Subsequent Catheterization Research Articles

HIDDEN DANGER: A RARE ANOMALOUS CORONARY ARTERY

SESSION TITLE: Medical Student/Resident Imaging Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Anomalous aortic origin of a coronary artery (AAOCA) in the general population is quite rare. Generally, they are typically seen in 1-2% of the population that undergo coronary angiography. Although overall rare, these anomalies have a risk of sudden cardiac death (SCD), which is largely unknown, so it is important to properly evaluate them if seen in practice. CASE PRESENTATION: The patient is a 75-year-old woman with a past medical history of severe aortic stenosis who presented for a left heart cardiac catheterization prior to planned aortic valve replacement. Subsequent catheterization revealed evidence of an anomalous right coronary artery as seen in Figure 1. Consequently, coronary computed tomography (CT) was advised to further delineate the anatomy prior to aortic valve replacement in order to mitigate risks of surgery. The CT determined that this anomalous right coronary artery coursed in between the pulmonary artery and the aorta. A heart team discussion was started about performing a transcatheter aortic valve replacement (TAVR) versus a surgical aortic valve replacement. The patient was deemed a high risk due to the anomalous course of the right coronary artery and was subsequently sent for a single vessel bypass with a saphenous vein graft (SVG) to the distal RCA and a surgical aortic valve replacement. DISCUSSION: Overall, there is no typical way that patients present with AAOCA. Most are found incidentally on an echocardiogram or computed tomography (CT) angiogram that is performed for another reason, such as a heart murmur. The best method to identify AAOCA is a transthoracic echocardiogram with doppler color flow mapping due to availability, cost-effectiveness, and lack of radiation exposure as compared to coronary angiography. If needed, coronary CT angiography or cardiac MRI can be used to obtain better visualization of the coronary artery anatomy to confirm the diagnosis. For our patient, due to the high risk location, the heart team recommended a coronary artery bypass graft (CABG) along with a surgical aortic valve replacement. TAVR is typically chosen over surgical aortic valve replacement due to comparable outcomes with the benefit of TAVR not requiring open heart surgery. However, CABG requires an open heart surgery, so it was agreed that surgical aortic valve replacement would result in better outcomes since the patient requires an invasive surgery either way. CONCLUSIONS: This case highlights the importance of delineating the anatomy prior to going to percutaneous valve replacement in the setting of anomalous coronary arteries. Surgical intervention is recommended for those with signs of myocardial ischemia, but intervention in asymptomatic patients depends on interarterial course. AAOCA with an intramural course is associated with SCD due to ischemia and arrhythmias, so it is important to choose the correct surgical approach. Reference #1: Angelini, P. (2007). Coronary Artery Anomalies. Circulation, 115(10), 1296-1305. doi:10.1161/circulationaha.106.618082 Reference #2: Brothers, J. A., Frommelt, M. A., Jaquiss, R. D., Myerburg, R. J., Fraser, C. D., & Tweddell, J. S. (2017). Expert consensus guidelines: Anomalous aortic origin of a coronary artery. The Journal of Thoracic and Cardiovascular Surgery, 153(6), 1440-1457. doi:10.1016/j.jtcvs.2016.06.066 DISCLOSURES: No relevant relationships by Akash Patel, source=Web Response No relevant relationships by Sagar Patel, source=Web Response

Negative-Pressure Suction Cannula for Treatment of Lactational Residual Milk Cavity: A Case Series Study.

Background: Several Chinese mothers experience problems related to their breasts during breastfeeding and are referred to hospitals for treatment after a massage by a "cuirushi." Some of these patients develop large breast abscesses. Notably, the treatment of residual milk cavities is difficult after pus aspiration. Lactational residual milk cavities in the breast hinder effortless breastfeeding, but no solution has been reported thus far. This study aims to explore the use of a simple and minimally invasive method for treating lactational residual milk cavities and enabling mothers to breastfeed effortlessly. Materials and Methods: We retrospectively analyzed clinical data of 28 patients with lactational residual milk cavities treated using negative-pressure suction cannula and drainage at our department from December 2016 to May 2019. The success rate, safety, and feasibility of this technique are summarized. Results: Among the 28 patients, the first catheterization was successful in 7 (25%) patients, the second in 13 (46.4%) patients, and the third or subsequent catheterizations in 8 (28.6%) patients. The intubation time was <10 days in 3 patients, between 10 and 20 days in 12 patients, and >20 days in 13 patients. During and after treatment, 21 patients (75%) continued breastfeeding with the affected breast. Conclusions: Ultrasound-guided negative-pressure suction cannula is a new method to treat lactational residual milk cavities that may remain after initial therapy for lactational breast abscess. The treatment of lactational residual milk cavities offers significant advantages in supporting mothers during breastfeeding.

