Sheath Technique Research Articles

Modified telescopic sheath method for exchange of luminally encrusted ureteral stents

A novel telescopic access sheath technique has beendescribed to maintain access to the ureterincases of stent encrustation, placing a suture onthe externalised distal end of the stentfollowedby advancing a sheath over to peeloffencrustations and maintain access in theureter,as well as application of this techniqueinachild. Herein we present a modification of thetelescopic sheath technique thatallows exchange of luminally encrusted stentswithoutrequiring passage of the sheathintothe ureter or ureteroscopy alongside the stent.

Area reduction of perforation with a small-size sheath technique for iatrogenic femoral artery pseudoaneurysm with a large perforation.

Open surgery for femoral artery pseudoaneurysms is invasive, and complications can be detrimental. Several cases of treatment of iatrogenic femoral artery pseudoaneurysms using percutaneous suture-mediated closure devices have been reported. However, it is difficult to properly deploy the foot of the device to the arterial wall when the perforation area is large. We developed a technique using a double guidewire to partially occupy the perforation with a small-size sheath, which reduces the area of the perforation. This AREPAS (area reduction of perforation with a small-sized sheath) technique might allow for minimally invasive closure of perforations even in patients with large perforation areas.

Transvenous lead extractions in a single high-volume center over a 24-year period: High success rate and low complication rate

Transvenous lead extraction (TLE) procedures can be complicated and are associated with a small but significant risk of cardiovascular complications. However, methods and tools vary among centers. The purpose of this study was to the present the methods and results of pacemaker and implantable cardioverter-defibrillator TLE procedures in our center over a 24-year period. From April 1997 through 2020, we attempted to extract 2964 leads in 1780 procedures and 1642 patients. We mainly utilized single sheath technique using snaring or mechanical rotational sheaths and steel sheaths when necessary. Difficult procedures were performed by an experienced cardiologist, and close supervision was emphasized. Most of the extractions were performed using local anesthesia with sedation. Median age of patients was 65.0 [interquartile range 20.00] years, and median dwelling time of leads was 5.0 [7.0] years. Clinical success was achieved in 1739 procedures (97.7%) and complete technical success in 2841 leads (95.8%). Clinical success (leaving <4 cm of the lead in the body and achieving the clinical goal for the patient) was achieved for 79 leads (2.7%). TLE failed in 44 leads (1.1%) and 41 procedures (2.3%) among 36 patients (2.2%). There were 23 cases (1.3%) of major complications, with only 1 death directly related to the procedure (<0.1%). In addition, 2 patients with sepsis died within the first 24 hours after the procedure. No caval tears occurred. Single sheath lead extractions utilizing snaring or mechanical rotational sheaths were effective and safe in our high-volume center as performed by experienced operators.

Transcatheter Mitral Valve-in-Valve Implantation Applying a Long Pre-Curved Sheath for Patients with Degenerated Bioprosthetic Mitral Valve.

Percutaneous transseptal transcatheter mitral valve-in-valve implantation (TMViV) has become an alternative minimally invasive treatment choice for patients with degenerated mitral bioprosthesis and high surgical risk. However, transseptal approach is more technically challenging than transapical approach in TMViV procedures. The objective of this study was to introduce the experience of applying long pre-curved sheaths in transseptal TMViV procedures and to evaluate the effect of long pre-curved sheath techniques in TMViV procedures. Between January 2020 and December 2021, 27 patients with degenerated bioprosthetic mitral valve underwent TMViV procedures using a balloon-expandable valve via the transseptal approach. The regular 14/16F expandable sheath were used for low-profile delivery in first 10 cases, and 22F long pre-curved sheath were used in the next 17 cases during procedures. We retrospectively reviewed the catheter techniques, perioperative characteristics, and prognosis. The median follow-up time was 12 (1-21) months. To further scrutinize our data, we divided the group into the early 10 patients using 14/16F expandable sheath and the subsequent 17 patients with long pre-curved sheath in order to assess the impact of different sheaths and procedural details on outcomes. Procedural success was obtained in all patients with no in-hospital mortality. Seventeen patients received 26 mm prostheses; the remaining ten patients received 29 mm prostheses. Post balloon dilatation was performed in one case. Total procedure time was (96.1 28.2) min, the fluoroscopic time was (27.4 6.5) min, and total contrast volume was (50.7 10.1) mL. One patient received blood transfusion because of hemorrhage at the femoral puncture site. One patient received a permanent pacemaker implantation due to high-degree atrioventricular block at postoperative day 3. There were no other major post-procedure complications and the median length of hospital stay was 4 days. Twenty-five (92.6%) patients improved by 1 New York Heart Association (NYHA) functional class at 30 days. In subsequent sub analysis, there were shorter procedural time [(85.2 24.3) vs. (115.2 25.6) min, p = 0.0048] and shorter fluoroscopic time [(24.3 5.2) vs. (31.3 5.1) min, p = 0.0073] in cases with the long pre-curved sheath than ones with regular expandable sheath. The iatrogenic atrial septal defect (ASD) closure was performed because of the transeptal large right to left shunt in 2 cases with regular expandable sheath, but no patient needed intraoperative ASD closure in cases with the long pre-curved sheath. Transseptal TMViV using long pre-curved sheath could simplify transseptal approach with reliable outcomes for patients of degenerated mitral bioprosthesis.

