Transseptal Needle Research Articles

A Novel-Design Poly-L-Lactic Acid Biodegradable Device for Closure of Atrial Septal Defect: Long-Term Results in Swine

Objectives: The aim of this study is to evaluate the long-term effectiveness and safety of a self-expandable, double-disk biodegradable device made of poly-<smlcap>L</smlcap>-lactic acid (PLLA) for closure of atrial septal defects (ASDs) in swine. Methods: ASDs were created by transseptal needle puncture followed by balloon dilatation in 20 piglets. The experimental group comprised 18 animals, while the remaining 2 animals were used as controls. Effectiveness and safety were evaluated by rectal temperature, leukocyte count, chest radiography, electrocardiogram, transthoracic echocardiography (TTE), intracardiac echocardiography (ICE), and histologic studies. Animals were followed up at 1, 3, 6, and 12 months. Results: An ASD model was successfully created in 19 animals; 1 piglet died during the procedure. The ASD diameters that were created ranged from 5 to 6.4 mm. Devices were successfully implanted in 17 animals. No animal died during the follow-up studies. Rectal temperatures and electrocardiograms were normal at follow-up, while leukocyte counts transiently increased from 1 to 6 months. Radiography, TTE, ICE, and macroscopic studies demonstrated that PLLA occluders were positioned well, with no shifting, mural thrombus formation, or atrioventricular valve insufficiency. Histologic evaluations showed that PLLA devices were partially degraded in the follow-up study. Conclusions: ASD closure with the novel PLLA biodegradable device is safe and effective. Longer-term studies are needed to evaluate long-term biodegradability.

Transesophageal echocardiography guided transseptal puncture for atrial fibrillation ablation in a patient with a 30 mm atrial septal closure device.

Percutaneous device closure is a well-established treatment of atrial septal defects (ASD) and the method of stroke prevention in a selected group of patients with patent foramen ovale (PFO). However, in case of drug-refractory atrial fibrillation (AF), when catheter ablation of pulmonary veins (PV) is required, the access to the left atrium is more difficult due to the ASD/PFO closure device. We report a case of a 58-year-old man with PFO closure performed due to recurrent stroke (Nit-Occlud PFO device 30 mm in diameter). 3.8 years after the successful procedure the patient suffered from frequent, symptomatic episodes of drug-refractory AF. Before the pulmonary vein isolation (PVI) procedure a computed tomography scan was obtained to access the PV anatomy and to visualize the device position (Figure 1 A). Figure 1 A – Computed tomography scan merged with CARTO map of left atrium (LA) indicating relation of the device (green arrows) to the anatomical structures and ablation line (red dots). Projections shown in Figure 1: right anterior oblique (RAO) 46o ... During PVI four venous accesses were obtained: two in the right and two in the left femoral veins. Diagnostic catheters were placed in coronary sinus and His bundle position. Left atrial access was obtained with a double transseptal puncture under both fluoroscopic and transesophageal echocardiography (TEE) guidance (Vivid q). Two 8.5-Fr transseptal sheaths were advanced over a guide wire to the superior vena cava. Then a transseptal needle was introduced into the sheath, and the whole unit was withdrawn under the fluoroscopic antero-posterior view and TEE guidance. The typical “jump” of the needle could not be observed due to device presence. The optimal site of the transseptal puncture was determined mostly on TEE guidance. In the bicaval view the correct position in the vertical axis was fixed. In the short axis view the position of the puncture needle was corrected in the anterior-posterior (A-P) axis (Figure 1 B). The transseptal system was positioned in relation to the interatrial septum, visualized by TEE and directed to the thinner part of the septum, below and posterior to the occluder device. When the transseptal unit was placed in the desired location, the position was confirmed by the typical tenting of the septum caused by the transseptal unit, and the needle was advanced through the septum. Effectiveness of the puncture was confirmed by saline injection to the left atrium and assessed by TEE (Figure 1 C). Finally, the transseptal sheath was advanced over the wire to the left atrium. A second transseptal puncture was performed using a similar technique, slightly inferior to the first access. The ablation strategy consisted of PVI with two wide antral circumferential RF ablations around ipsilateral PV using an electroanatomical mapping system (CARTO 3), a 3.5-mm irrigated-tip catheter and a circular mapping catheter. All four PV were isolated with confirmed entrance and exit block (Figure 1 A). There were no procedure-related complications. More and more patients after device PFO/ASD closure will undergo procedures requiring transseptal access. As described in this case and several previous reports [1–4], transseptal access in a patient with an atrial septal occluder device can be performed successfully and allow pulmonary vein isolation. The TEE is an effective method to guide transseptal puncture in this group of patients.

