Target Vein Research Articles

Comparative Effectiveness, Efficiency, and ED Nurse Preference Between Two Methods of Visualization for Midline Catheter Insertion: A Pilot Study.

Rapid and reliable peripheral IV access is essential for many patients admitted to the emergency department (ED) to ensure administration of life-saving medications, and successful intravenous cannulation can significantly affect patient care. The objective of this study was to assess the impact of a continuous needle tracking system on the accuracy, speed, and quality of ultrasound-guided peripheral venous catheter insertions. A convenient sample study based on the study setting using simulated tissue was conducted with 49 US-based ED nurses to compare the insertion of a midline catheter using traditional ultrasound guidance versus an advanced needle-tracking technology along with ultrasound guidance. The purpose of this evaluation was to assess the impact of continuous needle tracking system. Informed consent was obtained from all individual participants involved in this study. All participants were made aware that the results may be published. There was no IRB approval for this study. All sources were properly disclosed within the text. The addition of the advanced needle-tracking technology significantly reduced total insertion attempts, insertion time, backwall penetrations, and redirects (probes to hit the target vein), while improving image clarity and confidence for participants. The innovative needle-tracking system evaluated in this pilot study has the potential to improve emergent difficult vascular access. EDs should assess the value of this technology to potentially improve the management of difficult intravenous access patients in their settings.

917 HYBRID TRANSVENOUS AND SURGICAL APPROACH FOR THE EXTRACTION OF CORONARY SINUS LEADS: A CASE SERIES

Abstract Background The rates of cardiac device-related infection have increased substantially over the past years. Transvenous lead extraction is the standard therapy for such cases. In some patients, however, the procedure cannot be completed through the transvenous route alone. A hybrid surgical and transvenous approach may provide the solution in such cases. Methods We present three cases who underwent hybird transvenous and surgical extraction for coronary sinus leads due to infection of CRT-D systems. One patient had an Attain Starfix lead implanted in the coronary sinus. The procedures were performed under local anaesthesia with continuous hemodynamic and transthoracic echocardiographic monitoring. We highlight the characteristics of the patients, the features of the devices, the technical difficulties and the outcomes of the procedures. Results In all cases, the right atrial and right ventricular leads were extracted through the transvenous route. In one patient, they were extracted using regular stylets and manual traction, while in the other two patients, telescoping dilator sheaths (Cook), Tightrail hand-powered mechanical sheaths (Spectranetics) and/or Glidelight Excimer Laser sheaths (Spectranetics) were used. The coronary sinus lead could not be retrieved due to extensive fibrosis after utilizing locking stylets and mechanical dilator sheaths in all 3 cases, in addition to rotational mechanical sheaths and Laser. sheaths in one case, so the so the patients were referred to surgery. Two patients underwent left mini-thoracotomy and one patient underwent midline sternotomy to extract the remaining CS lead. The target vein was identified and ligated, then the fibrosis around the lead was dissected, this was followed by lead retrieval through the surgical incision. The patient who underwent sternotomy suffered from mediastinitis, which required reoperation and mediastinal lavage. There were no complications in the other two patients. All three patients were reimplanted with a new CRT-D device on the contralateral side after the resolution of infection. Conclusion A hybrid surgical and transvenous approach can be complementary in case the transvenous route alone fails to completely extract the coronary sinus lead. The transvenous approach can be used to free the proximal part of the lead, while the distal adhesions can be removed surgically, preferably though a limited thoracic incision.

Clinical application of the contrast-enhancement boost technique in computed tomography angiography of the portal vein