Outcomes Associated with Complete versus Partial LV Unloading in Patients with LVAD

Purpose LVAD implantation improves survival in end-stage heart failure (HF) patients. It is unclear at this time whether the goal of partial or complete left ventricle (LV) unloading is the best long-term strategy to maintain favorable outcomes especially when it relates to patients who received LVAD as destination therapy. Methods We conducted a retrospective analysis of end-stage HF patients who underwent continuous-flow LVAD implantation and subsequent right heart catheterization (RHC) to determine partial or complete LV unloading using invasive hemodynamics. Complete LV unloading was defined as cardiac index (CI) > 2.2 and pulmonary capillary wedge pressure (PCWP) Results Our sample size included 142 patients. Mean age 57.4 (range 25-79), 75.5% of male gender and 55% had an ischemic etiology of HF. Complete LV unloading was seen in 52 (36.6%) patients compared to 90 (63.4%) patients with partial LV unloading. There was a trend towards worse outcomes (mortality and HF readmission) in the group with partial LV unloading, however, did not reach statistical significance (Table 1). Conclusion Our institution uses invasive hemodynamics based on RHC for LVAD speed optimization and alterations in LVAD speed done at the time of RHC may potentially have played a role in influencing outcomes of the partially unloaded LV group and hence not met statistical significance. Best long-term strategy for LV unloading remains unclear at this time and further studies are needed to guide management to maintain favorable long-term outcomes.

Abstract No. 599 Adrenal vein sampling: multipurpose catheter shape facilitates sampling in a subset of right adrenal veins

Adrenal vein sampling (AVS) is a technically challenging procedure, with failure rates reported as high as 70 percent. AVS failures are commonly attributable to difficulties cannulating the right adrenal vein (RAV). Knowledge of RAV anatomy and anatomic variants can inform proper catheter choice and may greatly influence AVS success rates. Normally, the RAV is caudally oriented at an acute angle to the IVC. Anatomic variants in which the RAV is cranially oriented at various angles to the IVC have been reported in up to 11% of patients. In such patients, use of a multipurpose (MPA) catheter may facilitate RAV sampling. We evaluated the use of an MPA catheter to cannulate cranially oriented right adrenal veins. AVS was performed via right femoral venous access by a single operator, with SI>5 considered diagnostic. Between 2014 and 2018, 272 patients underwent AVS and an MPA catheter was used to cannulate the RAV in 11 patients (4%, 3M/8F). Data regarding pre-AVS imaging, procedural details, and AVS results were retrospectively collected. The RAV angle was calculated using the right lateral wall of the IVC as the craniocaudal axis, with 0° degrees defined as caudal and 180° as cranial. Dedicated pre-procedural imaging to evaluate venous anatomy was not obtained in any patient. A cranially oriented RAV was identified intra-procedurally in all patients (n=11), with a mean angle of 139.4°±20.1° (range 97.4°-168.2°). An MPA catheter was the 2nd choice catheter in 7 patients (63.6%) and at most the 8th choice catheter (n=1, 9%). Mean fluoroscopic time (7.5 pulses/sec) was 16±11 minutes (range 3-39 minutes). Adequate sampling of the right adrenal vein was achieved in all patients, with all SI>5 (mean=24±12, range 10-52). Six patients (55%) were diagnosed with a left aldosteronoma, 1 (9%) with a right aldosteronoma, 3 (27%) with bilateral adrenal hyperplasia, and 1 (9%) had bilaterally suppressed aldosterone-to-cortisol ratios. Identification of cranially oriented RAVs and subsequent catheterization with an MPA catheter facilitates sampling. MPA catheters should be readily considered when cranially oriented RAVs are present.