Different transseptal puncture for different procedures: Optimization of left atrial catheterization guided by transesophageal echocardiography.

Background:Left atrial catheterization through transseptal puncture is frequently performed in cardiac catheterization procedures. Appropriate transseptal puncture is critical to achieve procedural success.Aims:The aim of the study is to evaluate the feasibility of selective transseptal punctures, using a modified radiofrequency (RF) transseptal needle and transesophageal echocardiography (TEE), in different types of procedures that require specific sites of left atrial catheterization.Setting and Design:This was an observational trial in a cardiac catheterization laboratory of a teaching hospital.Materials and Methods:Patients undergoing different percutaneous procedures requiring atrial transseptal puncture such as atrial fibrillation (AF) ablation, left atrial appendage (LAA) occlusion, and mitral valve repair were included in the study. All procedures were guided by TEE and an RF transseptal needle targeting a specific region of the septum to perform the puncture.Statistical Analysis:The statistical analysis was descriptive only.Results:RF-assisted transseptal punctures were performed in six consecutive patients who underwent AF ablation (two patients), LAA closure (two patients), and mitral valve repair (two patients). In all patients, transseptal punctures were performed successfully at the desired site. No adverse events or complications were observed.Conclusions:Selective transseptal puncture, using TEE and an RF needle, is a feasible technique that can be used in multiple approaches requiring a precise site of access for left atrial catheterization.

Conduit Puncture for Electrophysiological Procedures in Patients with Fontan Circulation

Background: Electrophysiological procedures are challenging in pa- tients who have undergone lateral tunnel or extracardiac conduit Fontan operation because the caval veins are not connected to the cardiac atria and ventricles. This study describes our experience in managing a series of patients with Fontan circulation requiring cath- eter ablation for arrhythmias. Methods: This study included eight consecutive patients with Fontan circulation who underwent catheter ablation or pacemaker implan- tation via Fontan conduit puncture (median age (interquartile range), 21.5 (16.0-25.8) years; 5 men). Lateral tunnel and extracardiac con- duit were equally distributed among the eight patients. A standard technique for conduit puncture and subsequent electrophysiologic procedure was used. The time taken for conduit puncture was com- pared for different types of conduits. Results: The median age of patients in this series was 21.5 years (interquartile range: 16.0-25.8 years). Fontan conduit puncture via right femoral vein under intracardiac echocardiographic guidance was successfully performed without complications in seven of the eight patients. Conduit puncture failed in one patient with extracardiac conduit made of the pericardium due to interruption of both femoral veins. In three patients with Fontan conduit made of pericardium, a Bronckenbrough transseptal needle or a radiofrequency transseptal needle with a snare was used. In four patients with Fontan conduit made of Gore-tex, a radiofrequency transseptal needle with a snare, and percutaneous transluminal angioplasty balloon were used. Fontan conduit puncture time was significantly longer in patients with conduit made of Gore-tex (median time, 91 min; interquartile range, 59.8-130.5 min) than in patients with conduit made of the pericardium (median time, 11.5 min; interquartile range, 10.0-18.3 min), respectively (p=0.020). Conclusions: Conduit puncture is feasible and safe in patients with lateral tunnel and extracardiac Fontan circulation. Puncture of the Gore-tex conduit is more difficult and time consuming than punc- ture of the pericardium conduit.