PurposeThe aim of this study was to explore the improved image quality of the portal vein using the contrast-enhancement boost (CE-boost) technique for the improved visibility of abdominal-enhanced computed tomography (CT) scans in clinical practice.MethodsThis retrospective study included 50 patients in Group A who underwent routine abdominal-enhanced CT and 50 patients in Group B who underwent abdominal computed tomography angiography (CTA) with matched body mass index, age, and sex. Images in Group A were postprocessed with the CE-boost technique for further enhanced visibility of the portal vein. Both subjective and objective assessments of different branches of the portal vein in three types of images (i.e., Group A with CE-boost and without CE-boost, Group B) were statistically analyzed.ResultsThe subjective scores of two experienced radiologists showed good consistency (kappa value > 0.624, p < 0.001), and the score of Group A with CE-boost (mean, 4.64) was significantly higher than that of the others (p < 0.001). The liver parenchyma and most target veins in Group A with CE-boost showed the highest CT, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) values and the lowest standard deviation (SD), while the CNR of most portal veins in Group A without CE-boost had the lowest CNR (p < 0.001). There were no differences in the SNR of the portal vein in Group A without CE-Boost and Group B (p > 0.05).ConclusionCE-boost can significantly improve image quality in portal vein imaging without any additional scanning settings or changes in the clinical workflow.Graphical

The significance of minimally invasive treatment methods in the single-stage elimination of varicose vein disease of the great and small saphenous veins of the lower limbs and their branches

Introduction. This article presents a clinical case of successful and single-stage endovenous laser coagulation combined with miniphlebectomy in a patient with extensive and combined varicose lesion of all major subcutaneous veins of the lower limbs with significant symptoms of chronic venous insufficiency.Aim. To determine the possibilities of simultaneous elimination of all main subcutaneous veins and their varicose tributaries on both lower limbs using minimally invasive methods.Materials and methods. A 44-year-old female patient complained of gastrocnemius muscle cramps, swollen shins, feeling of heaviness at the end of the working day and the presence of varicose veins in both lower extremities. The severity of the chronic vein disease before the intervention according to the VCSS (Venous clinical Severity Score) was 8. As a result, patency of deep veins and condition of their valve apparatus, insufficiency of valves of the sapheno-femoral and sapheno-popliteal annexes on both sides with reflux through large and small saphenous veins and anterior accessory large saphenous vein on the right, insufficiency of perforating veins of both tibias were determined. Endovenous laser coagulation of the great and small saphenous veins on both sides and the right anterior accessory great saphenous vein, miniphlebectomy of dilated tributaries within both lower limbs was performed. The symptoms of chronic venous insufficiency decreased markedly. Swelling of the lower legs and cramps in the gastrocnemiu muscles have almost completely disappeared, and the feeling of heaviness in the legs after static loads has significantly decreased.Conclusion. Endovenous laser coagulation with miniphlebectomy should be given preference in varicose vein disease with combined affection of all great saphenous veins of both lower limbs. Their application provides an opportunity to eliminate simultaneously incompetence of all target veins and to remove varicose dilated tributaries, providing good therapeutic and cosmetic effect without hospitalization and detachment of the patient from his or her work activity.

Pilot single-arm study to investigate the efficacy and safety of endovenous Microwave ablations for treatment of varicose veins in Singapore - one year results of the MAESTRO registry.

Aim was to report a prospective two-centre Singaporean experience using Endovenous Microwave Ablation (EMA) to treat symptomatic primary great saphenous vein reflux. We evaluated 1-year safety, efficacy and patient satisfaction. 50 patients (63 limbs; 29 females; mean age 58.0 ± 12.1years) were included. Patients were reviewed at 2-weeks, 3-, 6- and 12-months and underwent Duplex ultrasound assessment. Three quality of life (QoL) questionnaires were completed. The truncal closure rates at 2-weeks, 3-, 6- and 12-months were 63/63 (100%), 59/59 (100%), 58/58 (100%) and 59/60 (98.3%), respectively. There was 100% technical success and no serious adverse events. There were sustained improvement of QoL questionnaire scores from 2weeks to 12months. EMA is a safe and efficacious venous ablative technology at 12 months and is associated with a high rate of target vein occlusion and sustained QoL improvement.