Left ventricular lead delivery system used to implant right ventricular lead via persistent left superior vena cava.

Left ventricular lead delivery system used to implant right ventricular lead via persistent left superior vena cava.

Transvenous removal of pacing and ICD leads: single Italian referral center experience

Abstract Introduction Device related complications are rising the need of Transvenous Lead Removal (TLR). Transvenous extraction of Pacing (PL) and Defibrillating Leads (DL) is a highly effective technique. Aim of this report is to analyse the longstanding experience performed in a single Italian Referral Center. Methods From January 1997 to December 2021, we managed 2925 consecutive patients (2220 men, mean age 65.3 years) with 5370 leads (mean dwell time 74.0 months, range 1–576). PL were 4209 (1903 ventricular, 1801 atrial, 505 coronary sinus leads), DL were 1161 (1140 ventricular, 6 atrial, 15 superior vena cava leads). Indications to TLR were infection in 78% (systemic 27%, local 51%) of leads. We performed mechanical dilatation using a single polypropylene sheath technique and, if necessary, other intravascular tools; we performed an approach through the Internal Jugular Vein (JA) in case of free-floating leads or failure of the standard approach. Results We attempted removal in 5359 leads because the technique was not applicable in 11 PL. Among these, 5223 leads were completely removed (97.4%), 51 (1.0%) were partially removed, 85 (1.6%) were not removed. Among 5271 exposed leads: manual traction removed 879 (16.7%) leads; mechanical dilatation using the venous entry site removed 3860 (73.2%) leads; femoral approach (FA) removed 50 (0.9%) leads; and JA removed 346 (6.6%) leads. All the free-floating leads were completely removed, 26.1% by FA and 73.9% by JA. Major complications occurred in 23 cases (0.78%): cardiac tamponade (21 cases, 5 deaths), hemothorax (2 cases, 1 death). Conclusions Our experience shows that in centers with wide experience, TLR using single sheath mechanical dilatation has a high success rate and a very low incidence of serious complications. TLR through the Internal Jugular Vein increases the effectiveness and safety of the procedure also in case of free-floating or challenging leads. Funding Acknowledgement Type of funding sources: None.

Management of massive hemopericardium in the electrophysiology laboratory: The double long sheath technique.

To describe a simple and useful technique for acute management of massive hemopericardium inside the Electrophysiology (EP) laboratory METHODS AND RESULTS: Five patients from a single center experience were identified, all with blood loss above 1000 ml after initial pericardiocenthesis. Using two long 8.5 F transseptal sheaths inside the pericardium space, with continuous negative pressure, allowed the complete cessation of bleeding or hemodynamic maintenance until definitive surgical repair in all patients CONCLUSION: The use of two long sheaths for blood drainage, instead of conventional pericardiocenthesis, might be helpful to manage massive hemopericardium inside EP lab, avoiding urgent cardiac surgery or maintaining clinical stability until surgical staff is available.

