Supraclavicular Access Research Articles

An extended brachial plexus blockade with an original method of catheter fixation: clinical case

BACKGROUND: For extended blockade of the brachial plexus from the supraclavicular access, the catheter is fixed in the supraclavicular region. Owing to the anatomical features of the supraclavicular fossa and the short inner part of the catheter, this fixation method cannot be fully considered reliable and convenient both for the personnel operating the catheter and the patient. The most convenient place for fixing the catheter is the infraclavicular region because of its flat surface. If a catheter is installed to the brachial plexus from the supraclavicular access and the catheter is passed under the skin in the infraclavicular region, then the catheter exit site on the skin will be located further from the surgical intervention area and the inner part of the catheter will be larger.
 CLINICAL CASE DESCRIPTION: This study describes a clinical case of blockade of the brachial plexus by interscalene access with catheterization for prolonged analgesia via supraclavicular access and fixation of the catheter under the skin in the subclavian region in an older patient with polymorbidity during surgical treatment of a closed fracture of the middle third of the humerus. In anesthetic provision, when inducing brachial plexus blockade via a supraclavicular approach, the catheter was fixed in the subcutaneous tunnel of the infraclavicular region for prolonged blockade of the brachial plexus.
 CONCLUSION: This fixation method prevented internal and external dislocation of the catheter, which contributed to high-quality and long-term postoperative analgesia, early patient activity, and absence of infectious complications and created comfortable conditions for the handling of the catheter for both the medical staff and the patient.

Experience in the use of prolonged analgesic peripheral nerve blocks as part of multimodal analgesia regimens in the treatment of patients with gunshot wounds of the limbs

The use of regional analgesic techniques as part of multimodal analgesia regimens provides better control of acute pain. Effective anesthesia is one of the key tasks in the treatment of the wounded at all stages of medical care.
 Three clinical cases of the use of prolonged regional analgesic blockades as part of a multimodal analgesia regimen in the treatment of patients with gunshot wounds of the extremities are presented. Catheterizations of the perineural space of the peripheral nerves were performed using ultrasound imaging.
 Clinical case 1 - a patient with a gunshot shrapnel through wound of the left tibia with gunshot comminuted fractures of both bones of the lower third of the left tibia and the upper third of the fibula of the left tibia, was admitted two days after the injury. Performed catheterization of the perineural space of the left sciatic nerve in the popliteal fossa, constant infusion of 0.25 % bupivacaine solution at a rate of 5 ml per hour using a perfusor. A satisfactory analgesic effect was observed, narcotic analgesics were not prescribed.
 Clinical case 2 - a patient with a gunshot shrapnel through wound of the left shoulder with a gunshot comminuted fracture of the left humerus in the middle third and with damage to the neurovascular bundle, was admitted more than 6 weeks after the injury. Performed catheterization of the perineural space of the left brachial plexus interscalene access, continuous infusion of 0.25 % bupivacaine solution at a rate of 5 ml per hour using a perfusor. However, in the absence of complaints of soreness at the fracture sites and postoperative wounds, the patient began to be disturbed by neuropathic pain.Satisfactory analgesic effect was observed sporadically, narcotic analgesics were prescribed. On the second day of observation, dislocation of the catheter was detected.Considering that the patient was more concerned about pain in the distal part of the limb, catheterization of the perineural space of the left brachial plexus was performed by supraclavicular access, and a constant infusion of 0.25 % bupivacaine solution was started at a rate of 5 ml per hour using a perfusor. Satisfactory analgesic effect was observed sporadically, narcotic analgesics were prescribed.
 Clinical case 3 - a patient with a gunshot shrapnel through wound of the left thigh with a gunshot comminuted fracture of the left femur in the lower third and with damage to the popliteal artery, was admitted three weeks after the injury. Performed paravertebral catheterization of the left lumbar plexus, constant infusion of 0.25 % bupivacaine solution at a rate of 5 ml per hour using a perfusor. In combination with oral analgesic adjuvants (effect on neuropathic pain), a satisfactory analgesic effect was observed without the prescription of narcotic analgesics.After repeated surgical treatment with the installation of the VAC-system on the posterior surface of the thigh, an unsatisfactory effect of non-opiate analgesia was observed, and narcotic analgesics were additionally prescribed.