Pilot Study of the Impact of a Head-Mounted Display and Probe Fixation for Ultrasound-Guided Peripheral Intravenous Cannulation

Highlights Abstract Background: Ultrasound is an efficient and effective technique to aid intravenous cannulation, in which good hand-eye coordination is crucial. To reduce the difficulty, the ultrasound image should be projected and visible in front of the practitioner during cannulation, and the probe should be stabilized on the target vein. The current study investigates the impact of a head-mounted display and probe fixation for ultrasound-guided peripheral intravenous cannulation success and time needed to successful insertion. Materials and Methods: This nonclinical pilot study included 49 nurse anesthetists. They were divided into an intervention group (cannulation with a head-mounted display and probe stabilizer for ultrasound-guided peripheral intravenous cannulation, n = 24) and control group (conventional method of ultrasound-guided cannulation, n = 25). Participants performed 20 procedures each on phantoms, with focus on first attempt cannulation success and time taken to completion of successful cannulation. Results: In the intervention group, 98% succeeded on their very first attempt at cannulation, compared to 52% in the control group (P &amp;lt; 0.001). Time to successful cannulation on the first attempt was 1.13 ± 0.4 minutes in the intervention group, compared with 1.69 ± 0.8 minutes in the control group (P = 0.003). Overall, first attempt cannulation success was 92% in the intervention group and 90% for the control group (P = 0.359). Times required for successful cannulation was reduced by 0.08 minutes in the intervention group (P &amp;lt; 0.001). Conclusions: This pilot study is the first describing the use of a head-mounted display and probe fixation for ultrasound-guided peripheral intravenous cannulation, which resulted in an increased success rate and decreased time to cannulation success.

Angioscopic evaluation after venous stents

BackgroundVenous stenting is increasingly used to manage femoro-ilio-caval venous outflow obstruction/stenosis due to post-thrombotic syndrome. Although the safety, efficacy, and long-term patency of venous stents have been reported, re-interventions due to stent occlusion and in-stent restenosis (ISR) have also been reported. The mechanism of ISR and the in-stent neointimal growth after venous stenting remains unclear. We performed angioscopy to evaluate intraluminal details after venous stenting, allowing real-time direct visualization of the vessel lumen. MethodsTen angioscopic procedures in four patients with post-thrombotic syndrome were performed. All evaluated vessels were stented iliac veins, and their native pathology was chronic post-thrombotic occlusion. Nine procedures in three patients underwent serial evaluation of the neointimal changes after stent implantation to study the natural time course of neointimal proliferation/coverage over the stent. The serial follow-up angioscopic evaluations were performed at the end of the venous stent deployment procedure, and at 6 months, 12 months, and 24 months. One procedure was performed 1 month after the stent implantation to evaluate ISR, which was observed at the first month of routine stent surveillance. A 5.7F angioscope was used to visualize the target veins. Continuous irrigation was used to displace blood and clear the visual field. ResultsAt 6 months after stent implantation, stent struts were covered by a thin neointima in two of the three patients. The struts were partially covered in one patient, but there was little neointimal growth overall. Neointimal coverage increased over time, and at 12 months stent struts in 2 patients were almost completely covered. There was no significant change between the 12 and 24 months after stent implantation. In the ISR case, angioscopy demonstrated an overgrown thickened neointima, and the stent struts were fully embedded and invisible in the entire stented area. No thrombus and no webs or trabeculae were found in the area evaluated as an ISR lesion. ConclusionsAt 6 months after stent placement, the stent struts were almost covered by a neointima. The stent struts were completely covered 1 year after stent implantation. Neointimal coverage was unchanged from the 1-year follow-up to the 2-year follow-up, suggesting that neointimal proliferation proceeded gradually with subsequent neointimal remodeling up to 1 year. The cause of ISR might be the overgrown thickened neointima rather than the formation of thrombosis.

Advanced Techniques for Ethanol Ablation of Left Ventricular Summit Region Arrhythmias.

