Artery Catheter Placement Research Articles

RR8. Outcome of Rectus Femoris Muscle Flaps for Femoral Arterial Graft Complications

Objectives: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Because large cannulas (16-24F) are necessary to achieve adequate oxygenation, the femoral artery is the most common access site. Unfortunately, femoral cannulation has been associated with limb complications (10%-70%), including ischemia, limb loss, and compartment syndrome. This study aimed to evaluate these complications and management related to limb salvage. Methods: A retrospective review was conducted of 91 consecutive patients requiring VAECMO via femoral cannulation from July 2010 until January 2015. At the time of cannulation, most patients had percutaneous placement of distal arterial perfusion catheters (DPC). After cannulation, all patients were monitored by a near-infrared spectroscopy (NIRS) algorithm and hourly lower extremity examination by trained cardiac intensive care nursing staff, with immediate notification of any change from baseline. ECMO decannulation involved a femoral cutdown with arteriotomy closure by either primary repair or patch angioplasty with bovine pericardium. Study end points included limb ischemia, compartment syndrome requiring fasciotomies, and limb loss. Results: Ninety-one patients were supported with VA-ECMO with femoral arterial cannula sizes from 1624F. Mean length of time on ECMO was 9.1 days (range, 1-40 days). Percutaneous DPC was placed immediately in 62 of 91 patients, with no subsequent ischemia. Of the 29 patients without initial DPC placement, 12 (41.4%; 13.2% of all VA ECMO) developed acute ischemia. Two patients subsequently had DPC placement only, 5 had DPC placement and fasciotomies, 4 had fasciotomies only, and 1 patient required amputation after presenting with acute ischemia after cannulation at another hospital. After DPC placement, all patients had resolution of limb ischemia. The remaining 17 patients without DPC placement experienced no vascular compromise. Overall survival in our VAECMO population was 64%; in patients with limb complications, mortality was 75%. Conclusions: Historically, femoral VA-ECMO has been associated with significant limb ischemic complications. A systematic protocol including NIRS monitoring, trained intensive care nursing staff, DPC placement, decannulation with primary repair of arteriotomies or patch angioplasty can decrease rates of limb ischemia leading to limb loss.

Persistent Left Superior Vena Cava Detected Incidentally after Pulmonary Artery Catheterization

We present a case of pulmonary artery catheter (PAC) placement through the right internal jugular vein, bridging vein and coronary sinus in a patient with previously unrecognized persistent left superior vena cava (LSVC) and diminutive right superior vena cava. A 61-year-old male patient was scheduled for mitral valve repair for regurgitation. Preoperative transthoracic echocardiography revealed dilated coronary sinus, but no further evaluations were performed. During advancement of the PAC, right ventricular and pulmonary arterial pressure tracing was observed at 50 and 60 cm, respectively. Transesophageal echocardiography ruled out intracardiac knotting and revealed the presence of the PAC in the LSVC, entering the right ventricle from the coronary sinus. Diminutive right superior vena cava was observed after sternotomy. The PAC was left in place for 2 days postoperatively without any complications. This case emphasizes that the possibility of LSVC and associated anomalies should always be ruled out in patients with dilated coronary sinus.

Isolated limb infusion chemotherapy with or without hemofiltration for recurrent limb melanoma.

To better define the efficacy and the safety of intra-arterial infusion performed with or without hemofiltration for recurrent limb melanoma. Patients with the following characteristics were included in the study: recurrent limb melanoma not indicated for surgical resection, measurable disease in the extremity, > 18 years, performances status (Eastern Cooperative Oncology Group ) was 0-1 and life expectancy of at least 6 mo. Twenty nine consecutive patients were enrolled in the study. Patients underwent fluoroscopic placement of angiographic arterial and venous catheters to infuse the drug in the artery [isolated limb infusion (ILI)], and to stop the out flow (venous). Melphalan was rapidly infused into the isolated limb via the arterial catheter after the inflation of venous balloon catheter. Then the circulation of the limb was completely blocked with a pneumatic cuff at the root of the limb. Haemofiltration (HF) was available only in the main center, and was performed with an extracorporeal perfusion system, in order to reduce high systemic toxic peaks of drug. Thirty seven ILI were done in 29 cases (31 ILI-HF and 6 ILI) between 2001 and 2014 at Ancona and Pesaro Hospitals, Italy. Clinical outcomes were monitored 30 d after treatment. Eleven patients (38%) received infusion of melphalan alone, 7 (24%) melphalan associated to mitomicin C and 7 (24%) melphalan associated to cisplatin, the remaining 4 were treated with cisplatin, melphalan and epirubicin or cisplatin and mitomicin C. The overall response rate was 66%, in particular, 3 patients (10%) were complete responders and 16 (56%) were partial responders; whereas 7 patients (24%) had stable disease, and 3 (10%) showed progressive disease. Limb toxicity was assessed adopting Wieberdink scale, with evidence of 90% of low grade (I and II) toxicity. ILI-HF and ILI are effective and safe treatments for recurrent non-resectable limb melanoma. They present evidence of favorable clinical benefit and is effective in delaying progression.