Sharp Central Venous Recanalization in Hemodialysis Patients: A Single-Institution Experience

We report our institutional experience with sharp central venous recanalization in chronic hemodialysis patients who failed standard techniques. Since January 2014, a series of seven consecutive patients (four males and three females), mean age 35years (18-65years), underwent sharp central venous recanalization. Indications included obtaining hemodialysis access (n=6) and restoration of superior vena cava (SVC) patency to alleviate occlusion symptoms and restore fistula function (n=1). The transseptal needle was used for sharp recanalization in six patients, while it could not be introduced in one patient due to total occlusion of the inferior vena cava. Instead, transmediastinal SVC access using Chiba needle was obtained. Technical success was achieved in all cases. SVC recanalization achieved symptoms' relief and restored fistula function in the symptomatic patient. One patient underwent arteriovenous fistula creation on the recanalized side 3months after the procedure. The remaining catheters were functional at median follow-up time of 9months (1-14months). Two major complications occurred including a right hemothorax and a small hemopericardium, which were managed by covered stent placement across the perforated SVC. Sharp central venous recanalization using the transseptal needle is feasible technique in patients who failed standard recanalization procedures. The potential high risk of complications necessitates thorough awareness of anatomy and proper technical preparedness.

Transbaffle catheter ablation of atrial re-entrant tachycardia within the pulmonary venous atrium in adult patients with congenital heart disease.

Catheter ablation of atrial re-entrant tachycardia in patients after atrial switch procedure for transposition of the great arteries or with a Fontan circulation is technically challenging if the critical part of the re-entry circuit is located within the pulmonary venous atrium (PVA). We report our experience in transbaffle access (TBA) to the PVA for ablation of atrial re-entrant tachycardia focusing on technical details. In eight patients, six after Mustard procedure and two with a Fontan circulation, endocardial mapping of atrial re-entrant tachycardia revealed the critical part of the re-entry circuit within the PVA. A total of 10 ablation procedures were performed. Detailed angiographic assessment of the anatomy of the systemic and pulmonary venous atria was performed prior to baffle puncture. Transbaffle access was successfully established with a standard transseptal needle in 9 of 10 procedures. No major complications occurred. At the end of the procedure and the removal of the transseptal sheath, there was no residual shunt in any patient. Transbaffle access to the PVA for ablation of atrial re-entrant tachycardia is feasible, less invasive than alternative approaches and can be safely applied in patients after Mustard procedure or with a Fontan circulation. However, the rigidity of prosthetic material may preclude baffle puncture at least in a subset of those patients.

Acquired aortic atresia: Catheter therapy using covered stents

To maintain aortic continuity, aortic arch interruption is usually treated surgically. We present our experience of aortic arch reconstruction using percutaneous implantation of covered stents and mid-term follow-up. To describe the feasibility, safety, and effectiveness using percutaneous placement of covered stents for functional aortic atresia and mid-term follow-up. Nine patients (7 males), mean age of 30.8 ±16.2 years (range 13-58 years) and mean body weight of 65.7± 14.9 kg (range 52-95 kg), were investigated for systemic hypertension and found to have functional aortic interruption. All were treated with percutaneous perforation, combined with balloon dilation and implantation of covered stents. After stent implantation, control angiograms were performed. All the patients had functional aortic interruption and continuity was established by perforating the atretic segment with trans-septal Brockenbrough needle or the stiff end of a guide wire. A covered Cheatham-Platinum CP stent was used to establish the luminal continuity of the aortic arch. Angiograms after stent deployment showed good forward flow through the stent and hemodynamic assessment revealed minimal gradients across the stent. The mean invasive descending aortic systolic blood pressure before stenting was 86.6 ± 14.3 mm Hg, which increased to 116.5 ± 16.3 mm Hg, after stenting (P = 0.004). The mean invasive descending aortic diastolic blood pressure before stenting was 63.6 ± 8.1 mm Hg, which increased to 79.7 ± 13.3 mm Hg after stenting (P = 0.002). Percutaneous treatment of functional aortic atresia with covered stents is feasible, safe, and effective alternative to surgery with excellent short- and mid-term results.