Coronary venous ethanol ablation (VEA) can be used as a strategy to treat ventricular arrhythmias arising from the left ventricular summit, but collateral flow and technical challenges cannulating intramural veins in complex venous anatomies can limit its use. Advanced techniques for VEA can capitalize on collateral vessels between target and nontarget sites to improve success. Of 55 patients with left ventricular summit ventricular arrhythmia, advanced techniques were used in 15 after initial left ventricular summit intramural vein mapping failed to show suitable targets for single vein, single-balloon VEA. All patients had previous radiofrequency ablation attempts. Techniques included: double-balloon for distal protection to block distal flow and target the proximal portion of a large intramural vein where best signal was proximal (n=6); balloons in 2 different left ventricular summit veins for a cross-fire multivein VEA (n=4); intramural collateral vein-to-vein cannulation to reach of targeted vein via collateral with antegrade ethanol and proximal balloon block (n=2); prolonged ethanol dwell time for vein sclerosis of large intramural vein and subsequent VEA (n=3); and intramural collateral VEA (n=1). Fifteen (8 females) patients (age 60.6±17.6 years) required advanced techniques. Procedure time was 210±49.9 minutes, fluoroscopy time was 25.3±14.1 minutes, and 113±17.9 cc of contrast was utilized. A median of 7 cc of ethanol was delivered (range, 4-15 cc). Intraprocedural radiofrequency ablation was delivered before ethanol in 9 out of 15 patients but failed. Ethanol achieved acute success in all 15 patients. Ethanol was used as the sole treatment in two patients. At a median follow-up of 194 days, one patient experienced recurrence. Advanced techniques capitalizing on venous anatomy can enable successful VEA and selective targeting of arrhythmogenic sites, by blocking distal flow, utilization of collaterals between nontarget and target veins and multivein VEA. Understanding individual anatomy is critical for VEA success.

Skin necrosis following sclerotherapy. Part 1: Differential diagnosis based on classification of pathogenic mechanisms.

Background: Tissue necrosis is a significant but uncommon complication of sclerotherapy. The pathogenic mechanisms of this often-debilitating complication have been poorly described in the literature.Purpose: To elucidate the pathological mechanisms, we propose a morphological approach to classify sclerotherapy-induced skin necrosis into two categories of round and stellate (star-like) necrosis.Research Design: Comprehensive literature review was conducted.Results: Round necrosis is typically caused by extravasation of sclerosants. It typically presents as an ulcer with smooth and non-geographic borders. Historically, extravasation has been cited as the main cause of sclerotherapy-related necrosis. While this may be the case with osmotic or irritant sclerosants, it is far less likely with the use of detergent agents particularly in the foam format.The more commonly encountered pattern of stellate necrosis is an ischaemic ulcer secondary to arterial/arteriolar occlusion. In contrast to round necrosis, stellate necrosis follows an intra-vascular injection of sclerosants such as an inadvertent intra-arterial injection. But more frequently, stellate necrosis may follow a perfectly executed intra-venous or intra-telangiectatic delivery of sclerosants. Several pathogenic pathways can be considered. The physiologic response of veno-arteriolar reflex vasospasm (VAR-VAS) is possibly the most frequent pathway. It follows a high-pressure injection of the sclerosant in a target vein resulting in a rapid rise of intravenous pressures which in-turn would trigger a sympathetic neuronal reflex vasospasm of the pre-capillary sphincters and a corresponding opening of the normally closed arterio-venous anastomoses(AVAs). This communication would allow entry of the sclerosing agent into the arteriolar side of the circulation resulting in arteriolar occlusion and infarction of the corresponding skin. Similarly, an intravenous administration of sclerosants in the vicinity of defective boundary valves or persistently open AVAs can result in the entry of detergent agents into the arteriolar side of the microvasculature causing an ischemic stellate ulcer.Conclusions: In this first instalment of these two-part series, we review the pathogenic mechanisms of post-sclerotherapy necrosis. In the second instalment, we describe risk minimisation and management strategies.

PO-624-04 ADVANCED TECHNIQUES TO MAXIMIZE TISSUE REACH OF CORONARY VENOUS ETHANOL IN ABLATION-REFRACTORY VENTRICULAR ARRHYTHMIAS

Venous ethanol infusion can treat ablation-refractory ventricular arrhythmias (VAs). Ethanol tissue delivery can be compromised by collateral flow and technical challenges cannulating intramural veins in complex anatomies. To develop advanced and multi-balloon approaches to ethanol delivery in complex venous anatomy. 14 patients referred for initial ablation (n=4) or after failed ablation (n=10) underwent endocardial (n=14), epicardial (n=1), and coronary venous mapping (n=14). 7 patients had left ventricular summit VAs, and 7 had scar-mediated VAs. Double or triple balloons were used in the coronary veins. Advanced strategies for ethanol delivery include use of secondary balloons to (1) block collateral flow in a target vein (2) block collateral flow into a non-target vein (3) cannulate collaterals to reach a target vein that is not easily accessible via its ostium (4) serve as a distal mechanical block to facilitate more proximal vein cannulation and (5) occlude the coronary sinus to allow ostial delivery of ethanol in a branch vessel. Successful ethanol infusion was accomplished in the following target veins: LV annular (n=2), septal (n=6), lateral (n=1), middle cardiac (n=1), anterolateral (n=2) and postero-lateral (n=3). At median follow up of 130.5 days, no patients experienced recurrences. Utilization of collaterals between non-target and target veins can facilitate ethanol delivery with the multiple balloon technique. Understanding of CS venous anatomy and advanced approaches to balloon deployment may increase the efficacy of venous ethanol for treatment of VAs.