A NOVEL MUTATION IN A PATIENT WITH PULMONARY VENO-OCCLUSIVE DISEASE MASQUERADING AS PULMONARY ARTERIAL HYPERTENSION

A NOVEL MUTATION IN A PATIENT WITH PULMONARY VENO-OCCLUSIVE DISEASE MASQUERADING AS PULMONARY ARTERIAL HYPERTENSION

An Unfortunate Case of Dyspnea in Cryptogenic Cirrhosis

Portopulmonary hypertension is a type of pulmonary arterial hypertension associated with portal hypertension. It is a known complication of cirrhosis and can predict increased mortality after liver transplantation. A 35 year—old—female with suspected cirrhosis and acute dyspnea on exertion was transferred to our hospital for further management. Two weeks prior to transfer she had hematemesis; an upper endoscopy revealed medium—sized bleeding esophageal varices requiring banding. Cross—sectional imaging was concerning for a cirrhotic appearing liver. She had no past medical history and had an unknown family history as she was adopted. On admission she felt short of breath. Her physical exam was notable for scleral icterus, jugular venous distension to 10cm, right ventricular heave, and an abdominal fluid wave. Laboratory values included platelet 88x1000/uL (reference range 140—440), INR 1.4 (range 0.89—1.12), albumin 3.1g/dL (range 3.5—5.0), and total bilirubin 5.5mg/dL (range 0.1—1.2). She had an extensive laboratory workup for cirrhosis, of which the only remarkable finding was a positive anti—mitochondrial antibody at 73.8 units (range <20.0). She had an magnetic resonance imaging (MRI) liver which showed a cirrhotic—appearing liver with evidence of portal hypertension (Figure 1). A transjugular liver biopsy showed stage 4 fibrosis and areas of sinusoidal dilatation without signs of primary biliary cirrhosis. She had a hepatovenous pressure gradient (HVPG) of 11mmHg (reference range 0—5). Workup of her dyspnea included an echocardiogram which showed a dilated right ventricle (Figure 2) with an elevated right ventricular systolic pressure of 65mmHg (reference range 15—25). Subsequent right heart catheterization showed an elevated mean pulmonary artery pressure (mPAP) of 43mmHg (range 5—10) with a relatively normal pulmonary capillary wedge pressure of 12mmHg (range<10), indicative of pulmonary arterial hypertension. In the setting of cirrhosis a diagnosis of portopulmonary hypertension was made. Per consultation with pulmonology she was started on a prostacyclin analog and endothelin—receptor antagonist. Her case was discussed at the liver transplantation recipient review committee, but placed on hold pending improvements in her right—sided cardiac pressures. A diagnosis of pulmonary hypertension can be made via right heart catheterization indicating a mPAP >25mmHg. Per the 2013 AASLD liver transplant guidelines, a mPAP < 35mmHg is required for transplant.3052_A.tif Figure 1: MRI abdomen, T1—weighted; white arrow points to steatotic and echogenic liver consistent with cirrhosis; black arrow points to a recanalized paraumbilical vein, indicating portal hypertension3052_B.tif Figure 2: Transthoracic echocardiogram, short axis, showing dilated right atrium (RA) and right ventricle (RV)3052_C.tif Figure 3: Liver core biopsy, trichrome stain, blue area indicates fibrosis

Invasive Hemodynamic after LVAD Implantation and Association with Outcomes

Background There is paucity of data on assessment of invasive hemodynamics via right heart catheterization (RHC) after LVAD implantation and association with outcomes. We sought out to define if right ventricular (RV) dysfunction, persistent volume overload and low cardiac output state defined via invasive hemodynamics is associated with adverse 1-year outcomes. Methods We conducted a retrospective analysis of end-stage heart failure (HF) patients who underwent continuous-flow LVAD implantation and subsequent right heart catheterization (RHC) to determine invasive hemodynamics. 1-year outcomes including mortality, all-cause readmission and HF readmissions were assessed after index RHC. Definitions included low cardiac output state (CI) 12 mm Hg), moderate right ventricle (RV) dysfunction (RAP/pulmonary capillary wedge pressure (PCWP) >0.75) and severe right ventricle dysfunction (RA/PCWP >1). Chi-square for categorical variables and Student's T-test for continuous variables were used to determine significant differences in each group. Results A total of 142 patients underwent invasive hemodynamics after LVAD implantation. The median time from LVAD implantation to RHC was 6 months. RAP/PCWP ratio was not predictive of adverse outcome and although RAP > 12 mmHg was not associated with increased mortality it was associated with significantly increased HF readmissions at 1 year. Discussion RV dysfunction defined using invasive hemodynamic criteria did not predict adverse 1-year outcomes. RAP > 12 mmHg indicative of persistent volume overload after LVAD implantation was significantly associated with increase HF readmissions at 1 year.