Simultaneous Brachial Plexus Block and Combined Two-Segment Spinal-Epidural Anesthesia with Fixation of an Epidural Catheter in the Subcutaneous Canal in a Patient with Polytrauma

The article reports an example of the simultaneous use of brachial plexus block and combined two-segment spinal-epidural anesthesia with fixation of an epidural catheter in the subcutaneous canal in an 81-year-old patient after receiving a household injury - closed fracture of the olecranon of the right ulna with displacement of fragments and closed transtrochanteric fracture with a fracture of the right femur fragments. After preoperative preparation and examination, the patient underwent two consecutive surgical interventions within a day: open reduction of comminuted transtrochanteric fracture of the right hip, dynamic femoral screw osteosynthesis and open reduction of fracture of the right olecranon, Weber’s osteosynthesis. Surgical interventions were carried out under regional anesthesia: block of the brachial plexus via supraclavicular access and combined two-segment spinal-epidural anesthesia with a method developed in our clinic for fixing an epidural catheter in the subcutaneous canal using a modified spinal needle. After the operation, the patient underwent postoperative pain relief in the form of epidural analgesia for 72 hours. The postoperative period passed without complications. On the 13th day, the patient was discharged for outpatient treatment by a traumatologist. The use of local anesthesia in the form of two methods of regional anesthesia during two consecutive surgical interventions, in an elderly patient with a high anesthetic risk, followed by long-term postoperative anesthesia in the form of epidural analgesia with a reliable method of epidural catheter fixation in the subcutaneous canal without the use of narcotic analgesics, contributed to the successful carrying out two surgical interventions at once, early activation of the patient, absence of complications in the postoperative period. Reliable catheter fixation is very important for the quality of epidural analgesia. Dislocation of catheters by more than 2 cm can lead to migration of catheters from the epidural space, changing the course of anesthesia, deteriorating its quality, or even interrupting it altogether. The new method of catheter fixation in the subcutaneous canal developed by us made it possible to prevent catheter dislocation.

TAA 21. Hybrid Repair of Ruptured Aortic Arch Aneurysm Combined With Aberrant Right Subclavian Artery: Case Report

Surgical repair of aortic arch aneurysms is still an invasive procedure requiring arch replacement during deep hypothermic circulatory arrest. Endovascular aortic arch repair is less invasive compared with the open surgical aortic arch repair in treating aortic arch disease; this correlates with low morbidity and mortality rates, even in high-risk patients. Aortic arch diseases, such as aneurysms and dissections, often involve the origin of the supra-aortic branches. Surgical aortic arch debranching is therefore indicated before covering of these branches. On the other hand, an aberrant right subclavian artery is the most common abnormality arising in the development of the aortic arch. We describe an original method of revascularization followed by stent graft insertion in the case of ruptured aortic arch aneurysm with existing aberrant right subclavian artery. A 56-year-old woman was admitted to our emergency department because of chest pain, cough, and hemoptysis. At the time of admission, the blood pressure was 200/100 mm Hg; pulse rate was 115 beats/min. The initial laboratory findings showed hemoglobin level of 8.9 g/dL. The computed tomography scan showed a 6-cm fusiform aneurysm of the aortic arch 0.5 cm distal to the left carotid artery, extravasation of the contrast material from the posterior wall, and aberrant right subclavian artery (Fig 1). After a multidisciplinary team discussion, a decision was made to perform a hybrid procedure as a safer and more viable option than surgical replacement of the aortic arch. In our case, the hybrid procedure was performed in three steps: bilateral subclavian to carotid bypass with supraclavicular access, followed by midline sternotomy and aorta-bicarotid bypass (Dacron 16/8 mm) from ascending aorta, and finally implantation of an endovascular stent graft that completely covered the aortic arch. The operation was performed under brain oxygenation monitoring. No extracorporeal circulation was used. After the procedure, normal blood flow to the branches of the aortic arch was restored; the aortic aneurysm was completely isolated, and there was no endoleak (Fig 2). The patient was discharged 15 days after the operation with stable hemodynamics, without symptoms of neurologic deficiency and in a good general condition. Endovascular repair after aortic arch debranching has the potential to reduce the morbidity and mortality rates in patients with ruptured aortic arch aneurysm and abnormality of the supra-aortic branches.Fig 2Aorta-bicarotid bypass, bilateral subclavian to carotid bypass, and aortic stent graft.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Simplified frozen elephant trunk technique for combined open and endovascular treatment of extensive aortic diseases.