Troubleshooting the difficult left ventricular lead placement in cardiac resynchronization therapy: current status and future perspectives

ABSTRACT Introduction Cardiac resynchronization therapy (CRT) is an important option in modern cardiac implantable electronic device (CIED) treatment. Techniques for left ventricular (LV) lead placement in the coronary sinus and its tributaries are neither well described nor studied systematically, despite attention regarding where to place the LV lead. Areas covered This review presents specialized tools and techniques to overcome some of the most common problems encountered in LV lead placement in CRT. These tools and techniques are termed Interventional CRT (I-CRT), as they share technology with other interventional procedures. The main principle in I-CRT, compared to the traditional over-the-wire technique, is to add better support for delivery of the LV lead through dedicated inner catheters that also allows more flexibility with the use of more guidewires and better imaging with direct venography in the target vein. Expert opinion Even though CRT is an established therapeutic option, there are still many challenges in the implementation of the therapy. The cornerstone should be an ease of delivering the CRT and specifically implantation of the LV lead. Therefore, knowledge of the principles in I-CRT is necessary, as I-CRT could make implantation simpler in general and easier to reach the optimal LV pacing site.

Risk Factors and Management of Hemodialysis Associated Distal Ischemia

A review of the Vascular Quality Initiative between 2011 and 2019. Hemodialysis-associated distal ischemia requiring intervention occurred in about 3% of patients (970/35,236) who underwent vascular access placement, although 17% developed mild ischemia not requiring intervention. Intervention included catheter-based approaches (41%), access ligation (23%), distal revascularization with interval ligation (20%), banding (13%), proximalization of arterial inflow (1.5%), and revision using distal inflow (1.4%). The median time to hemodialysis-associated distal ischemia was 7 weeks. Multivariate regression demonstrated that white race, female sex, peripheral artery disease, diabetes, prosthetic grafts, upper arm access, and target vein diameter greater than 4 mm were significantly associated with an increased risk for distal ischemia. Hemodialysis-associated distal ischemia complicates about 3% of cases and is more likely in white females with diabetes and arterial disease after upper arm prosthetic graft placement.

Comparison Between Open and Ultrasonography Guided Venous Access Ports in Children with Malignancy

Background: Long-term central venous access is used in children for various reasons specially for delivering chemotherapy. Since vessels in children have smaller diameters, they are more prone to injury and complications such as thrombosis. Different methods are used for implantation of port-a-cath in children. We aimed to compare the complications of insertion of central venous access ports between two methods of open and ultrasound (US) guided. Methods: All children who were referred to pediatric surgery department of a children hospital from April 2018 to March 2020 for implantation of port-a-cath were included. Right jugular vein was the target vein and patients were randomly divided between two methods of insertion of open lateral neck exploration and ultrasound real-time guided percutaneous insertion and the reservoir was fixed in subpectoral fascia pouch. All open cases in which jugular vein was ligated proximally were excluded. Patients were followed up for early and late complications two days and one week later by the surgical team, then monthly by a trained nurse and were referred to the surgeon if any complication or malfunction had occurred for at least 6 months. Results: We included 76 patients (21 girls and 55 boys) less than 18 years of age: 24 patients with ultrasound guided method (1-13 years, median 3 years) and 52 patients with open exploration method (4 months-17 years, median 6 years). We observed no statistically significant difference between two groups with respect to sex, underlying disease, and complications. Most patients had hematological malignancies including ALL (52.9%), AML (19.1%) and the rest had solid organ malignancies. Early complications were observed in 2 (3.8%) in the open and 1 (4.2%) in the US- guided group (P=1). Late complications were observed in 9 (17.3%) patients in the open group and 1 (4.2%) in the US guided group. Infection was observed in 9.6% and malfunction in 5.8% of the open group leading to earlier removal of the catheter. There was not any complication indicative of infection in the US-guided group. Conclusion: US-guided method can be suggested for routine use as a safe method of insertion of port venous access in children.