Complete Versus Partial LV Unloading after LVAD Implantation and Association with Outcomes

Background LVAD implantation improves survival in end-stage heart failure (HF) patients. It is unclear at this time whether the goal of partial or complete left ventricle (LV) unloading is the best long-term strategy to maintain favorable outcomes especially when it relates to patients who received LVAD as destination therapy. Methods We conducted a retrospective analysis of end-stage HF patients who underwent continuous-flow LVAD implantation and subsequent right heart catheterization (RHC) to determine partial or complete LV unloading using invasive hemodynamics. Complete LV unloading was defined as cardiac index (CI) > 2.2 and pulmonary capillary wedge pressure (PCWP) Results Our sample size included 142 patients. Mean age 57.4 (range 25-79), 75.5% of male gender and 55% had an ischemic etiology of HF. Complete LV unloading was seen in 52 (36.6%) patients compared to 90 (63.4%) patients with partial LV unloading. There was a trend towards worse outcomes (mortality and HF readmission) in the group with partial LV unloading, however, did not reach statistical significance ( Table 1 ). Discussion Although there was a trend towards worse 1-year outcomes in patients with partial LV unloading, this did not reach statistical significance. Our institution uses invasive hemodynamics based on RHC for LVAD speed optimization and alterations in LVAD speed done at the time of RHC may potentially have played a role in influencing outcomes of the partially unloaded LV group and hence not met statistical significance. Best long-term strategy for LV unloading remains unclear at this time and further studies are needed to guide management to maintain favorable long-term outcomes.

Pulmonary Pressure Assessment with the Total Artificial Heart.

Reversal of pulmonary hypertension has been observed in patients during a bridge to transplant with a left ventricular assist device. Total artificial heart (TAH) implant prevents subsequent right heart catheterization. Consequently, controversy exists over whether the prosthetic right ventricle improves or exacerbates pulmonary hypertension. A pulmonary artery (PA) pressure monitor was placed in two patients undergoing TAH implant, as a bridge to transplant. One patient had pulmonary hypertension at implant; the other had normal pulmonary pressures. Daily measurements were taken of systolic, diastolic, and mean PA pressures throughout support. Patient 1 received successful transplant after TAH support of 91 days. Systolic/diastolic (mean) PA pressures steadily decreased from 55/39 (28) mm Hg at implant to 29/18 (7) mm Hg currently. Patient 2 received support for 101 days before death due to abdominal ischemic complications. Pulmonary arterial pressures stayed consistent throughout this period, from 26/17 (20) mm Hg at implant to 23/13 (17) mm Hg at the time of death. These findings suggest that an implantable PA pressure monitor may be useful in optimizing hemodynamics and planning appropriate timing of transplant with TAH support.

Continuous PECS II block for postoperative analgesia in patients undergoing transapical transcatheter aortic valve implantation

It has been reported that PECS II block can alleviate postoperative pain following transapical transcatheter aortic valve implantation (TA-TAVI). However, the effectiveness of continuous PECS II block with catheterization has not yet been reported on the postoperative pain in patients undergoing TA-TAVI. We experienced two cases of TA-TAVI who received PECS II block with catheterization to manage postoperative pain. In the first case, a bolus injection for intraoperative pain and subsequent catheterization were performed before the implantation. However, the patient developed severe pain postoperatively in spite of the continuous block due to displacement of the catheter. In the second case, a bolus injection and the catheterization for the continuous block were performed before and after the implantation, respectively, which provided high-quality pain control. Continuous PECS II block may be useful to control perioperative pain associated with TA-TAVI. The insertion of the catheter after the implantation could be useful to avoid its displacement during the surgery.

Our own method of combined treatment of acute purulent pyelonephritis: first results

The article describes the author’s method of retroperitoneoscopic decapsulation of the kidney with removal of purulent foci, sanitation and drainage of the retroperitoneal space with subsequent catheterization of the renal artery with continuous intraarterial infusion of alprostadil in combined treatment of patients with acute purulent pyelonephritis. The results of treatment of 13 patients showed high efficiency as described above. The possibility and expediency of using of described technique is shown. (For citation: Anan’ev VA, Antonov AV. Our own method of combined treatment of acute purulent pyelonephritis: first results. Urologicheskie vedomosti. 2017;7(3):34-37. doi: 10.17816/uroved7334-37).