Endovascular Treatment of an Iliac Aneurysm for the Preservation of a Native Pelvic Kidney: Co-Axial Double Sheath Technique as a Strategy for Easier, Safer, and Faster Anterograde Branch Catheterisation

Endovascular Treatment of an Iliac Aneurysm for the Preservation of a Native Pelvic Kidney: Co-Axial Double Sheath Technique as a Strategy for Easier, Safer, and Faster Anterograde Branch Catheterisation

WILD Sheath Technique: “WIre Loop Directional” Sheath for Retrograde Femoral Access in Branched Endovascular Aortic Aneurysm Repair

Branched endovascular aortic aneurysm repair (BEVAR) necessitates upper limb access (ULA) to facilitate the antegrade cannulation of downward directional branches and the placement of the bridging stent grafts. Various technical solutions to avoid ULA have been proposed and successfully applied in a limited number of cases. This can be necessary in specific clinical scenarios such as hostile aortic arch and descending thoracic aortic anatomy, or in the case of previous aortic arch and supra-aortic vessels surgery complicating the conventional approach with ULA in BEVAR. Taking inspiration from the prior description of a precursory technique, we report the application of our technique in BEVAR procedures, using standard introducer sheaths as a directional stable platform to facilitate an “All Femoral Access” (AFA) approach without the need for ULA, snaring or commercial steerable sheaths. Our concept is based on utilizing a wire loop to form a directional sheath (WILD sheath technique).

肺膿瘍・感染性肺囊胞の治療におけるEBUS-GSを用いた経気管支ドレナージ

肺膿瘍・感染性肺囊胞の治療におけるEBUS-GSを用いた経気管支ドレナージ

Endoscopic Bilateral Optic Nerve Decompression for Treatment of Idiopathic Intracranial Hypertension.

Objective: To evaluate the results of bilateral endoscopic optic nerve decompression (EOND) with the opening nerve sheath (ONS) technique in patients with idiopathic intracranial hypertension (IIH). Methods: Between the years of 2017 and 2019, we retrospectively evaluated nine IIH patients with progressive visual impairment despite medical treatment and who were treated with the EOND and ONS techniques. We also demonstrated our surgical technique recipe on postmortem human heads in a stepwise manner. Results: There were 9 patients (7 females and 2 males) between the ages of 21 and 72 included in this study, and the mean age was 40.8. All patients had an impairment in visual acuity and/or their visual field, with signs of papilledema and/or optic atrophy. The patients were followed up with for 9–48 months. Improvements in visual acuity were observed in 7 out of 9 patients (78%). Visual field defects improved in 5 out of 8 patients (62.5%). Papilledema was resolved in all patients (100%). Headaches improved in all symptomatic patients (100%). No intraoperative or postoperative complications were observed. Conclusions: EOND is a safe and effective surgical procedure in selected patients with IIH. Bilateral wide bony decompression and nerve fenestration can also be an additional benefit for headache relief. Further clinical series and long-term follow-up are needed for more precise results.

Experience with the novel unifemoral parallel sheath technique in percutaneous intervention of chronic total coronary occlusions

BackgroundPercutaneous interventions to address chronic coronary occlusions (CTO-PCI) often require simultaneous ipsi- and contralateral coronary injections. Although radial access is increasingly popular, bifemoral artery access is still the preferred choice of CTO operators.The aim of this case series is to demonstrate the feasibility and safety of the unifemoral parallel sheath technique, which avoids two puncture sites, increases patient comfort, and improves procedure ergonomics.It offers rapid second access to the femoral artery adjacent to the first sheath as well as closure by unilateral manual compression without or with 1 or 2 vascular closure devices.ResultsWe retrospectively evaluated the procedure results in 90 consecutive CTO patients where an ipsilateral parallel sheath access was considered. Placement of the second sheath uneventfully failed in two because of severe femoral calcification and narrowing. In 96.6%, the first sheath was 7 F (3.4% 6F), while the second sheath was 4 F in 22.7%, 5 F in 64.7%, and 6 or 7 F in 11.4% each.No major complications nor severe bleeding events occurred, and the mean drop of hemoglobin was low (0.6 g/dL ± 0.86).ConclusionIn CTO-PCI requiring contralateral coronary injections or the retrograde technique, the ipsilateral parallel sheath technique might be a feasible alternative to the standard bifemoral or femoral-radial access.