Indian venaseal™ Experience study – Outcomes of nonthermal and nontumescent endovenous glue ablation for treatment of truncal reflux in varicose vein disease

Background: Varicose veins is a common disease in nearly 37.25% of the Indian population significantly affecting the quality of life. Endovenous thermal ablation has been the first-line treatment for superficial venous reflux. A new technique, available now, is nonthermal nontumescent vein sealing system (VenaSeal™), which comprises endovenous delivery of cyanoacrylate tissue adhesive into the vein causing obliteration of lumen and has shown better results in terms of safety and efficacy. Being a new modality, only handful of institutes across India perform this procedure and there is a scarcity of Indian data on its outcomes. Aims and Objectives: To evaluate the outcomes of VenaSeal™ glue ablation in terms of vein occlusion rates and improvement in Venous Clinical Severity Score (VCSS). Materials and Methods: Single-centre prospective study of fifty patients over 1 year and 4 months with 3- and 6-month follow-up. Results: The study showed the mean age of the study group to be 43.8 years and the majority (90%) had an early varicose vein (C2/C3) disease. The average length of vein treated per limb was 89.1 cm, and the average glue used per limb was 2.95 ml. All patients showed improvement in VCSS score from preoperative average of 2.6 ± 1.4 to 0.32 ± 0.19 (P &lt; 0.0001, n = 89) with target vein occlusion rate of 100% at 3 months and 97.75% at 6 months. Conclusion: Thus, VenaSeal™ glue ablation procedure is a promising and effective modality for the treatment of varicose veins with excellent treatment success rates, minimal complications, and maximum patient acceptability. It is a feasible Out patient department (OPD) based procedure.

Risk Factors and Management of Hemodialysis Associated Distal Ischemia

Hemodialysis-associated distal ischemia (HADI) is an uncommon, but significant complication after hemodialysis access creation that might require additional intervention. This study examines the risk factors for HADI and compares the outcomes of the different treatment modalities. The Vascular Quality Initiative hemodialysis access (2011-2019) registry was reviewed. Patients were classified based on the occurrence of HADI requiring intervention or not, and their respective characteristics were compared. Multivariable logistic regression was used to identify independent factors associated with HADI. Kaplan Meier curves of secondary patency after different modalities of surgical revision were compared. There were 35,236 vascular access creations and 970 (2.75%) were complicated by HADI requiring intervention. Treatment was performed with access ligation in 224 patients (23%) and catheter-based techniques in 394 (41%). Open surgical revision consisted of banding in 127 (13%), distal revascularization interval ligation (DRIL) in 196 (20%), proximalization of arterial inflow (PAI) in 15 (1.5%), and revision using distal inflow (RUDI) in 14 (1.4%). Median time to HADI was 49 days (IQR 17 -91 days). Multivariate regression demonstrated that white race, female sex, peripheral artery disease, coronary artery disease, diabetes, post-procedure antiplatelets, prosthetic grafts, upper arm access, and target vein diameter greater than 4 mm were significantly associated with increased risk for HADI. When compared to procedures without HADI, access patency was decreased when revision (excluding access ligation) was performed (secondary patency at 12 months, HADI revision versus none: 89.0% vs. 92.4%, P <0.01). However, after multivariate Cox adjustment, revision for HADI was not independently significantly associated with access failure. HADI complicates 2.75% of hemodialysis access cases and is more likely in white females with diabetes and arterial disease after upper arm prosthetic graft placement. The patency of dialysis access does not seem to be negatively impacted by the various methods of surgical revision for HADI.