Comparison of three cutaneous antiseptic solutions for the prevention of catheter colonization in an ICU for adult patients: a multicenter prospective randomized controlled trial

The current CDC guideline for the prevention of intravascular catheter-related infections recommends skin preparation with a greater than 0.5% chlorhexidine with alcohol solution before central venous catheter (CVC) or peripheral arterial catheter (AC) placement. However, few studies investigated the superiority of 1% alcoholic chlorhexidine gluconate (1% CHG) over either 0.5% alcoholic chlorhexidine gluconate (0.5% CHG) or 10% aqueous povidone iodine (10% PVI) for the prevention of catheter colonization. The aim of this study is to compare the effectiveness of three skin antiseptic solutions for the prevention of intravascular catheter colonization.

Transthoracic echocardiography assists appropriate pulmonary artery catheter placement: An observational study

Transthoracic echocardiography assists appropriate pulmonary artery catheter placement: An observational study

An analysis of the factors influencing pulmonary artery catheter placement in anesthetized patients.

Background:Pulmonary artery catheters are usually placed by resident anesthesiologists with pressure wave monitoring from educational point of view. In some cases, the placement needs longer time or is difficult only by observing the pressure waves.Aims:We sought to examine the time required for the catheter placement in adult patients and determine factors influencing the placement.Settings and Designs:Prospective, observational, cohort study.Methods:We examined the time required for the catheter placement. If the catheter is placed in longer than 5 min, this could be a difficult placement. We examined the effect of the patient's age, body mass index, cardiothoracic ratio (CTR) and tricuspid regurgitation, left ventricular ejection fraction (LVEF) and training duration of a resident on the difficult catheter placement. Next, we excluded the difficult cases from the analysis and examined the effect of these factors on the placement time.Statistical Analysis:The data were analyzed by logistic regression analysis to assess factors for the difficult catheter placement and multiple linear regression analysis to evaluate the factors to increase the placement time after univariate analyses.Results:The difficult placement occurred in 6 patients (5.7%). The analysis showed that LVEF was a significant factor to hinder the catheter placement (P = 0.02) while CTR was a significant factor to increase the placement time (P = 0.002).Conclusion:LVEF and CTRs are significant factors to be associated with the difficult catheter placement and to increase the placement time, respectively.

Association between arterial catheter use and hospital mortality in intensive care units.

Arterial catheters are used frequently in intensive care units (ICUs). Clinical effectiveness and adverse events associated with the use of the catheters have not been formally evaluated in clinical studies. To determine whether an association exists between arterial catheter use and hospital mortality in ICU patients. Propensity-matched cohort analysis of data in the Project IMPACT database, from 2001 to 2008. A total of 139 ICUs in the United States were included. Participants were ICU patients 18 years or older. Arterial catheter use. Our main outcome was hospital mortality. We assessed a primary cohort of medical patients requiring mechanical ventilation and 9 secondary cohorts. We used propensity score-matched pairs as the primary analytic strategy. Sensitivity analyses included 4 alternative methods of comparison in the primary cohort: multivariate modeling without propensity adjustment, mixed-effects multivariate logistic regression without propensity adjustment, multivariate modeling with propensity adjustment, and stratification based on propensity quintiles. Our primary cohort consisted of 60 975 patients; 24 126 of these patients (39.6%) had an arterial catheter in place during their ICU stay, and analyses were based on 13 603 propensity score-matched pairs. We found no association between arterial catheter use and hospital mortality in medical patients requiring mechanical ventilation in the primary analysis (odds ratio [OR], 0.98; 95% CI, 0.93-1.03; P = .40) or the 4 sensitivity analyses (P ≥ .58 for all). In 8 of 9 secondary cohorts we were unable to detect an association between arterial catheter use and hospital mortality. In the cohort of patients receiving vasopressors, arterial catheter use was associated with an increased odds of death (OR, 1.08; 95% CI, 1.02-1.14; P = .008). In this propensity-matched cohort analysis, arterial catheters were not associated with improvements in hospital mortality in medical ICU patients requiring mechanical ventilation. Given the costs and potential harms associated with invasive catheters, randomized clinical trials are needed to further evaluate the usefulness of these frequently used devices.