This study aims to analyse the impact of a simplified frozen elephant trunk (FET) technique on early outcome. Between October 2010 and August 2018, 92 consecutive patients (mean age 64.4 ± 12.2 years) underwent FET surgery. Underlying pathologies were thoracic aneurysm in 35 patients, acute aortic dissection in 25 patients and chronic dissection in 32 patients. Thirty patients underwent a simplified FET technique with deployment of the stent graft in arch zone 2 with an extra-anatomic bypass to the distal left subclavian artery using the third branch of the Thoraflex™ Hybrid Plexus prosthesis via a supraclavicular access during reperfusion. These patients were compared to 62 patients who received the conventional FET procedure, in which a distal anastomosis is performed in arch zone 3. Circulatory arrest (41.7 ± 10.5 vs 76.5 ± 33.0 min; P < 0.001) and antegrade cerebral perfusion times (60.9 ± 13.5 vs 92.1 ± 33.1 min; P < 0.001) were significantly reduced in zone 2 vs zone 3 patients, respectively. The 30-day mortality rate was 3.3% (n = 1) in zone 2 patients vs 17.7% (n = 11) in zone 3 patients (P = 0.75). Stent deployment in zone 2 was associated with significantly reduced rates of postoperative stroke [zone 2: n = 0 (0.0%); zone 3: n = 11 (17.7%), P = 0.046] and recurrent nerve palsy [zone 2: n = 1 (3.3%); zone 3: n = 14 (22.6%), P = 0.020). Simplifying the FET procedure leads to reduced circulatory arrest and cerebral perfusion times and improves early outcome.

Vascular and lymphatic complications after thoracic duct cannulation

ObjectiveThe objective of this study was to determine the incidence of vascular and lymphatic complications after attempted transabdominal thoracic duct cannulation. MethodsThere were 58 patients who underwent attempted thoracic duct cannulation. Patients presented with chyle leak in the chest (n = 40), abdomen (n = 9), neck (n = 8), and pelvis (n = 1). Vertebral body level and geographic access, needle gauge, additional access for treatment, technical success, intervention performed, immediate and delayed complications, and follow-up duration were recorded. Imaging and electronic medical records were reviewed at follow-up for complications and treatment success. ResultsAccess into the lymphatic system was obtained at L1 (n = 21), T12 (n = 17), L2 (n = 14), L3 (n = 3), T11 (n = 1), L4 (n = 1), and L5 (n = 1). Lymphatic access was achieved in the center (n = 28), on the right (n = 16), or on the left (n = 14) of the vertebral body; 21-, 22-, and 25-gauge needles were used in 45 patients, 12 patients, and 1 patient, respectively. Arm venous and percutaneous supraclavicular access was successful in 15 patients and eight patients, respectively. Cannulation of the thoracic duct was achieved in 52 (89.7%) patients. Embolization, disruption, and stenting were performed in 41 (70.7%), 12 (20.7%), and 2 (3.4%) patients; 3 (5.2%) patients had normal thoracic ducts after successful cannulation. Immediate complications consisted of shearing of the access wire in two (3.4%) patients. Retrospective analysis of initial follow-up imaging in 49 (84.5%) patients revealed the following late complications: inferior vena cava and right renal vein thrombosis and one perinephric lymphatic collection. ConclusionsOf 58 patients who had attempted thoracic duct cannulation, successful access was achieved in 90% of patients. Early and delayed complications occurred in 3.4% and 4% of patients, respectively. Thoracic duct cannulation represents a highly successful technique that aids in the treatment of chyle leaks in medically complex patients.

Anatomic Bases for Brachial Plexus Block of Capuching (Sapajus libidinosus)