The use of curved sheath technique to facilitate difficult internal carotid artery occlusions

Carotid Artery Occlusive Disease or Carotid Artery Stenosis (CAS), a widely prevalent disease, involves blockage of the arterial wall through atherosclerotic plaques. Due to the high prevalence of carotid artery stenosis, innovative approaches to improve the outcome are required, particularly for more difficult and unique cases. Within this report, we present a particularly difficult case of Type III Aortic Arch – Right Internal Carotid Artery (ICA) stenosis making it a challenging case. We describe a symptomatic 87-year-old male who presented to Cardiology clinic. CT angiogram showed 70% occlusion of right internal carotid artery and patient was deemed high risk for carotid artery surgery; hence, the patient underwent internal carotid artery stenting. After the procedure, angiogram results were excellent, and the patient was transferred to CICU in stable hemodynamic condition. This case demonstrates the significance of innovative new techniques in the development of medical treatment.&#x0D; Keywords: Carotid Artery Stenting, Curve Sheath Technique, Type 3 Aortic Arch, Right Internal Carotid Artery Stenosis

A Modified Through and Through Guidewire Steerable Sheath Technique for Transfemoral Access to Visceral Arteries with Hostile Anatomy

A Modified Through and Through Guidewire Steerable Sheath Technique for Transfemoral Access to Visceral Arteries with Hostile Anatomy

75 Effect of mycobacterium cell wall fraction immunostimulant on conception rates in heifer recipients

In cattle, the average pregnancy for IVF embryos around Days 45 to 90 is 35% (Ealy et al. 2019 J. Anim. Sci. 97, 2555–2568). Among other factors, uterine contamination with pathogens from the vagina during embryo transfer may affect pregnancy success. Prophylactic antibiotic treatment for this purpose in embryo recipients is considered malpractice. An alternative to antibiotics is the use of mycobacterium cell wall fraction (MCWF) immunostimulant (Amplimune, NovaVive Inc.) against these pathogens. Therefore, the objective was to determine the effect of MCWF on conception rates in heifer recipients. For this purpose, Holstein heifers were synchronized with 2 injections of prostaglandin F2α 14 days apart and randomly allocated to 2 groups: (1) MCWF (n=292), single intramuscular injection of 5mL of Amplimune on the day of pretransfer oestrus; (2) Control (n=296): no Amplimune treatment. Embryo transfers using quality 1 frozen IVF embryos were performed in all recipients 7 to 8 days after oestrus and with a corpus luteum ≥22mm, using a double sanitary sheath technique. Data were analysed using the generalized linear mixed model (GLMM). Results are shown in Table 1. In conclusion, treatment with MCWF increased the number of recipients to be used for embryo transfer and improved the conception rate at Day 60. Importantly, MCWF treatment was more efficient for getting a recipient pregnant by Day 60 per total of synchronized recipients. Table 1. Effect of mycobacterium cell wall fraction (MCWF) on pregnancy in heifer recipients transferred frozen embryos (quality 1) Variable MCWF Control Utilisation rate 227/292a 174/296b (No. of transferred recipients/no. of synchronized recipients) (78%) (59%) Pregnancy Day 30 144/227 94/174 (No. of pregnant recipients at Day 30/no. of transferred recipients) (63%) (54%) Pregnancy Day 60 131/227a 83/174b (No. of pregnant recipients at Day 60/no. of transferred recipients) (58%) (48%) Embryo mortality 13/144 11/94 (No. of embryo loss at Day 60/no. of pregnant recipients at Day 30) (9%) (12%) Pregnancy Day 60 per total of synchronized 131/292a 83/296b (No. of pregnant recipients/no. of synchronized recipients) (45%) (28%) a,bValues with different superscripts within a row are different (P ≤ 0.05).