Selective Arterial Prostatic Embolization (SAPE) for the Treatment of Lower Urinary Tract Symptoms in the Setting of Benign Prostatic Hyperplasia: A Brief Review

Tel: 212-241-9955 Benign prostatic hyperplasia (BPH) is a common condition related to aging that can lead to a cluster of chronic symptoms collectively known as lower urinary tract symptoms (LUTS), including urinary frequency, urinary urgency, nocturia, hematuria, and decreased urinary stream. It is estimated that BPH affects 75% of men in the United States by age 70, with more than $1 billion US dollars a year spent in direct health care expenditures related to BPH, exclusive of outpatient medications [1]. Treatment options for BPH are outlined out by the American Urologic Association Clinical Guidelines and include watchful waiting, medical therapy, minimally invasive therapies (including transurethral ablations), or surgical therapies including open prostatectomy or transurethral resection of the prostate (TURP) [2]. Medical therapy is often considered the first-line option for symptomatic patients; however, a large subset of patients does not respond to or cannot tolerate pharmacotherapy, in part owing to a number of side effects including sexual dysfunction [3]. TURP has remained the ‘gold standard’ surgical treatment for BPH for over half a century, owing to its high success rate in reducing LUTS. Over the past two decades, the TURP procedure has undergone significant technical improvements, with morbidity rates reported to be <1% [4]. However, with a general shift towards minimally invasive treatment options, the number of TURPs performed has fallen in more recent years [5]. Manuscript Click here to download Manuscript SAPE final (1).docx Embolization of the prostatic arteries has been used for many years as a technique to control severe bladder and prostate hemorrhage as well as hematuria following TURP [6-9]. A case report by DeMeritt et al in 2000 described a patient with BPH and refractory hematuria treated by prostatic artery embolization, who subsequently had alleviation in his LUTS and reduction in the volume of his prostate [10]. This case report introduced the idea that BPH could intentionally be treated by selective arterial prostatic embolization (SAPE). In 2008, Carnevale et al used SAPE as the primary treatment in two patients with BPH [11]. After 6-month follow-up, MRI demonstrated a relative prostate reduction of 47.8% in the patient who had undergone bilateral SAPE and 27.8% in the patient who had undergone unilateral SAPE. Since this initial study, there has been an enthusiastic response in the literature regarding the future role of this technique, and the Society of Interventional Radiology has encouraged further research into this intervention [12]. A growing body of literature suggests that SAPE enables reduction in prostate volume with improvements in uroflometry parameters, quality of life, and sexual function [13]. The largest prospective non-randomized series published to date looked at 255 patients who underwent SAPE [14]. The authors describe technical success in 250 of the patients (98%), with a clinical success rate of 82% at one month decreasing to 72% at 3 years. In the only RCT to date assessing SAPE, 57 patients were assigned to prostatic artery embolization and 57 were assigned to TURP for the treatment of BPH [15]. The authors demonstrated that all parameters: including improvement of the International Prostate Symptom Score (IPSS), quality of life (QOL), peak urinary flow, and post void residual(PVR) urine volume were improved by both treatment modalities and there was no difference at two years between the treatment arms. The paper does state there was a higher complication rate for PAE, if one controls for acute urinary retention post operatively, there would be similar complication rates for both groups. The technique for SAPE involves unilateral access of the femoral artery and subsequent catheterization of the anterior division of the internal iliac artery. Digital subtraction angiography is used to confirm arterial anatomy and allow for superselective catheterization of the prostatic artery. A number of different embolic materials have been used, including polyvinyl alcohol particles, trisacryl gelatin microspheres, and Embozene Selective Arterial Prostatic Embolization (SAPE) for the Treatment of Lower Urinary Tract Symptoms in the Setting of Benign Prostatic Hyperplasia: A Brief Review

MP74-10 QUANTIFICATION OF RISK FACTORS IN 500 CONSECUTIVE PATIENTS WITH POSTOPERATIVE URINARY RETENTION (POUR)