Background: In captivity, capuchin monkeys compete for space and rank. Fights can result in traumas, especially to the limbs, requiring interventions that are often outpatient. Local anesthesia as a tool in these procedures, as an aid to chemical restraint, is very relevant for small outpatient surgeries, or even for pain relief. Knowledge of peripheral nerve anatomy is essential to perform local anesthesia. Thus the objective of the present study was to determine, by anatomical studies of the brachial plexus region, the best access pathways for anesthetic blocking of the nerve.Materials, Methods &amp; Results: Seven adult capuchin monkeys (Sapajus libidinosus) were used, weighing 2-3 kg, fixed and preserved in formaldehyde aqueous solution at 10%. In five of these animals the supraclavicular, infraclavicular and axillar regions were dissected to visualize the muscles, clavicle and bracchial plexus nerves. An analogical pachymeter was used to measure the depth of the plexus in relation to the cranial and caudal clavicle face and axillary fossa, comparing the length of two hypodermic needles (13x4.5 mm and 15x5 mm). Simulation of the anesthetic block was tested in two animals: before dissecting an acrylic varnish solution was injected using a syringe and 13x4.5 mm needle in the supraclavicular, infraclavicular regions and axillary fossa. To assess the positioning points of the syringe, dissection was performed and the varnish perfusion in the plexus was observed. For the anesthetic block in the supraclavicular region the dorsal median of the clavicle with a 95º deltoclavicular angle with the needle perpendicular to the skin was taken as point of reference. In the infraclavicular the reference point was the caudal face of the median clavicle with an 80º deltoclavicular angle. In the axillar region, with the limb at 90º, the syringe was positioned perpendicular to the axillar at the height of the mid portion of the thorax. The mean and standard deviation of the skin-brachial plexus distance for the supraclavicular, infraclavicular and axillar techniques were, respectively, 1.76 ± 0.1387 cm, 1.12 ± 0.239 cm and 1.59 ± 0.365 cm. These data showed the viability of executing the anesthesia technique by three access pathways. However, in the supraclavicular access pathway in the anesthetic simulation with the 13x4.5 mm hypodermic needle, the stain diffused to the plexus, showing, when compared with the 1.76 cm mean skin- plexus distance a safe distance to prevent the needle from perforating the nerve.Discussion: The techniques reported in the human literature for brachial plexus block presented a series of complications, with incomplete blocks and hemorrhages when the axillar access pathway was used and presented risk of pneumothorax in the supraclavicular. In the capuchin monkey the supraclavicular access pathway in anesthetic simulation with 13x4.5mm hypodermic needle showed a safe distance for the needle not to perforate the nerve, so that the use of this needle could be indicated in 2-3 kg animals. However, hypodermic needles are not recommended for use in this area because of the risk of perforating the subclavicular artery close to the plexus. As an alternative some anesthesiologists use the infraclavicular access pathway with atraumatic needles recommended for brachial plexus block, with relative success and fewer complications. Although the supraclavicular region showed the best depth in relation to the technique used here, anesthetic tests should be made to confirm the efficaciousness of executing the brachial plexus anesthetic technique in capuchin monkeys using atraumatic needles for nerve block.

Ultrasound-guided supraclavicular access to the innominate vein for central venous cannulation.

Ultrasound-guided supraclavicular access to the innominate vein for central venous cannulation.

Externalization of Tunneled Hemodialysis Catheter in Patients with Tunnel or Exit-Site Infections and Limited Access Options

PurposeTo evaluate the viability and effectiveness of temporary externalization of a tunneled hemodialysis (HD) catheter in catheter-dependent HD patients presenting with catheter-related tunnel or exit-site infection, documented central venous stenosis, and limited alternative venous access. Materials and MethodsAll catheter-dependent HD patients with known central venous stenosis presenting with exit-site or tunnel infection and who subsequently underwent catheter externalization between February 2008 and May 2012 were reviewed. After catheter externalization, patients were concurrently treated with antibiotics for approximately 3 weeks before reinsertion of a new tunneled catheter. Treatment outcomes were collected, with treatment failures defined as reinfection with the same organism within 45 days of tunneled catheter reinsertion. ResultsThere were 42 catheter externalization procedures performed in 26 patients for 42 exit-site or tunnel infections. Technical success rate for catheter externalization was 100%, with no complications during the externalization procedure and preservation of all original access sites. Treatment failure occurred in 9.8% (4 of 41) of cases. Median infection-free survival after treatment and retunneling of a new dialysis catheter was 80 days. One major periprocedural complication of death occurred before reinsertion of a new tunneled catheter. Minor complications after the procedure occurred in four patients and included three cases of a small persistent wound at the temporary supraclavicular access site and one initially nonfunctioning externalized catheter. ConclusionsTemporary dialysis catheter externalization appears both technically feasible and effective for the treatment of exit-site and tunnel infections, while allowing preservation of the venous access site in catheter-dependent HD patients with central venous stenosis and limited alternative venous access.

