolysis and to perform venous angioplasty simultaneously were developed. The piggyback model has a side lumen catheter with side holes attached to the shaft of the balloon catheter (5 mm width × 4 cm length ). The side lumen terminates before the balloon. The horseshoe models made of polyethylene terephthalate have a 10 cm long and 4 mm wide compliant balloon with a double lumen catheter and multiple side ports till the balloon tip.

Mechanical breakdown and thrombolysis in subacute massive pulmonary embolism: A prospective trial

To assess role of combined modality of mechanical fragmentation and intralesional thrombolysis in patients with massive pulmonary embolism presenting subacutely. Eight of 70 patients presenting in tertiary care centre of North India with massive pulmonary embolism within 4 years had subacute presentation (symptom onset more than 2 wk). These patients were subjected to pulmonary angiography with intention to treat basis via mechanical breakdown and intra lesional thrombolysis. Mechanical breakdown of embolus was accomplished with 5-F multipurpose catheter to re-establish flow, followed by intralesional infusion of urokinase (4400 IU/kg over 10 min followed by 4400 IU/kg per hour over 24 h). Eight patients, mean age 47.77 ± 12.20 years presented with subacute pulmonary embolism (mean duration of symptoms 2.4 wk). At presentation, mean heart rate, shock index, miller score and mean pulmonary pressures were 101.5 ± 15.2/min, 0.995 ± 0.156, 23.87 ± 3.76 and 37.62 ± 6.67 mmHg which reduced to 91.5 ± 12.2/min (P = 0.0325), 0.789 ± 0.139 (P = 0.0019), 5.87 ± 1.73 (P = 0.0000004) and 27.75 ± 8.66 mmHg (P = 0.0003) post procedurally. Mean BP improved from 80.00 ± 3.09 mmHg to 90.58 ± 9.13 mmHg (P = 0.0100) post procedurally. Minor complications in the form of local hematoma-minor hematoma in 1 (12.5%), and pseudoaneurysm (due to femoral artery puncture) in 1 (12.5 %) patient were seen. At 30 d and 6 mo follow up survival rate was 100% and all the patients were asymptomatic and in New York Heart Association class 1. Combined modality of mechanical fragmentation and intralesional thrombolysis appears to be a promising alternative to high risk surgical procedures in patients with subacute massive pulmonary embolism.

Cierre transcatéter de ductus arterioso persistente

Percutaneous closure of patent ductus arteriosus (PDA) is a wellknown technique and is the first choice for this condition. Objective: To report our pioneer experience in the region, the first 6 percutaneously treated PDA cases. The smallest diameter was less than 3 mm and they were closed using transcatheter technique with controlled-release coils in Las Higueras Hospital, Talcahuano. Patients and Methods: Between December, 2010 and September, 2011, six female patients carrying PDA were treated via interventional catheterization. Three presented a type A1 from Krichenko ductus arteriosus, two patients of the type A2 and one patient of the type E. Under general anesthesia, cardiac catheterization was performed via the femoral artery and aorto-graphy. The ductus was reached using a multipurpose catheter and through this, the coil was inserted closing the abnormality from the pulmonary to the aortic end using the controlled-release coil. Results: All patients achieved angiographic ductal closure without residual shunt before discharge. The procedure lasted an average of 55 minutes, the mean fluoroscopy time was 14 minutes and there were no complications. Patients were discharged the day after surgery after undergoing chest radiography and echocardiography. In later follow-ups, patients were asymptomatic. Conclusion: The closure of percutaneous PDAs is an effective, safe and less invasive technique, which has been performed for some time in Santiago, with this being the first regional report.

Successful Thrombolysis of Occluded Inferior Vena Cava Filter with IVC Syndrome.

Thrombosis of Inferior Vena Cava (IVC) following filter insertion can occur in up to 30% of the cases. The optimal management of such cases is unknown. We describe a simple and less expensive method of achieving successful recanalization of the IVC in a 40 year old hypertensive man who developed recurrent pulmonary embolism after his orthopedic treatment. An IVC filter was inserted, which developed extensive thrombosis of the whole IVC and venous system of the lower limbs. Catheter directed thrombolysis using a multiple side-hole multipurpose catheter and balloon angioplasty was carried out in order to "crush and lyse" the IVC thrombi.