Assessment of Duplex Ultrasound Carried Out by the Vascular Surgeon After Locoregional Anesthesia for Preferred Arteriovenous Fistula Access

Preoperative vascular mapping by duplex ultrasound is required in construction of an arteriovenous fistula for hemodialysis (AVF). Due to venous vasospasm in cool temperatures and variability of the dialysis patient's blood volume, the conditions for performing this examination may be less than ideal. However, local regional anesthesia (LRA) resulting in vasodilation of the limb, can allow the use of veins considered to be of insufficient caliber during preoperative ultrasound mapping. The aim of this study was to assess the functionality of AVF when duplex ultrasound is performed by the surgeon following LRA. These results were compared with those from the preceding year, during which preoperative duplex ultrasound had been performed without LRA by vascular specialists, (Clinical Trial registration number: NCT04978155). This is a prospective study of all the patients having received AVF after systematic immediate preoperative ultrasound (US) under LRA (US-LRA group) in 2020. The initial surgical programming based on the Silva criteria was reported by a vascular medicine specialist. The change of AVF strategy following US-LRA was reported together with AVF usability and patency and compared to the results of the control group, in which AVF had been performed in 2019 without US-LRA. Ninety patients were included in the US-LRA group and 93 in the control group. Modified surgical planning was observed in 38% of cases (35/90) in the US-LRA group including more distal AVF in 28% of patients (26/90) and alternative target vein in 6.6% (6/90). AVF usability at 6 weeks was 80% (72/90) in the US-LRA group and 51.6% (48/93) in the control group (P < 0.001). Median follow-up was 12 months [IQR:9-15] in the US-LRA group and 13 months [IQR:9-18] in the control group. Primary patency at 6, 12, 18 months was significantly better in the US-LRA group (73.6% vs. 57.4%, 54.4% vs. 40.2%, 31.3% vs. 28.2%, respectively, P < 0.001). Assisted patency and secondary patency were comparable in the two groups. This study showed the benefit of having the surgeon perform US-LRA before starting the procedure, thereby allowing for more distal AVF, better usability and patency.

689 Hybrid transvenous and surgical approach for the extraction of coronary sinus leads: a case series

Abstract Aims The rates of cardiac device-related infection have increased substantially over the past years. Transvenous lead extraction is the standard therapy for such cases. In some patients, however, the procedure cannot be completed through the transvenous route alone. A hybrid surgical and transvenous approach may provide the solution in such cases. Methods and results We present three cases who underwent hybird transvenous and surgical extraction for coronary sinus leads due to infection of CRT-D systems. One patient had an Attain Starfix lead implanted in the coronary sinus. The procedures were performed under local anaesthesia with continuous haemodynamic and transthoracic echocardiographic monitoring. We highlight the characteristics of the patients, the features of the devices, the technical difficulties, and the outcomes of the procedures. In all cases, the right atrial and right ventricular leads were extracted through the transvenous route. In one patient, they were extracted using regular stylets and manual traction, while in the other two patients, telescoping dilator sheaths (Cook), Tightrail hand-powered mechanical sheaths (Spectranetics), and/or Glidelight Excimer Laser sheaths (Spectranetics) were used. The coronary sinus lead could not be retrieved due to extensive fibrosis after utilizing locking stylets and mechanical dilator sheaths in all three cases, in addition to rotational mechanical sheaths and laser sheaths in one case, so the patients were referred to surgery. Two patients underwent left mini-thoracotomy and one patient underwent midline sternotomy to extract the remaining CS lead. The target vein was identified and ligated, then the fibrosis around the lead was dissected, this was followed by lead retrieval through the surgical incision. The patient who underwent sternotomy suffered from mediastinitis, which required reoperation and mediastinal lavage. There were no complications in the other two patients. All three patients were reimplanted with a new CRT-D device on the contralateral side after the resolution of infection. Conclusions A hybrid surgical and transvenous approach can be complementary in case the transvenous route alone fails to completely extract the coronary sinus lead. The transvenous approach can be used to free the proximal part of the lead, while the distal adhesions can be removed surgically, preferably though a limited thoracic incision.

A critical review of surgical strategies to minimise venous stenosis in arteriovenous grafts.