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Introduction: Real-time ultrasound guidance is considered to be the standard of care for central venous access for non-emergent central lines. Traditional sites for ultrasound guided central line placement are the internal jugular vein and subclavian vein via an infraclavicular approach. The AxoTrack system (Soma Access Systems, Greenville, SC) recently cleared for human use by the United States Food and Drug Administration, is a novel ultrasound guidance system designed to simplify ultrasound guided central venous access by eliminating the hand-eye coordination challenges of conventional ultrasound needle guidance. The ultrasound probe houses a separate set of magnetic sensors that, in real-time, precisely monitors the depth of the needle and projects on the ultrasound system monitor a virtual image of the needle as it moves through the tissue toward and into the target vein. The design and function of the device facilitates a unique approach to ultrasound guided supraclavicular approach to cannulation of the subclavian vein. Methods: After FDA clearance, the AxoTrack system was released to three hospitals in the United States. Physicians and Nurse Practitioners who work in the Intensive Care Unit or Emergency Department and who place central venous catheters were trained to use the AxoTrack system. De-identified quality assurance data was prospectively collected at each of the three hospitals every time the AxoTrack system was used for central venous cannulation (CVC) to determine if the system was successful and to describe any complications from the procedure. After IRB review, we consolidated the data for the first 100 central line procedures for retrospective review. Results: The AxoTrack system was used in 100 consecutive patients undergoing central venous cannulation from September 2012 to July 2013. A subset of 33 patients underwent supraclavicular access with no reported complications, including pneumothorax, hemothorax, arterial puncture, or arterial cannulation. Conclusions: The AxoTrack system is a safe, straightforward, and effective tool that facilitates CVC insertion at an alternative site. Furthermore, this device can be used by a variety of health care practitioners with little additional training.

Abstract No. 327 - TETHC—a novel technique for treatment of tunnel/exit site infections in catheter dependent hemodialysis patients with central venous stenosis and limited venous access options

Purpose To evaluate the viability and effectiveness of a novel technique of temporary externalization of a tunneled hemodialysis catheter (TETHC) in catheter-dependent hemodialysis patients presenting with catheter-related tunnel/exit site infection, central venous stenosis and limited alternative venous access. Materials and Methods All catheter-dependent hemodialysis patients with documented central venous stenosis presenting with catheter-related infection of the exit site or tunnel who had subsequently undergone TETHC between February 2008 and May 2012 were reviewed. Patients were concurrently treated with intravenous antibiotics prior to reinsertion of a new tunneled hemodialysis catheter. Treatment outcomes were collected, with treatment failures defined as re-infection with the same organism within 45 days of catheter reinsertion. Results Forty-two TETHC procedures were performed in 26 patients. Indications included 20 tunnel infections and 22 exit site infections. The technical success rate for temporary catheter placement was 100%, with no intra-procedural complications and preservation of the original venous access site in all patients. Treatment failure occurred in 9.8 % (4/41) of cases. One patient died prior to reinsertion of the new tunnelled dialysis catheter due to catheter related bacteremia unrelated to the procedure. The median infection free survival of the new tunneled dialysis catheters was 80 days. Post-procedural complications were encountered in four patients and included 3 cases of a small persistent wound at the temporary supraclavicular access site and 1 non-functioning temporary externalized catheter. Conclusion The novel use of TETHC appears safe and is both viable and effective in the treatment of exit-site and tunnel infections while allowing preservation of the venous access site in catheter-dependent hemodialysis patients with central venous stenosis and limited alternative venous access.

Quality improvement: ultrasonography-guided venous catheterization in organ transplantation

Central venous catheterization (CVC) is a procedure, not exempt of risk. Transplantation patients represent by themselves a high-risk group for CVC. Ultrasonography provides us of the exact localization of the target vein and its relationship with artery and nerve structures, detecting anatomic variations and thromboses of vessels. A description of technical skills, a review of the clinical evidence of ultrasonography-guided CVC and basic training guidelines are presented. The internal jugular vein is the most common target vein selected because it is easier and safer, therefore it is the target vein recommended for learning the ultrasonography procedure. For subclavian-axillar vein insertion, the more distal (deltoid) access is the preferred approach; the supraclavicular access has been described with high success in paediatric patients. Anatomic variations of the venous system are not uncommon; small size, overlap artery and tissue oedema around the neck are the main causes of CVC failure. Training guidelines for ultrasound-guided vascular catheterization are necessary, and skill maintenance is crucial. Ultrasonography-guided venous catheterization is an easily learned technique for internal jugular vein insertion, with significant improvements in overall success in those patients in whom a difficult vein access can be anticipated.