Use of the Baylis radiofrequency trans-septal needle to create an atrial communication in hypoplastic left heart syndrome

Hypoplastic left heart syndrome with intact/highly restrictive atrial septum often requires emergent creation of an atrial communication to decompress the left atrium. Transcatheter trans-septal puncture in the setting of a thickened septum and a small left atrium can be a difficult and dangerous intervention. Trans-septal puncture using the Nykanen radiofrequency (RF) perforation wire in conjunction with a coaxial catheter and the Baylis RF generator has become the standard method in most centers. This approach can be challenging due to technical difficulties related to the RF wire and the flimsy coaxial catheter. We report two patients in whom we used a novel method of perforating the atrial septum using the RF Baylis trans-septal needle. The advantages of this technique are discussed.

A highly effective technique for transseptal endocardial left ventricular lead placement for delivery of cardiac resynchronization therapy.

Implantation of a left ventricular (LV) lead fails in 5% to 10% of patients in whom cardiac resynchronization therapy (CRT) is attempted. Alternatives for delivery of CRT are surgical epicardial and endocardial transvenous leads. Endocardial transseptal LV lead delivery is challenging because of the absence of dedicated equipment designed for this procedure. The purpose of this study was to describe a new technique for delivery of a transseptal LV lead. This dual approach from the right femoral vein and left subclavian vein involves use of an Endrys transseptal needle and Mullins sheath to deliver a gooseneck snare from the left subclavian vein into the right atrium that can then be used to deliver a deflectable sheath into the left atrium. An active fixation lead is advanced into the LV through the sheath and screwed into the lateral wall. The procedure was performed successfully in 12 patients in whom transvenous LV lead implantation had previously failed. The Endrys transseptal needle, ideally suited for this technique, facilitated passage of the gooseneck snare into the left atrium with no difficulty. Median procedure time was 148 minutes (interquartile range [IQR] 113-176 minutes), and median fluoroscopy time was 16 minutes (IQR 10-19 minutes). There was no need for repeat procedures after median follow-up of 97 days (IQR 36-313 days). This approach using an Endrys needle and a gooseneck snare provides a reliable and effective alternative technique for delivery of an endocardial LV lead that is delivered easily through a deflectable sheath inserted transseptally into the LV.

Abstract 12600: Microrna From Atrial Tissue Harvested During Transseptal Puncture as a Predictor for Non-pv Trigger in Patients Undergoing Af Ablation: Preliminary Results From a Pilot Study

Introduction: Catheter ablation of atrial fibrillation (AF) is the most valid therapeutic option to achieve rhythm control. Pulmonary veins (PV) are the most known trigger of AF, although recently we have become more aware of the importance of non-PV triggers. Expression of microRNA (miRNA) has been shown to be regulated in many cardiovascular disease. We sought to study expression patterns of miRNA in patients (pts) with AF undergoing ablation to facilitate their application as both diagnostic and prognostic markers. Methods: As part of the standard procedure for AF ablation a double transseptal sample of myocardial tissue is obtained via a transseptal needle. The small piece of atrial septal tissue can be retrieved from the needle as a result of piercing the atrial septum. MiRNA was hybridized to microarrays to determine relative levels of miRNAs in the samples. For a subset of the miRNAs we validated expression through quantitative real time PCR. All pts underwent PV-antrum and non-PV trigger ablation guided by isoproterenol challenge test. Results: Atrial tissue of 11 pts undergoing AF ablation has been utilized for MiRNA assessment. Mean age was 61.27 ± 10.5 years and 8 (72.7%) pts were male. Six (54.5 %) pts had paroxysmal AF. During the ablation non-PV triggers were detected in 8 (72.7 %) pts. Recurrence of AF occurred in 3(27.3 %) pts. Expression of miR-21, miR-26a and miR-29a was higher in pts with non-PV triggers, while miR-30c had lower expression in pts who had recurrence of atrial tachyarrhythmias. Spearman’s nonparametric correlation coefficient was calculated and miR-21, miR-26a, miR-29a were positively correlated with non-PV triggers (r = 0.58, p=0.06 for all three miRNAs), while miR-30c level had inverse correlation (r = (-) 0.78 %, p=0.005) with recurrence (Figure). Conclusions: Expression of miR-21, miR-26a, miR-29a correlates with the presence of non-PV triggers. This information could be clinically relevant in planning patient specific procedures.