Analysis of Radial Artery Catheter Placement by Respiratory Therapists Using Ultrasound Guidance

The use of ultrasound (US) guidance for radial artery cannulation has been shown to improve first attempt success rate, reduce time to successful cannulation, and reduce complications. We sought to determine whether properly trained respiratory therapists (RTs) could utilize US guidance for the placement of radial artery catheters. Primary outcome measurements were successful cannulation and first attempt success rate. Secondary outcomes included the effect of systolic blood pressure, prior attempts, palpable pulse strength, and gender in relation to US-guided radial artery cannulation success rates. RTs certified in arterial catheter insertion were trained in radial artery catheterization using US by emergency medicine physicians. Subjects were enrolled based on the need for an arterial catheter placement. The catheters and US devices used were standardized. Data recorded included pulse strength, systolic and diastolic blood pressure, number of attempts, and successful/unsuccessful artery cannulation. All catheterization attempts were performed according to institutional policy and procedure. One hundred twenty-two radial artery catheter insertion attempts were made between December of 2008 and October of 2011, in patients in whom the treating physician requested RT radial artery cannulation. The overall success rate was 86.1%, whereas the first attempt success rate was 63.1%. There was no difference found between the overall mean success rate for weak or absent pulses, age, systolic blood pressure, gender, or prior attempts. RTs can effectively utilize US technology to place radial artery catheters. Systolic blood pressure, prior attempts, and gender are not reliable predictors of success for US-guided radial artery cannulation. Training on the use of US should be strongly encouraged for all practitioners who place radial artery catheters.

Arterial Catheters as a Source of Bloodstream Infection

Catheter-related bloodstream infections are associated with significant costs and adverse consequences. Arterial catheters are commonly used in the critical care setting and are among the most heavily manipulated vascular access devices. We sought to evaluate the prevalence of arterial catheter-related bloodstream infection. PubMed, CinAHL, EMBASE, and Web of Science. Included studies reported prevalence rate of catheter-related bloodstream infection for arterial catheters used for critical illness or postoperative monitoring. For the purposes of this study, catheter-related bloodstream infection was defined as positive blood culture collected from an arterial catheter and from the periphery with the same organism in a patient demonstrating systemic signs of sepsis. The study population, site of insertion, antiseptic preparation, catheter days, and prevalence of catheter-related bloodstream infection were abstracted. When data were not available, authors were contacted for further information. Forty-nine studies met criteria including 222 cases of arterial catheter-related bloodstream infection in 30,841 catheters. Pooled incidence was 3.40/1,000 catheters or 0.96/1,000 catheter days. Prevalence was considerably higher in the subgroup of studies that cultured all catheters (1.26/1,000 catheter days) compared with those studies that cultured only when the arterial catheter was suspected as the source for the catheter-related bloodstream infection (0.70/1,000 catheter days). Pooled data also found a significantly increased risk of infection for femoral site of insertion compared with radial artery for arterial catheter placement (relative risk, 1.93; 95% CI, 1.32-2.84; p = 0.001) CONCLUSIONS: Arterial catheters are an underrecognized cause of catheter-related bloodstream infection. Pooled incidence when catheters were systematically cultured and correlated to blood culture results indicated a substantial burden of arterial catheter-related bloodstream infection. Selection of a radial site over a femoral site will help reduce the risk of arterial catheter-related bloodstream infection. Future studies should evaluate technologies applied to preventing central venous catheter-related bloodstream infection to arterial catheters as well.