Novel approaches for the treatment of the aberrant right subclavian artery and its aneurysms

We report a minimally invasive, hybrid endovascular approach that was used to treat two patients with aberrant right subclavian arteries. The first patient was a 50-year-old woman who presented with dysphagia lusoria. She underwent endovascular plugging and depressurization of the aberrant artery and a carotid-subclavian bypass using right supraclavicular access. The second patient, a 77-year-old woman who presented with a 5.5-cm aneurysm at the origin of a previously bypassed aberrant artery on the distal aortic arch, was treated using bilateral carotid-subclavian bypasses through neck incisions and a thoracic endoluminal graft exclusion of the arch aneurysm that covered both subclavian arteries.

The Operation of Symptomatic Aneurysm of the Left Subclavian Artery with Supraclavicular Access

The Operation of Symptomatic Aneurysm of the Left Subclavian Artery with Supraclavicular Access

Transthoracic cuffed hemodialysis catheters: a method for difficult hemodialysis access

Recurrent vascular access failure is a major cause of morbidity in patients receiving long-term hemodialysis. Central venous catheters are often necessary for dialysis, and easily accessed vessels (ie, the internal jugular vein and subclavian vein) frequently occlude because of repeated cannulation. When standard access sites occlude, unconventional access methods become necessary. We report a technique of placing hemodialysis catheters directly into the superior vena cava (SVC). Between January 2002 and December 2004, 22 patients with documented bilateral jugular and subclavian vein occlusion underwent transthoracic SVC permanent catheter placement. Femoral vein access was obtained, and a sheath was placed. Under fluoroscopic guidance, a diagnostic catheter was then inserted into the SVC, and a venogram was obtained. By using the fluoroscopic image as a reference guide, supraclavicular access directly into the SVC was performed with lateral and anteroposterior views to better localize the SVC. Once venous blood was obtained, a hydrophilic wire was passed into the inferior vena cava. A 5F sheath was then placed, and, with the use of an exchange catheter, the wire was switched for a stiffer wire. The hemodialysis catheter was then placed in the standard fashion over this wire. In a 24-month period, 22 patients underwent transthoracic permanent catheter placement. All patients had the permanent catheters successfully inserted. Two major complications occurred. One patient experienced a pneumothorax, and another patient experienced a hemothorax. Both patients were successfully treated with chest tube decompression. All permanent catheters functioned immediately with a range of 1 to 7 months. Transthoracic permanent catheter placement is an appropriate alternative for patients in whom traditional venous access sites are no longer available.

Bedside exclusion of clinically significant recirculation volume during venovenous ECMO using conventional blood gas analyses

Study objectiveTo investigate prospectively whether blood gas samples drawn from extracorporeal membrane oxygenation (ECMO) cannulae help to exclude at least clinically significant recirculation volumes in patients with acute respiratory failure. DesignFeasibility study. SettingIntensive care unit at a university-affiliated hospital. PatientsTen consecutive adult patients suffering from severe respiratory failure and undergoing ECMO. InterventionsThe drawing (venous) ECMO cannula was placed into the inferior vena cava via a femoral vein, and the oxygenated blood was returned via the right subclavian vein by supraclavicular access directly into the right atrium. Blood gas samples were obtained from both cannulae. Measurements and main resultsThe median arterial oxygen tension (PaO2) obtained from the arterial cannula was 537 mmHg (range, 366 to 625 mmHg), the median mixed venous oxygen tension (PvO2) drawn from the venous cannula was 42 mmHg (range, 25 to 54 mmHg), which was less than 10% of that observed in the arterial cannula, and also within the physiologic range of PvO2. The ECMO flow necessary to maintain patients′ oxygen saturation above 90% (4.1 L/min; range, 1.95 to 5.8 L/min) was significantly lower than the patients′ cardiac output (CO; 6.2 L/min; range, 4.1 to 7.9 L/min; p < 0.001). ConclusionsWe recommend obtaining blood gas samples—immediately after initiation of ECMO—from both cannulae. A PvO2 within physiologic range and below 10% of PaO2 rules out any clinically relevant recirculation volume.