Transvenous removal of pacing and ICD leads: single italian referral center experience

Abstract Introduction Device related complications are rising the need of Transvenous Lead Removal (TLR). Transvenous extraction of Pacing (PL) and Defibrillating Leads (DL) is a highly effective technique. Aim of this report is to analyse the longstanding experience performed in a single Italian Referral Center. Methods Since January 1997 to December 2019, we managed 2769 consecutive patients (2100 men, mean age 65.5 years) with 5086 leads (mean pacing period 73.6 months, range 1–576). PL were 3998 (1828 ventricular, 1704 atrial, 466 coronary sinus leads), DL were 1088 (1067 ventricular, 6 atrial, 15 superior vena cava leads). Indications to TLR were infection in 79% (systemic 27%, local 52%) of leads. We performed mechanical dilatation using a single polypropylene sheath technique and if necessary, other intravascular tools; an Approach through the Internal Jugular Vein (JA) was performed in case of free-floating leads or failure of the standard approach. Results Removal was attempted in 5076 leads because the technique was not applicable in 10 PL. Among these, 4952 leads were completely removed (97.6%), 49 (1.0%) partially removed, 75 (1.4%) not removed. Among 4989 exposed leads, 818 were removed by manual traction (16.4%), 3664 by mechanical dilatation using the venous entry site (73.4%), 48 by femoral approach (FA) (1.0%) and 335 by JA (6.7%). All the free-floating leads were completely removed, 25.3% by FA and 74.7% by JA. Major complications occurred in 20 cases (0.72%): cardiac tamponade (19 cases, 4 deaths), hemotorax (1 death). Conclusions Our experience shows that in centers with wide experience, TLR using single sheath mechanical dilatation has a high success rate and a very low incidence of serious complications. TLR through the Internal Jugular Vein increases the effectiveness and safety of the procedure also in case of free-floating or challenging leads. Funding Acknowledgement Type of funding source: None

The usefulness and feasibility of placing a clinch knot with a guidewire to achieve temporary hemostasis in arteriovenous dialysis access interventions.

To evaluate the usefulness and feasibility of using a reversible clinch knot with a guidewire in place rather than eliminating the access route during an arteriovenous hemodialysis access (AV access) intervention using the facing sheath technique. From July 2016 to June 2019, we retrospectively studied 78 sessions performed as interventional treatment for arteriovenous (AV) hemodialysis (HD) access using the "facing-sheath technique." In all sessions, all antegrade sheaths were removed while a 0.035-inch guidewire remained in place with purse-string suture and the clinch knot. Seventy-two sessions were performed in patients with thrombosed AV accesses (69 arteriovenous grafts [AVGs] and three arteriovenous fistulas [AVFs]), and six sessions were carried out to treat non-thrombosed AV accesses (four AVGs and two AVFs). We evaluated whether proper hemostasis and successful reinsertion of the sheath over the wire into the clinch knot was achieved. Clinical success was defined as achieving prompt restoration of blood flow for AV access, and the postintervention primary and secondary patency were also evaluated. In all 87 clinch knots created in 78 total sessions, proper hemostasis was achieved. All clinch knots that required reversal for additional procedures were successfully reopened (55 clinch knots in 50 sessions). The postintervention primary patency rates at 1, 3, and 6 months, and at 1 year were 77.8%, 68.9%, 55.6%, and 33.3%, respectively. The postintervention secondary patency rates at 1, 3, and 6 months, and also at 1 year were 93.3%, 91.1%, 86.7%, and 86.7%, respectively. Our AV access intervention which used a clinch knot with purse-string suture while the guidewire remained in place was both useful and feasible for maintaining temporary hemostasis.

Peel-Away Catheter Introducer Sheath for Reducing Nasal Traumatic Injury During Pediatric Endoscopic Skull Base Surgery