Percutaneous Catheter and Port Placement for Hepatic Arterial Infusion Chemotherapy: Catheter Placement from Subclavian Artery

Hepatic arterial infusion chemotherapy (HAIC) has been performed for patients with life-threatening liver tumors resistant to standard therapies for more than 30 years. Placement of the port and catheter system for HAIC is performed by surgeons or interventional radiologists. Surgical placement requires laparotomy, whereas the interventional radiologic approach places a port and a catheter percutaneously. The interventional radiologic technique of implanting a port and catheter was originally developed in Japan in the 1980s. The procedure consists of arterial redistribution, catheter and port placement, and evaluation and management of the drug distribution. For the catheter and port placement, the subclavian artery, femoral artery, or inferior epigastric artery is used as an access route. We have used a subclavian artery for HAIC to have the stability of the system at the anterior chest wall and the ease to advance a catheter into hepatic arteries at the time of the placement; however, there are some risks, such as cerebral infarction, and the specific skills of a cutdown procedure are required to access the subclavian artery. No procedure can be perfectly appropriate for all patients, and we should consider what we choose on a case-by-case basis. With this video (available online at www.jvir.org), we hope many interventional radiologists will be aware that this could be within their scope of practice with training.

Evaluation and Management of ST-elevation Myocardial Infarction and Shock.

Cardiogenic shock is the deadliest complication of acute ST-elevation myocardial infarction. Prompt recognition and intervention are critical for patient survival. The diagnosis of cardiogenic shock is primarily a clinical one based on signs and symptoms of low cardiac output and heart failure, and can be confirmed with placement of a pulmonary arterial catheter. Vasopressor and inotropic therapies are typically required, and in severe cases, an intra-aortic balloon pump can provide additional haemodynamic support. Although mortality for cardiogenic shock associated with ST-elevation myocardial infarction remains high, early reperfusion strategies primarily via percutaneous coronary intervention or coronary artery bypass graft surgery have led to improved outcomes.

Biological effects of anti-CD34-coated ePTFE vascular grafts. Early in vivo experimental results.

Aim of the studyTo assess the biological activity of anti-CD34 antibody-coated ePTFE vascular prostheses.Material and methodsIndium111-labeled autologous thrombocytes were administered to 5 anesthetized pigs after the placement of femoral arterial and venous catheters. An arterio-venous fistula, created by the random interposition of 4 different ePTFE grafts (A = dry control, B = dry anti-CD34, C = wet control, D = wet anti-CD34), was blood perfused for 0, 10, 30, 60 and 120 minutes. Radioactivity of each graft was measured and expressed in cpm/mg. Morphological studies were performed to assess intraluminal deposition.ResultsThe median radioactivity of graft B was significantly higher than that of graft A after 60 min (1074 vs. 18; p = 0.021) and 120 min (1990 vs. 25; p = 0.043) of perfusion. Similarly, graft D was significantly more active than graft C (60 min: 1388 vs. 26; p = 0.021 and 120 min: 2780 vs. 23; p = 0.021). Histological and SEM results confirmed the radio-labeling in-vivo studies by showing significantly more protein/cell and platelet depositions (p = 0.012).ConclusionsAnti-CD34-coated ePTFE grafts bound significantly more platelets/cells and proteins than their uncoated counterparts, confirming the bioactivity of the antibody. This process is time-dependent and matches the morphological results. The anti-CD34 coating may enhance temporal and spatial endothelialization of vascular grafts and, thus, possibly improve clinical results by providing direct endothelial progenitor cell (EPC) adhesion/entrapment or by creating a biocompatible protein-thrombocyte/cell layer that indirectly enhances migration and further proliferation of EPCs.