Thoracic outlet syndrome in paediatrics: Clinical presentation, surgical treatment, and outcome in a series of eight children

Background/Purpose: This report reviews the clinical presentation, surgical treatment, and outcome of 8 children treated for the thoracic outlet syndrome (TOS) during the last 3 years. Methods: From 1998 through 2001 31 patients were admitted to our Vascular Surgery Unit with TOS. Eight of them (25.8%) were in the paediatric age group, 8 to 16 years (mean, 13 years). No sex prevalence was found. The presenting symptoms were neurologic in 2 patients (25%) and secondary to venous flow impairment in 6 (75%). At phlebography, venous thrombosis was seen in 2 cases, and functional intermittent obstruction was seen in 4. Seven patients underwent decompressive surgical partial resection of the first rib with transaxillary or supraclavicular access. One patient was treated conservatively. Results: There were no major postoperative complications. Mean hospital stay was 2.7 days. In no patient were there signs of recurrence after a mean follow-up of 18 months (range, 3 to 36 months). Conclusions: In the authors' experience TOS in paediatric patients occurs with the same symptoms and thrombotic complications as in adults. The same surgical strategy adopted in adult patients is advisable for affected children. J Pediatr Surg 38:58-61. Copyright 2003, Elsevier Science (USA). All rights reserved.

Safe and efficient emergency transvenous ventricular pacing via the right supraclavicular route.

Infraclavicular and internal jugular central venous access are techniques commonly used for temporary transvenous pacing. However, the procedure still has a considerable complication rate, with a high risk/benefit ratio because of insertion difficulties and pacemaker malfunction. To enlarge the spectrum of alternative access sites, we prospectively evaluated the right supraclavicular route to the subclavian/innominate vein for emergency ventricular pacing with a transvenous flow-directed pacemaker as a bedside procedure. For 19 mo, 17 consecutive patients with symptomatic bradycardia, cardiac arrest, or torsade de pointes requiring immediate bedside transvenous pacing were enrolled in the study. The success rate, insertional complications, pacemaker performance, and patients' outcomes were recorded. Supraclavicular venipuncture was successful in all patients, in 16 of 17 at the first attempt. Adequate ventricular pacing was achieved within 1 to 5 min (median, 2 min) after venipuncture and within 10 s to 4 min (median, 30 s) after lead insertion (</=30 s in 15 of 17 patients). The median pacing threshold was 1 mA (range, 0.7 to 2.5 mA). No procedure-related complications were recorded. Throughout the pacing period of 1538 h (median: 62 h, range, 1-280 h) two reversible malfunctions caused by inadvertent lead dislodgement after 122 and 171 h were recorded; in one patient the pacemaker had to be removed because of local infection after 14 days of pacing. We conclude that the right supraclavicular route is an easy, safe, and effective first approach for transvenous ventricular pacing and might provide a useful alternative to traditional puncture sites, even in a preclinical setting. Temporary transvenous cardiac pacing can yield high complication rates especially under emergency conditions. We investigated emergency pacing via the right supraclavicular access in 17 consecutive hemodynamically compromised patients and found good safety, efficacy, and a low complication rate.

Safe and Efficient Emergency Transvenous Ventricular Pacing via the Right Supraclavicular Route

Infraclavicular and internal jugular central venous access are techniques commonly used for temporary transvenous pacing. However, the procedure still has a considerable complication rate, with a high risk/benefit ratio because of insertion difficulties and pacemaker malfunction. To enlarge the spectrum of alternative access sites, we prospectively evaluated the right supraclavicular route to the subclavian/innominate vein for emergency ventricular pacing with a transvenous flow-directed pacemaker as a bedside procedure. For 19 mo, 17 consecutive patients with symptomatic bradycardia, cardiac arrest, or torsade de pointes requiring immediate bedside transvenous pacing were enrolled in the study. The success rate, insertional complications, pacemaker performance, and patients’ outcomes were recorded. Supraclavicular venipuncture was successful in all patients, in 16 of 17 at the first attempt. Adequate ventricular pacing was achieved within 1 to 5 min (median, 2 min) after venipuncture and within 10 s to 4 min (median, 30 s) after lead insertion (≤30 s in 15 of 17 patients). The median pacing threshold was 1 mA (range, 0.7 to 2.5 mA). No procedure-related complications were recorded. Throughout the pacing period of 1538 h (median: 62 h, range, 1–280 h) two reversible malfunctions caused by inadvertent lead dislodgement after 122 and 171 h were recorded; in one patient the pacemaker had to be removed because of local infection after 14 days of pacing. We conclude that the right supraclavicular route is an easy, safe, and effective first approach for transvenous ventricular pacing and might provide a useful alternative to traditional puncture sites, even in a preclinical setting. Implications: Temporary transvenous cardiac pacing can yield high complication rates especially under emergency conditions. We investigated emergency pacing via the right supraclavicular access in 17 consecutive hemodynamically compromised patients and found good safety, efficacy, and a low complication rate.