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Non-neurogenic Voiding Dysfunction I1 Apr 2016MP74-10 QUANTIFICATION OF RISK FACTORS IN 500 CONSECUTIVE PATIENTS WITH POSTOPERATIVE URINARY RETENTION (POUR) Peter Tsambarlis, Benjamin Sherer, Karl Godlewski, Rebecca Deal, and Leslie Deane Peter TsambarlisPeter Tsambarlis More articles by this author , Benjamin ShererBenjamin Sherer More articles by this author , Karl GodlewskiKarl Godlewski More articles by this author , Rebecca DealRebecca Deal More articles by this author , and Leslie DeaneLeslie Deane More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1707AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Our institution established a nurse-driven protocol for early postoperative catheter removal in an effort to minimize catheter associated urinary tract infections (CAUTIs). This led to an increase in POUR (9.8% of 20,455 surgical patients in FY2013) and subsequent traumatic catheterizations. An Institutional Quality and Safety Initiative to reduce POUR and improve patient safety indicators (PSIs) was undertaken. The aim of this study was to identify the number of risk factors present in patients with POUR while examining the prevalence of those risk factors individually. METHODS A retrospective review of our institution's surgical database was performed to identify 500 consecutive cases of POUR between July 1, 2013 and July 1, 2014. POUR was defined as the inability to void postoperatively with bladder scan volumes >450ml and subsequent need for catheterization with output >450ml. These records were individually reviewed for 15 known independent risk factors for urinary retention (see results). Patients with incomplete records or preoperative baseline urinary retention requiring catheterization were excluded. RESULTS Of the 500 consecutive patients with POUR, 288 (57.6%) were male and 212 (42.4%) were female. At the time of void trial, all 500 patients with POUR (100%) had at least 1 perioperative risk factor identified and over 75% had 6 or more (Mean 6.88, Median 7, Range 1-12). See figures. CONCLUSIONS Multiple perioperative risk factors are present in the vast majority of patients with POUR. Many of the risk factors are modifiable and represent an opportunity for intervention. This could ultimately lead to a risk profile which could be used to optimize timing of postoperative void trials improving patient care (improve PSIs and patient comfort, and reduce trauma) while maintaining low rates of CAUTI. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e973 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Peter Tsambarlis More articles by this author Benjamin Sherer More articles by this author Karl Godlewski More articles by this author Rebecca Deal More articles by this author Leslie Deane More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

P21 Multi-modality imaging of the pulmonary blood supply in infants with pulmonary atresia with ventricular septal defect: Accuracy, cumulative radiation dose and anaesthetic time

Aims In newborns with pulmonary atresia with ventricular septal defect (PA/VSD), the pulmonary arteries (PAs) may be either hypoplastic or absent, with or without highly variable aortopulmonary collaterals. Comprehensive imaging of the native pulmonary blood supply is important to inform initial management. We sought to describe the accuracy, cumulative radiation dose and anaesthetic time associated with multi-modality imaging in newly diagnosed patients with PA/VSD prior to their first intervention. Methods The records of all patients diagnosed with PA/VSD between 2004 and 2014 were reviewed retrospectively, excluding all patients over 100 days old at the time of diagnosis. We determined the accuracy and benefits (if any) of serial investigations up to the time of the first intervention, comparing the results to the anatomical findings at operation. We then calculated the cumulative radiation dose and anaesthetic time per patient. Results 30 patients were identified, of which 13 were excluded (7 had no further imaging and 6 were >100 days old at diagnosis). In total, there were 13 catheters and 4 CT scans performed in the whole group before intervention. All were within 100 days of life. Aside from one patient with 2 MRI scans, no investigation was repeated. Echocardiography correctly identified PAs in 12/17 patients (71%), MRI in 9/13 patients (69%), CT in 1/4 patients (25%), and in all patients who underwent catheterisation (13/13, 100%). In the 4 patients who underwent cross-sectional imaging only (3 MRI, 1 CT), PAs were also correctly identified. The mean radiation dose during catheterisation was 119mGy*cm2 (47–231mGy*cm2), and for CT was 92mGy*cm2 (66–123mGy*cm2). 3 patients underwent both catheterisation and CT, with a mean cumulative dose of 297mGy*cm2 (191–461mGy*cm2). 3 underwent MRI only with no ionising radiation. The mean total anaesthetic time before intervention was 111 min (33–185 min). In the one child who had CT only, no anaesthetic was used. The mean age of those undergoing primary catheterisation was 3 days (1 – 6 days, n = 3). In those undergoing primary MRI or CT, the mean age at subsequent catheterisation was 35 days (8–86 days, n = 10, P = 00.09); however, there was no difference in the mean radiation dose or anaesthetic time of these procedures. Over the ten year period of our study, the maximum cumulative radiation dose in a single patient was 8022mGy/cm2 at the age of 6 years (via 5 catheters), and 1263 min of anaesthetic time at 5 years (via 5 catheters, 1 CT and 4 MRIs). Conclusions Echocardiography may not identify native PAs in all neonates and infants with PA/VSD. Catheterisation is highly accurate, but also carries the highest risk. Cross-sectional imaging alone may be appropriate in some cases; in others, it may allow for delayed catheterisation, but may not reduce the radiation dose or anaesthetic time. The cumulative effects of repeated diagnostic and interventional procedures can lead to large radiation doses and anaesthetic times, both before and after primary intervention. These risks are an important consideration when planning management in this complex patient group.