The Accuracy of Transcutaneous PCO2in Subjects With Severe Brain Injury: A Comparison With End-Tidal PCO2

In patients suffering from brain injury, end-tidal PCO2 (PETCO2 ) monitoring is controversial, but transcutaneous PCO2 (PtcCO2 ), which is noninvasive and utilizes immediate display, may be an alternative method. We hypothesized that PtcCO2 would be more accurate than PETCO2 for monitoring PaCO2 in patients with severe brain injury. A prospective observational study included consecutive mechanically ventilated adult subjects who had acute brain injury and an arterial catheter in place. When an arterial blood gas analysis was required, the PETCO2 and PtcCO2 values were simultaneously recorded. The agreement between the PETCO2 , PtcCO2 , and PaCO2 measurements (reference) was determined using the Bland-Altman method. The number of outliers defined by the formula ([PETCO2 or PtcCO2 ] - PaCO2 ) > ± 4 mm Hg indicated the proportion of measurements that were considered clinically unacceptable. A total of 25 subjects were included in the study, and 85 simultaneous measurements of PaCO2 , PtcCO2 , and PETCO2 were obtained. The bias and precision between PaCO2 and PtcCO2 were -0.75 and 6.23 mm Hg, respectively. The limits of agreement ranged from -12.97 to 11.47 mm Hg. The bias and precision between PaCO2 and PETCO2 were 0.68 and 5.82 mm Hg, respectively. The limits of agreement ranged from -10.72 to 12.08 mm Hg. There were 34 (40%) outliers for the PtcCO2 sensor and 34 (40%) outliers for the PETCO2 sensor (P > .99). The accuracy of PtcCO2 was not superior to that of PETCO2 for assessing PCO2 levels and should not be used to monitor these levels in subjects with severe brain injury.

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Introduction: Retrohepatic vena cava (RVC) injuries are among the most lethal of injuries, often leading to exsanguination while vena cava repair is attempted. One well known yet seldom studied method of controlling RVC hemorrhage is the atriocaval shunt. Methods: Four female Yorkshire swine (30-40kg) were anesthetized, intubated, and underwent placement of femoral and pulmonary arterial catheters for continuous hemodynamic monitoring. After laparotomy and sternotomy, swine were shunted with 28Fr thoracostomy tubes. Shunts were secured in place with a right atrial appendage purse string suture and umbilical tape around the infracardiac and infrahepatic IVC. Swine were actively resuscitated with IV fluids while hemodynamic parameters, resuscitation volumes, and blood loss were measured for up to 4 hours before animals were euthanized. Results: Prior to shunting, the mean heart rate (HR), mean arterial pressure (MAP), and cardiac output (CO) were 102 ± 9 bpm, 65 ± 7 mmHg, and 4 ± 1 L/min, respectively. Immediately following shunt placement (n=4; mean EBL, 889 ± 208cc), shock became physiologically evident in measured parameters: HR 122 ± 34 bpm, MAP 36 ± 10 mmHg, and CO 3 ± 1 L/min. Two swine died after 11 and 14 minutes (IVF, 1800 ± 707cc; EBL, 912 ± 52cc) and two survived 2 hours after shunting (IVF, 3400 ± 1697cc; EBL, 865 ± 354cc). When compared to pre-shunt values, animals surviving 2 hours after shunting had decreased mean arterial pressures (65.3 ± 6.5 vs. 36.5 ± 7.8 mmHg; p=0.008) and decreased cardiac output (4.0 ± 1.1 vs. 1.6 ± 1 L/min; p=0.04). One of 4 (25%) swine survived the entire 4 hour study period following shunt placement (IVF, 4600cc; EBL, 1115cc) and was euthanized Conclusions: Despite normal pre-shunt hemodynamic parameters and the absence of a RVC injury, only one swine survived 4 hours after atriocaval shunting. While further study is warranted, our results highlight the profound physiologic compromise caused by the atriocaval shunting procedure itself