Thrombus‐Aspiration through 5 Fr Guiding Catheter with Transradial Approach in Acute Coronary Syndromes: Feasibility of a Mini‐invasive Strategy

The purpose of this study was to assess the feasibility and safety of thrombus-aspiration through a 5 Fr guiding catheter with transradial approach in acute coronary syndromes. The use of thrombus-aspirating devices improves myocardial reperfusion but requires at least a 6 Fr guiding catheter. Transradial coronary interventions using a 5 Fr guiding catheter are attractive to reduce bleeding complications. We retrospectively selected patients presenting acute coronary syndromes with angiographically visible thrombus who underwent thrombus-aspiration through radial access using a 4 Fr multipurpose catheter in a 5 Fr guiding catheter. We described clinical and angiographic characteristics of the cohort, and the procedure's technique, success and complications. Among the 34 included patients, 29 presented ST-segment elevation myocardial infarction. Complete resolution of the ST-segment elevation was effective in 93% of these patients. TIMI flow grade after thrombus-aspiration was significantly improved compared to baseline TIMI flow grade or after passage of the guidewire (P < 0.001 for both). There was no dissection or perforation but we noted distal embolization in 5 cases probably explained by the high grade of intracoronary thrombus in our cohort. Thrombus-aspiration through a 5 Fr guiding catheter with transradial approach seems to be safe and effective in selected patients with acute coronary syndrome. This mini-invasive approach brought the advantages of the transradial access in 5 Fr but also its limitations.

Abstract 241: Piggyback and Horseshoe Balloon Catheter Models for Simultaneous Thrombolysis and Venous Angioplasty in Acute Ileofemoral Venous Thrombosis After IVC Filter Insertion

Background: To investigate the potential role of balloon mediated thrombolysis and venous angioplasty in acute ileofemoral thrombosis and to develop novel balloon catheter models for the same purpose. Methods: 2 patients and 1 patient on followup with extensive acute ileofemoral and popliteal vein thrombosis and partially extending into the inferior venacava (IVC) with diffuse swelling of lower limb and gluteal region were studied. The second patient stopped anticoagulation and presented with ileofemoral thrombosis in contralateral limb on followup. In both patients Gunther Tulip (Cook) IVC filter was placed. A 5F Multipurpose catheter with sideholes was placed in common iliac vein bifurcation and thrombolysis was done for 18 hours with streptokinase at 5000U/hr. Post thrombolysis IVC angiogram showed mild recanalisation of left common iliac veins leaving a stump. On the next day, the left common iliac vein was cannulated through a 5F Torcon catheter and a Terumo 035 J tipped wire was advanced through the clots. A 5cm x 4mm peripheral balloon was advanced and balloon directed 24 hour thrombolysis with streptokinase was done at 5000U/hr. The balloon was pulled back and multiple serial dilatations were done in femoral, internal iliac and common iliac veins. In both patients thrombolysis was started on the third day after the onset of symptoms. Results: Post procedure the venous channels were opened and were draining adequately. Limb edema subsided and there was no bleeding or embolic complications. Both patients are on oral anticoagulation and now on follow-up for 8 months being asymptomatic at present. Based on these interventions two novel balloon models to thrombolyse and to perform venous angioplasty simultaneously in a single procedure was developed. The first is a piggyback model which has a side port attached to the shaft of the balloon (5cm length and 4mm breath). The other model is a horse shoe balloon catheter which has a 14cm long and 4mm wide compliant balloon with 0.75mm diameter side port for thrombolysis till the balloon tip and on cross section gives a horse shoe appearance. Conclusion: Balloon mediated thrombolysis and venous angioplasty after IVC filter insertion is useful and novel balloon catheter models may be used in ileofemoral venous thrombosis.

Catheter-Based Reperfusion Treatment of Pulmonary Embolism

Case Presentation: A 76-year-old man with a history of hemicolectomy for colon cancer 10 days previously was admitted because of syncope and severe shortness of breath. On physical examination, the patient was hemodynamically unstable, with a systolic arterial pressure of 80 mm Hg, a heart rate of 124 beats per minute, and distended jugular veins. He was agitated and unable to speak full sentences. His respiratory rate was 28 breaths per minute, and oxygen saturation was 80% on room air. Contrast-enhanced computed tomography showed a filling defect of the left main pulmonary artery, complete occlusion of the left lower lobe pulmonary artery, nonobstructive filling defects of the right lower lobe pulmonary artery, and right ventricular enlargement (right-to-left ventricular dimension ratio of 1.4) (Figure 1). The hemodynamic situation remained unchanged after initiation of treatment with oxygen, intravenous unfractionated heparin, and normal saline. Figure 1. Contrast-enhanced chest computed tomogram from the first case. Left, Complete occlusion of the left lower lobe pulmonary artery (large arrow) and nonobstructive filling defect in the right lower lobe pulmonary artery (small arrow). Right, The subannular right-to-left ventricular dimension ratio was obtained from the reconstructed 4-chamber view.1 Right (47.3 mm) and left (33.9 mm) ventricular dimensions were measured perpendicular to the interventricular septum and 1 cm above the atrioventricular annulus plane. The right-to-left ventricular dimension ratio was calculated as 1.4. Case Presentation: A 55-year-old woman suddenly developed acute shortness of breath 3 weeks after resection of a meningioma. On physical examination, the patient appeared hemodynamically stable, with a systolic arterial pressure of 100 mm Hg, a heart rate of 96 beats per minute, a respiratory rate of 18 breaths per minute, and an oxygen saturation of 89% while receiving 3 L of oxygen via face mask. A contrast-enhanced computed tomography confirmed subtotal filling defects in both main pulmonary …