Limiting left-sided catheter dwelling time using 3-D NavX to mark and reaccess the left atrium via prior transseptal puncture site.

Ablations requiring transseptal access to the left heart place patients at increased risk for stroke, bleeding, and post-procedural cognitive dysfunction and other complications. Diminishing left atrial catheter dwelling time may decrease these risks. 3-D NavX can be used to facilitate reaccess of transseptal puncture sites to allow catheter removal from the left atrium immediately after ablation, with reaccess through the prior transseptal site if required. Here, we describe the techniques employed and our experience using 3-D NavX to limit left atrial catheter dwelling time by marking and reaccess of the left atrium via the previously marked transseptal puncture site, a potentially radiation-free technique. With the use of 3-D NavX, a right atrial geometry is created. The patent foramen ovale is marked by using a standard EP catheter, or the transseptal puncture site is marked using 3-D NavX by creating a unipolar electrode on the transseptal needle at the time of puncture and at the time of catheter withdrawal of the ablation catheter from the left atrium. Marking the access site allows the catheter to be removed from the left side of the heart immediately after the ablation. If reaccess to the left atrium is required, the previously marked transseptal site is used to navigate the ablation catheter to reaccess the left atrium. All patients <30 years who had undergone this technique were evaluated. Data gathered included patient demographics, need for and success of transseptal reaccess, left atrial catheter dwelling time, and complications. The transseptal site was marked by 3-D NavX in 54 patients. We were able to successfully reaccess the transseptal puncture site using 3-D guidance in all 10 patients where it was desired. In these 54 patients, the complication rate was low with one small post-procedural pulmonary embolism and one right bundle branch block. No other complications were noted. The median procedure time was 105 min (range 58-446 min), the median total fluoroscopic time for the entire procedure was 1.3 min (range 0.0-30.8 min), and the median left-sided catheter dwelling time was 21 min (range 6-112 min). In our retrospective review, reaccess of transseptal puncture site was reproducible, and early removal of the catheter from the left side was without the need for repeat transseptal punctures. This technique decreases the time the catheter dwells in the left atrium, which could decrease risks such as clotting, bleeding, and cognitive dysfunction.

Transseptal Access for Left Atrial Ablation: The Catheter‐Probing Techniques Are Not Without Risk

Transseptal puncture (TP) is a prerequisite for LA ablations. LA access can be gained by catheter probing in case of PFO (trans-PFO method) or puncture of the interatrial septum (IAS) using a transseptal needle. A 2nd access can again be gained via PFO, a 2nd TP or catheter probing of the previous puncture site (probe-TS method). This study investigates the risk factors and complications related to the mode of transseptal access. From August 2010 to August 2012, a total of 544 LA ablations, were performed. The mode of LA access was either a double TP or a single TP followed by the probe-TS or the trans-PFO method, respectively. TP was always guided by TEE and was successfully performed without complications in all cases. In contrast, 6/410 patients (1.5%) in whom catheter probing was performed (probe-TS, n = 4, trans-PFO, n = 2) had a dissection of the superior IAS originating from inside the oval fossa (n = 5) or perforation above the oval fossa (n = 1). Perforation into the pericardial space occurred in 4/6 patients, leading to one cardiac tamponade. In 5/6 patients, LA ablation was successfully completed, after repeated TP, despite effective anticoagulation. Patients with complications had the following characteristics: LA size 46 ± 4 mm, persistent AF (5/6), a repeat transseptal procedure (3/6) and a right-sided pouch (RSP, 5/6). Interatrial septum dissection/perforation, occasionally with perforation into the pericardial space, is an unreported complication of TP, especially with the catheter-probing techniques. An RSP is an unrecognized risk factor in this context and can be visualized by TEE.