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Introduction: Although an increased body mass index (BMI) is associated with an elevated risk of chronic health diseases such as diabetes and hypertension, it is unclear whether patients with high BMIs fare worse when they are admitted to an intensive care unit (ICU) for an acute disorder. Some studies have instead described an "obesity paradox" where obese patients (BMI>30 kg/m2) have a lower ICU mortality rate, particularly when diagnosed with acute infections and septic shock. However, most studies have not addressed the outcomes of patients with more extreme obesity, defined as "super obesity" (BMI > 50), who may have outcomes that are different from patients whose BMI are below this threshold. Methods: A retrospective analysis of patients admitted to the MICU at LAC+USC Medical Center from 2008 to 2013 was performed. Patients were divided into 3 groups: BMI of 30-39, 40-49 and >50. In this pilot study, the first 55 patients reviewed in each BMI set were assigned to their respective group. Variables assessed included age, sex, APACHE II score, reason for ICU admission, use of non-invasive and invasive mechanical ventilation, need for dialysis, tracheostomy, use of a pulmonary artery catheter, mortality, and hospital and ICU length of stay (LOS). Analysis of variance was used to detected differences in means of continuous data and a chi square test was used to evaluate categorical data among the three groups. A p<0.05 was considered significant. Results: The mean age for super obese patients (BMI >50) was younger (44 + 2.7 SEM) than either of the BMI 30-39 and BMI 40-49 groups at 49 + 2.7 and 51 + 3.1 years, respectively (p<0.05). There was no significant difference among APACHE II scores or ICU length of stay. However, the mean hospital LOS was 7 + 2.1 days longer for patients with BMI > 50 than those with a BMI = 30-39, and 4 + 1.5 days longer than those with a BMI = 40-49. Mortality was similar among the three groups. Although there was no difference in the need or duration of invasive mechanical ventilation, there was a higher proportion of noninvasive mechanical ventilation used in the BMI>50 cohort (p<0.05), in that 34 (62%) of the super obese patients used noninvasive ventilation compared with 16 (29%) in the 40-49 group and 6 (11%) in the 30-39 group. Although there was a trend toward higher rates of tracheostomy or pulmonary artery catheter placement in the super obese patients, this did not achieve statistical significance. Super obese patients did not have a higher propensity to require hemodialysis than did the other groups (p>0.05). Indications for admission were different among the groups, with the BMI>50 patients being admitted to the ICU more frequently for cardiopulmonary indications (arrhythmias, heart failure, dyspnea, hypoxia) than were patients in the other groups (p<0.05). Conclusions: Super obese patients with a BMI >50 who are admitted to the MICU were younger in comparison to less obese patients. While there was no difference in use or duration of invasive mechanical ventilation in the 3 groups, patients with BMI >50 more often required non-invasive ventilation. Patients at the higher extremes of obesity were admitted to the ICU for cardiopulmonary issues more so than patients with BMI 30-50. Despite these differences, crude mortality rates were similar among these 3 groups of obese patients.

Understanding Changes in Established Practice

Multiple studies suggest that routine use of pulmonary artery catheters is not beneficial in critically ill patients. Little is known about the patterns of "uptake" of practice change that involves removal of a device previously considered standard of care, rather than adoption of a new technique or technology. Our objective was to assess recent pulmonary artery catheter use across ICUs and identify factors associated with high use. Cohort study. U.S. ICUs in Project IMPACT. Adult ICU admissions from 2001 to 2008. None. Trends in pulmonary artery catheter use from 2001 to 2008 were assessed. For 2006-2008, we compared pulmonary artery catheter use across ICUs. We assessed characteristics of ICUs and hospitals in the top quartile for in-ICU pulmonary artery catheter placement (vs the bottom quartile) using chi-square and t tests and factors associated with in-ICU pulmonary artery catheter insertion using multilevel mixed effects logistic regression. Total pulmonary artery catheter use decreased from 10.8% of patients (2001-2003) to 6.2% (2006-2008; p < 0.001); insertion of pulmonary artery catheters in ICU decreased from 4.2% to 2.2% (p < 0.001). In 2006-2008, ICUs in the top quartile for in-ICU pulmonary artery catheter insertion (3.4-25.0% of patients) were more often surgical (54.2% vs 21.7% in the lowest quartile, p = 0.070), teaching hospitals (54.2% vs 4.3%, p = 0.001), and had surgeon leadership (40.9% vs 13.0%, p = 0.067). After multivariable regression, surgical patients (p < 0.001) and all patients in surgical ICUs (p = 0.057) were more likely to have pulmonary artery catheters placed in ICU. Use of pulmonary artery catheters in ICU patients has declined but with significant variation across units. Removal of this technology has occurred most in nonsurgical ICUs and patients.