A multi-purpose spiral high-density mapping catheter: initial clinical experience in complex atrial arrhythmias

There is an increasing need for catheter ablation procedures to treat complex atrial tachycardias (AT) and atrial fibrillation (AF), often requiring detailed endocardial mapping. The sequential point-to-point contact mapping of complex arrhythmias is time-consuming and may not always be feasible. We assessed the utility of a novel spiral duo-decapolar high-density (HD) mapping catheter to delineate complex arrhythmia substrates for ablation. The patients underwent HD mapping using a spiral catheter (AFocusII) and the EnSite NavX system, during catheter ablation procedures, to treat atrial arrhythmias. In 26 patients, a total of 32 atrial arrhythmias were mapped and ablated, comprising of five focal AT, eight macroreentrant AT, 11 persistent AF and eight paroxysmal AF. The HD catheter was used to acquire endocardial surface geometries in all cases and to map the pulmonary veins in patients undergoing AF ablation. In persistent AF, HD catheter mapping permitted the creation of highly detailed complex fractionated electrogram maps (left atrium 449 ± 128 points in 7.2 ± 2.6min; right atrium 411 ± 113 points in 6.7 ± 1.6min). In AT, activation mapping was performed with the acquisition of 305 ± 158 timing points in 7.3 ± 2.6min, guiding successful ablation in all cases. During the follow-up of 7.0 ± 2.6months, all AT patients remained free of significant arrhythmia. High-density contact mapping with a novel spiral multipolar catheter allows rapid assessment of focal and macroreentrant AT, and complex fractionated electrical activity in the atria. It has further multi-functional capabilities as a pulmonary vein mapping catheter and for accurate geometry creation when used with a 3D mapping system.

Paraplegia prevention branches: A new adjunct for preventing or treating spinal cord injury after endovascular repair of thoracoabdominal aneurysms

In this report, we describe a technique that could potentially be used for both prevention and treatment of spinal cord ischemia (SCI) in endovascular repair of thoracoabdominal aneurysms. This technique involves using a specially designed endograft with side branches (paraplegia prevention branches [PPBs]), which are left patent to perfuse the aneurysmal sac and any associated lumbar or intercostal arteries in the early postoperative period. The use of PPBs with this technique is feasible and allows for a temporary controlled endoleak that may be useful for preventing or reversing spinal cord injury. This technique may be considered as an adjunct to the more standard perioperative physiological manipulations such as permissive hypertension and spinal fluid drainage.

Combined Modality of Mechanical Breakdown and Intraembolus Thrombolysis in Failed Systemic Thrombolysis of Subacute Pulmonary Embolism Patients

Acute massive pulmonary embolism with failed systemic thrombolysis has a high morbidity and mortality with few treatment options available. This study assesses the role of combined modality of mechanical fragmentation and intralesional thrombolysis in failed systemic thrombolysis. Seven (13.5%) of 52 patients with massive pulmonary embolism with persistent cardiogenic shock that failed systemic thrombolysis underwent imaging to confirm pulmonary embolism, and then mechanical fragmentation and intralesional thrombolysis. Mechanical breakdown of embolus was accomplished with 5-F multipurpose catheter to re-establish flow, followed by intralesional infusion of urokinase (4,400 IU/kg over 10 minutes followed by 4,400 IU/kg per hour over 24 hours). Four (57.1%) of 7 were unsuccessfully thrombolyzed outside the hospital by urokinase, 2 (28.6%) with recombinant tissue-type plasminogen activator (rtPA) and 1 (14.3%) with streptokinase systemically before 24-48 hours of admission. At presentation, average heart rate and shock index were 121.7/min and 1.45, respectively. Average systolic pulmonary arterial pressure was 73 ± 2.65 mmHg at presentation, and postoperatively was significantly reduced to 39.7 ± 10.44 mmHg (P < 0.001). Mortality at 24 hours, 30 days, and 2 years follow-up was 0% (0/7). Mechanical breakdown of thrombus followed by urokinase infusion may be a cost-effective, minimally invasive, and potentially life-saving procedure for the management of acute massive pulmonary embolism. Randomized controlled trials are required to compare this new strategy to contemporary conventional approaches.