Patterns of Benign Prostatic Hyperplasia Associated Urinary Retention: Indwelling Urinary Catheter Use and Clinical Sequelae

IntroductionCurrent clinical practice guidelines aim to decrease the use of unnecessary indwelling urinary catheters to prevent catheter associated urinary tract infections. Patients with benign prostatic hyperplasia often experience increased post-void residual urine volume and subsequent bladder catheterization to prevent complications such as urinary tract infections or hydronephrosis. However, the management of urinary retention in patients with benign prostatic hyperplasia varies and clinical guidelines are lacking. In this study we gather information on post-void residual urine volume, the use of catheters and associated complications in a sample of older veterans with benign prostatic hyperplasia. MethodsA retrospective chart review was performed using 660 patients screened for documented post-void residual urine volume greater than 100 cc, age greater than 65 years and the absence of cancer. A final chart review of 136 male veterans was performed for this analysis. ResultsA total of 59 (43.4%) indwelling urinary catheters were placed. Catheters were placed in subjects with modest post-void residual urine volumes in the 100 to 150 cc range and in those with a post-void residual urine volume greater than 500 cc. Overall complication rates were low. Among those patients who had a catheter placed 51% reported hematuria, 36% reported pain and only 1 had documented urosepsis. Hydronephrosis occurred in 4 cases, each with a post-void residual urine volume of 301 to 400 cc, and 3 of these individuals had an indwelling urinary catheter placed. In those patients emergency room visits and hospitalizations were more frequently associated with placement of an indwelling urinary catheter. ConclusionsLarger studies are needed for the development of clinical guidelines on the treatment of patients with benign prostatic hyperplasia and urinary retention.

Correction of Doppler Gradients for Pressure Recovery Improves Agreement with Subsequent Catheterization Gradients in Congenital Aortic Stenosis.

In congenital aortic stenosis (AS), suboptimal agreement between Doppler-derived gradients and catheterization gradients may lead to inappropriate referrals for catheterization. To address this problem, the authors investigated whether adjusting Doppler gradients for pressure recovery (PR) improved their agreement with subsequent catheterization gradients. One hundred encounters in which patients with congenital AS underwent echocardiography and subsequent catheterization were retrospectively identified. Peak instantaneous and mean transaortic Doppler gradients were recorded from an apical view. PR (mm Hg) was calculated as 4VCW(2) × (2 × EOA/AOA) × (1 - EOA/AOA), where VCW is continuous-wave peak velocity, EOA is effective orifice area (stroke volume/velocity-time integral), and AOA is aortic cross-sectional area (π × radius(2)). The PR-corrected peak Doppler gradient was calculated as peak Doppler gradient - PR. Doppler gradients were tested for correlation and agreement with the peak-to-peak systolic gradient at catheterization (cath gradient). The median age was 12.9 years (range, 0.7-24.6 years). Median AS gradients were as follows: cath, 39 mm Hg (range, 0-103 mm Hg); peak Doppler, 48 mm Hg (range, 10-94 mm Hg); mean Doppler, 25 mm Hg (range, 4-58 mm Hg); and PR-corrected peak Doppler, 35 mm Hg (range, 5-78 mm Hg). Correlation coefficients between the various Doppler and cath gradients were not significantly different. The mean difference between Doppler and cath gradients was smallest for the PR-corrected peak Doppler gradient (-4.1 ± 14.1 mm Hg), followed by the uncorrected peak Doppler gradient (9.7 ± 15.9 mm Hg) and the mean Doppler gradient (-14.6 ± 15.6 mm Hg) (P < .001). Receiver operating characteristic curve analysis for a cath gradient ≥ 35 mm Hg revealed a significantly larger area under the curve for the PR-corrected peak Doppler gradient (0.85) compared with the uncorrected peak Doppler gradient (0.80) (P = .004) and the mean Doppler gradient (0.78) (P = .001). A PR-corrected peak Doppler gradient ≥ 27 mm Hg was associated with a cath gradient ≥ 35 mm Hg with 90% sensitivity and 61% specificity. In congenital AS, correcting the peak Doppler gradient for PR significantly improved agreement with the subsequently measured cath gradient. This approach may improve decisions regarding referral for catheterization.