Radiological Screening for Hickman Catheter Insertion

In Response: McLure and Filshie emphasize that fluoroscopic technique is an important aid in preventing malpositions and in overcoming difficulties during insertion of Hickman catheters. Analyzing their article [1], we found that guidewire kink, sheath introducer kink, and sheath introducer damage ("usually by the under surface of the clavicle") accounted for 44 difficult insertions. These difficulties are attributable to the infraclavicular access (especially from the right side) [2,3], which was used in the study from the Royal Marsden-Hospital (84% right-sided and 15% left-sided subclavian insertions). Cockburn et al. [2] have impressively evidenced that the sharp angle of insertion of the subclavian vein into the superior vena cava is the major cause of kinking (see Figure 1). Furthermore, by using the infraclavicular approach, the rigid sheath and dilator may push against the opposite wall of the superior vena cava, thus impeding catheter feeding. Cockburn et al. therefore preferred a left-sided infraclavicular approach, in which kinking is less likely because of the more obtuse angle [2].Figure 1: A large-bore indwelling catheter placed via the infraclavicular subclavian access. Difficulties during insertion typically occur 1) when passing the gap between the first rib and the clavicle (small arrow) and 2) at the nearly rectangular course from the subclavian vein into the innominate vein (large arrow). At this point, the introducer sheath or the dilator may push against the opposite wall of the superior vena cava. The angular course predisposes to malposition.As outlined in our article [4], this problem was also a crux to our staff in approximately 20% of infraclavicular cannulations, but it was not observed with the right internal jugular and the supraclavicular approach (because the 180[degree sign] curved tunnel, which is obligatory with the internal jugular vein approach, may predispose to obstruction, the supraclavicular approach has become the prefered method in our institution). Recently, we confirmed the superiority of the supraclavicular access to the subclavian/innominate vein for nonangiographic placement of large-bore dialysis catheters (including 109 tunneled devices placed via an introducer sheath) [5]. Avoiding the small gap between the first rib and the clavicle and the impressive anatomically proper coaxial lie of the catheter (Figure 2) enabled easy puncture and feeding of the catheter through the sheath. An internal review of 184 additional soft silicone catheters (83 Hickman catheters and 101 implantable ports) revealed similar results.Figure 2: Anatomically proper coaxial lie of a catheter placed via the supraclavicular access. The arrow indicates the puncture site.The high rate of guidewire malposition reported by McLure and Filshie may also be attributed to the right infraclavicular approach with its angular course. Consistent with previous reports, in a recent review [6] of 2580 percutaneously inserted central venous lines (including 650 tunneled Dacron-cuffed devices), we found the lowest incidence of malposition rate with the supraclavicular route (right and left) (0.96%). This is obviously due to the straight direction into the superior vena cava, which allows deep insertion of the introducer sheath (analogous to the internal jugular vein approach). The highest incidences were found with the left internal jugular and the right infraclavicular access. We disagree with the conclusion that malpositions necessitate catheter reinsertion, with its attendant risks and costs. When postinsertional chest radiographs actually detect malposition, repositioniong without a new puncture is possible by a small cut at the venous entry site. In these rare cases (less than 3%), fluoroscopic aid may be recommended. Our current experience therefore provides evidence that a large number of difficulties is related to the chosen access site and supports the thesis that the implantation of Hickman catheters can be performed without routinely using fluoroscopic guidance, in particular when supraclavicular access is used. Manfred Muhm, MD* Gere Sunder-Plassmann, MD dagger Robert Apsner, MD dagger *Department of Cardiothoracic/Vascular Anesthesia and dagger Acute Dialysis Unit, Internal Medicine III; University of Vienna, Vienna, Austria