P181 Transcutaneous CO2 monitoring in hypercapnoeic respiratory failure: a meta-analysis of prospective studies

IntroductionThe role of transcutaneous carbon dioxide monitoring (PtcCO2) for patients with respiratory failure has been studied in a variety of clinical settings. However, its accuracy compared to arterial partial pressure...

More Questions Than Answers in 6 Cases

Bechara and colleagues1 report a series of 12 patients treated over 11 years who sustained intraoperative carotid artery introducer sheathplacementduringattempted jugular vein cannulation. Six earlier patients were treated with open carotid artery exploration and primary repair, whereas the more recent 6 patients were treated with percutaneous closure using a suture-mediated closure device. No patients in either group had neurological events or other complications. However, the mean duration of treatment was shorter in the endovascular group than the operative group, 6 vs 32 minutes, respectively. The authors conclude that endovascular closure is as safe and effective as operative repair but more expeditious. Is it possible to extend the authors’ findings to the general group of patients having catheters placed into the carotidartery?Arterialpunctureduring internal jugularveincatheterization occurs in approximately 6% to 9% of cases.2 The low frequency of the authors’ cases, their carotid artery catheterplacement in theoperating roombyanesthesiologists, and their repairbyexperiencedvascularsurgeonssuggest that these cases are a highly selected group at low risk for complications after any repair.However, ifmost carotidartery catheterplacements occur outside the operating roomandoften involve inexperienced trainees who do not use ultrasonographic guidance, is endovascular repair appropriate for these patients? Interestingly, thecathetersplaced inthisstudywereall8.5F introducer sheaths, facilitating endovascular closure; smaller central venous catheters may be more amenable to manual compression or repair with a single Prolene stitch. The authors’ conclusion that “repair of the carotid artery puncture site” is mandatory seems unfounded given the lack of patients treatedwith compression, the lack of smaller catheters in the group, and the lack of a prospective trial. This case series is certainly intriguing and suggests that some patientsmay be treatedwith endovascular techniques. However, that group of patients is not yet clearly defined and the algorithm is not well understood. For example, angiographywas performed selectively in this series, in addition to ultrasonography, but this additional risk of stroke requires justification; who should undergo angiography in this scenario? Is it mandatory to inspect the runoff bed for emboli? The role of endovascular treatment continues to evolve, especially when performed by endovascular leaders. However, success in 6 attempts does not replace the standard of care; a single complicationmay have led to devastating complications. The gold standard for carotid artery repair remains open surgical exploration; the time savings (mean, 26 minutes) must be weighed against the cost of the closure device aswell.Despite theauthors’ success in6patients,wecaution readers against the quick and broad adoption of this method and suggest its use only in selected cases, such as in sites that have difficult surgical exposure.3

The current state of fellowship training in pulmonary artery catheter placement and data interpretation: A national survey of pulmonary and critical care fellowship program directors

PurposeGiven decreasing use of pulmonary artery (PA) catheterization, we sought to evaluate whether current pulmonary and critical care fellows have adequate opportunity to obtain proficiency in PA catheter placement and data interpretation. MethodsAll US pulmonary and critical care program directors were invited to participate in an anonymous online survey regarding current training opportunities in PA catheterization. ResultsThe response rate was 51% (69/136). Eighty-three percent reported that the number of PA catheterizations performed by fellows within their program has decreased in the past decade. Fifty-four percent estimated that their fellows currently participate in less than 10 supervised procedures during fellowship. The most frequently identified barriers to training were procedure volume and reluctance to place PA catheters in the medical intensive care unit. Forty-three percent of respondents agreed that training in PA catheter placement is currently adequate within their program, and 55% agreed that training in data interpretation is adequate. Only 39% of respondents believe that PA catheter placement should continue to be an Accreditation Council for Graduate Medical Education training requirement. ConclusionsMany current pulmonary and critical care fellows do not have the opportunity to gain proficiency in PA catheterization. Fellowship training programs should consider alternate means of training fellows in PA catheter data interpretation, such as simulation.

A Bedside Antecubital Technique for Pulmonary Artery Catheter Placement is a Feasible and Safe Approach

A Bedside Antecubital Technique for Pulmonary Artery Catheter Placement is a Feasible and Safe Approach