Heart beats: not to be beaten.

Heart beats: not to be beaten.

Dynamic Multiplanar Real Time Ultrasound Guided Infraclavicular Subclavian Vein Catheterization

Ultrasound guided vascular access has been well-characterized as a safe and effective technique for internal jugular and femoral vein catheterization. However, there is limited experience with the use of ultrasound to access the infraclavicular subclavian vein. Multiple ultrasound techniques do exist to identify the subclavian vein, but real time access is limited by vessel identification in a single planar view. To overcome this limitation, a novel technique of ultrasound guided infraclavicular subclavian vein catheterization using a real time multiplanar approach has been developed. The initial experience with this approach is described. A single surgeon used combined oblique, transverse, and longitudinal views along with Doppler color flow images to both define the infraclavicular anatomy and to obtain subclavian vein access in 42 adult patients (20 M/22 F and 22 L/20 R) with a mean body mass index of 29.2 (range = 18.9-55.4). Chest x-ray was obtained to confirm position and to rule out pneumothorax. Subclavian vein cannulation was achieved in 100 per cent of patients; subsequent catheterization was successful in 92.9 per cent. The number of attempts required for cannulation averaged 1.3 (range = 1-5), and decreased after a five patient learning curve. No patient developed a pneumothorax, hematoma, or cannula malposition. Ultrasound guided multiplanar infraclavicular subclavian vein access appears to be a safe and effective adjunct for central line placement.

Outcome of male cats managed for urethral obstruction with decompressive cystocentesis and urinary catheterization: 47 cats (2009-2012).

To characterize the duration of urinary catheterization, length of hospitalization, complications and clinical outcome in cats with urethral obstruction managed with decompressive cystocentesis and subsequent urinary catheterization. Retrospective, observational, descriptive study. University teaching hospital. Forty-seven client-owned male cats diagnosed with urethral obstruction. The medical records of 47 cats diagnosed with urethral obstruction were reviewed. Treatment of all cats included decompressive cystocentesis, placement of an indwelling urinary catheter and hospitalization for a minimum of 6 hours. Collected data included signalment, body weight, body condition score, owner-reported clinical signs, duration of clinical signs, vital signs, and venous blood gas or chemistry values. Mean duration of urinary catheterization was 27.9 hours, median length of hospitalization was 40 hours, and survival to discharge was 91%. Of 34 cats that had survey abdominal radiographs, 56% (19/34) had loss of peritoneal detail consistent with abdominal effusion. No cat was diagnosed with a ruptured bladder during hospitalization. Decompressive cystocentesis, in cats with urethral obstruction, followed by placement of an indwelling urinary catheter, did not result in a diagnosis of bladder rupture in any cat. The source of and clinical significance of the reported abdominal effusion is not known. Survival to discharge, duration of catheterization, and length of hospitalization were similar to previously reported populations.

Horner-s Syndrome following common carotid artery translocation in a horse: case report

Horner's syndrome (HS) is a sympathetic dysfunction caused by injuries to the sympathetic pathway. A clinical case of HS following common carotid artery transposition and catheterization in a horse is described. The animal presented head and neck sweating with focal skin temperature elevation, facial paralysis and ptosis. Most clinical signs were transient and persisted for two hours following percutaneous catheter removal. Recurrence of clinical signs was observed at subsequent catheterizations. Ptosis endured for 10 months as a consequence of the first catheter placement which demonstrates the importance of careful manipulation of the anatomical structures of the neck when performing any surgical manipulation in this area.