It is inevitable that complications arising from surgical procedures are ascribed to surgical technique, and this applies to venous stenosis (VS) in arteriovenous grafts. However, despite a wide range of cellular studies, computer modelling, observational series and clinical trials, there remains uncertainty on whether surgical technique contributes to VS. This article reviews evidence from basic science, fluid dynamics and clinical data to try and rationalise the main surgical options to modify the occurrence of venous stenosis. There is sufficient data from diverse sources to make recommendations on clinical practice (size of target vein, shape of anastomosis, angle of approach, distance from venous needling, trauma to the target vein) whilst at the same time this emphasises the need to carefully report the practical aspects of surgical technique in future clinical trials.

Early results of application of the system of mechanochemical obliteration of varicose veins for the treatment of varicose veins

Introduction . The basis of varicose veins is reflux in the great saphenous veins, and at present one of the basic principles of treating varicose veins is to eliminate reflux. Thermal obliteration is the gold standard, but non-thermal non-tumescent methods have several advantages. Target . Evaluation of the safety and effectiveness of mechanochemical obliteration in patients with venous insufficiency using the Flebogrif catheter. Materials and methods . The study included 8 women and 2 men over 18 years of age with reflux along the GSV with a target vein diameter of no more than 12 mm. The average age of the patients was 43.8 ± 11.5 years. Stage C2 (varicose saphenous veins) was detected in six patients (60%), stage C3 (edema) in 3 patients (30%), stage C4a (trophic changes of skin and subcutaneous tissues, hyperpigmentation and/or varicose eczema) in one patient (10%). Results. After the procedure, complete occlusion of the target segments of the varicose vein was achieved in 100 percent of cases (10 patients) at all study periods (up to 2 months). Palpation in the projection of the target vein was painless in all patients. The ultrasound imaging showed complete occlusion of the target vein and the absence of complete or segmented recanalization in all patients during all postoperative examinations. No adverse events or complications were reported. Conclusions . Mechanochemical obliteration is a reliable way to eliminate vertical reflux. The main advantages for the patient are speed, painlessness, beauty and outpatient procedures. A big plus for the doctor, in addition to the speed of the intervention and patient satisfaction, is the absence of the need for complex technical devices (thermogenerators), as well as the absence of the need for tumescent anesthesia, which makes the procedure more comfortable for the patient.

A multicenter randomized controlled trial of cyanoacrylate closure and surgical stripping for incompetent great saphenous veins

ObjectiveThe treatment of varicose veins has shifted from conventional surgical stripping (SS) to minimally invasive endovenous modalities. Cyanoacrylate closure (CAC) with the VenaSeal system (Medtronic, Dublin, Ireland) has increased in popularity owing to its nonthermal and nontumescent technique. The purpose of the present study was to compare the clinical outcomes of CAC and SS for the treatment of incompetent great saphenous veins. MethodsAn open-label, multicenter, prospective, randomized controlled trial was conducted. The subjects were randomized to either the CAC or SS procedure. The primary endpoint of the present study was to evaluate complete closure of the target vein at 3 months. Target vein occlusion was assessed on the third day and 1, 3, 6, and 12 months postoperatively using duplex ultrasound. The pain and ecchymosis grades were also assessed. Additionally, the clinical outcomes, such as the venous clinical severity score and Aberdeen Varicose Vein Questionnaire score, were assessed. ResultsThree-month follow-up data were obtained for all 126 enrolled and randomized subjects (63 with CAC and 63 with SS). At 3 months, complete target vein closure was observed in both groups. The postoperative pain score was significantly better in the CAC group than in the SS group (0.3 ± 0.6 in the CAC group and 1.1 ± 1.5 in the SS group; P < .001). In addition, the mean ecchymosis grade was 0.3 ± 0.5 in the CAC group and 1.1 ± 1.1 in the SS group (P < .001). The venous clinical severity score and quality of life had improved equally in both groups. The adverse events after both procedures were mostly minor complications (9 events in CAC group and 20 events in SS group). Major complications occurred in one patient who had undergone the SS procedure. ConclusionsThe CAC and SS procedures were both associated with complete occlusion of the target vein at 3 months. The postoperative pain and ecchymosis grades were significantly lower in the CAC group. Other differences between the two groups included the frequency and nature of the complications. The results showed that CAC has high success with few complications.