Pediatric endoscopic endonasal surgery represents a still-growing discipline to approach complex skull base lesions and is characterized by unfavorable anatomical conditions. Children have very small nostrils and narrow rhinosinusal corridors, which could lead more easily to accidental injury to the nasal structures. We describe the use of a peel-away catheter introducer sheath as an innovative and minimally invasive technique to further reduce surgical trauma tothe nasal mucosa and structures in pediatric rhinoneurosurgery. From January 2009 to December 2018, the peel-away sheath technique was used in 6 pediatric endoscopic procedures for biopsy and/or removal of skull base tumors. The endoscopic technique with the use of the peel-away catheter allowed clear visualization of the surgical field during the whole course of the procedure and good surgical maneuverability. The use of the peel-away sheath did not prolong the surgical operation time and provided a good working channel. No intraoperative or postoperative major complications were observed. No nasal short-term complications were registered in all patients. The use of a peel-away catheter introducer sheath technique represents a valid adjunct in the endoscopic pediatric skull base surgery repertoire. It can help in avoiding inadvertent surgical traumas to the sinonasal structures, especially by residents and junior surgeons. This could potentially reduce postoperative nasal morbidity.

Aspiration therapy for acute embolic occlusion of the superior mesenteric artery.

BACKGROUNDEmbolic superior mesenteric artery (SMA) occlusion is associated with high mortality rates. Delayed treatment often leads to serious consequences, including intestinal necrosis, resection, and even patient death. Endovascular repair is being introduced, which can improve clinical symptoms and prognosis and decrease the incidence of exploratory laparotomy. Many reports have described successful endovascular revascularization of embolic SMA occlusion. However, most of those reports are case reports, and there are few reports on Chinese patients. In this paper, we describe the technical and clinical outcomes of aspiration therapy using a guiding catheter and long sheath technique which facilitates the endovascular repair procedure.AIMTo evaluate the complications, feasibility, effectiveness, and safety of endovascular treatment for the acute embolic occlusion of the SMA.METHODSThis retrospective study reviewed eight patients (six males and two females) from August 2013 to October 2018 at Xuanwu Hospital, Capital Medical University. The patients presented with acute embolic occlusion of the SMA on admission and were initially diagnosed by computed tomography angiography (CTA). The patients who underwent endovascular treatment with a guiding catheter had no obvious evidence of bowel infarct. No intestinal necrosis was identified by gastrointestinal surgeons through peritoneal puncture or CTA. The complications, feasibility, effectiveness, safety, and mortality were assessed.RESULTSSix (75%) patients were male, and the mean patient age was 70.00 ± 8.43 years (range, 60-84 years). The acute embolic occlusion of the SMA was initially diagnosed by CTA. All patients had undertaken anticoagulation primarily, and percutaneous aspiration using a guiding catheter was then undertaken because the emboli had large amounts of thrombus residue. No death occurred among the patients. Complete patency of the suffering artery trunk was achieved in six patients, and defect filling was accomplished in two patients. The in-hospital mortality was 0%. The overall 12-mo survival rate was 100%. All patients survived, and two of the eight patients had complications (the clot broke off during aspiration).CONCLUSIONAspiration therapy is feasible, safe, and beneficial for acute embolic SMA occlusion. Aspiration therapy has many benefits for reducing patients’ death, resolving thrombi, and improving symptoms.

Novel extraction technique of retained pacemaker and defibrillator lead during heart transplantation

BackgroundRemoval of cardiac implantable electronic devices (CIEDs) by manual traction during orthotopic heart transplantation (OHT) sometimes results in retained lead fragments. Moreover, abandoned leads and retained lead fragments are a contraindication for magnetic resonance imaging (MRI) and may be a cause of CIED infection.ObjectiveTo eliminate complications of retained lead fragments, we completely removed residual leads using an excimer laser sheath technique during OHT. We report our clinical experience and high success rate of lead extraction using the excimer laser sheath compared with manual traction during OHT.Methods and resultsWe obtained data on 84 consecutive patients receiving OHT between August 2007 and August 2017. Thirty-nine of 84 patients had undergone CIED implantation before OHT and removal of all their leads was attempted during OHT. From 2007 to 2014, defibrillator and pacemaker leads were extracted by manual traction in all patients (N = 22). After 2015, all leads were extracted with the excimer laser sheath, and surgical assistance was prepared for the procedure (N = 17). Complete procedural success was achieved in 100% of patients in the excimer laser group and 77% of patients in the manual traction group.ConclusionExtraction of abandoned leads using the excimer laser sheath system during OHT is novel and safe technique, and has a higher success rate than extraction using manual traction during OHT.