Development of a Technique for Left Ventricular Endocardial Pacing via Puncture of the Interventricular Septum

Left ventricular (LV) pacing through the coronary sinus is the standard approach for cardiac resynchronization therapy. When this route is unavailable, the alternatives have major limitations. LV endocardial pacing through the interventriuclar septum may offer a simpler solution. We describe an initial case series to demonstrate technical feasibility and to describe our refinement of the puncture technique. Ten patients with previous failed coronary sinus lead implant or with nonresponse to cardiac resynchronization therapy and a suboptimal LV lead position were selected. All patients were anticoagulated. Left ventriculography and coronary angiography were performed to identify LV borders and septal vessels. Subclavian vein access was used for a superior approach ventricular transseptal puncture under fluoroscopic guidance, using a steerable sheath and a standard transseptal needle, radiofrequency needle, or radiofrequency energy delivered through a guidewire. An active-fixation pacing lead was successfully delivered to the endocardial wall of the lateral LV in all patients (9 men; age, 62±10 years). LV lead implant procedure time shortened with experience. The use of radiofrequency energy delivered through a guidewire was the most effective technique. Mean threshold and R wave at implant were 0.8±0.3 V and 10.8±3.9 mV. At follow-up (mean, 8.7 months; minimum, 0; and maximum 19), thresholds were stable, and there were no thromboembolic events. Of 9 patients, 8 were classed as clinical responders (1 had inadequate follow-up to assess response). LV endocardial pacing through a ventricular septal puncture is a feasible approach for cardiac resynchronization therapy.

Randomized Trial of Conventional Transseptal Needle Versus Radiofrequency Energy Needle Puncture for Left Atrial Access (the TRAVERSE‐LA Study)

BackgroundTransseptal puncture is a critical step in achieving left atrial (LA) access for a variety of cardiac procedures. Although the mechanical Brockenbrough needle has historically been used for this procedure, a needle employing radiofrequency (RF) energy has more recently been approved for clinical use. We sought to investigate the comparative effectiveness of an RF versus conventional needle for transseptal LA access.Methods and ResultsIn this prospective, single‐blinded, controlled trial, 72 patients were randomized in a 1:1 fashion to an RF versus conventional (BRK‐1) transseptal needle. In an intention‐to‐treat analysis, the primary outcome was time required for transseptal LA access. Secondary outcomes included failure of the assigned needle, visible plastic dilator shavings from needle introduction, and any procedural complication. The median transseptal puncture time was 68% shorter using the RF needle compared with the conventional needle (2.3 minutes [interquartile range {IQR}, 1.7 to 3.8 minutes] versus 7.3 minutes [IQR, 2.7 to 14.1 minutes], P=0.005). Failure to achieve transseptal LA access with the assigned needle was less common using the RF versus conventional needle (0/36 [0%] versus 10/36 [27.8%], P<0.001). Plastic shavings were grossly visible after needle advancement through the dilator and sheath in 0 (0%) RF needle cases and 12 (33.3%) conventional needle cases (P<0.001). There were no differences in procedural complications (1/36 [2.8%] versus 1/36 [2.8%]).ConclusionsUse of an RF needle resulted in shorter time to transseptal LA access, less failure in achieving transseptal LA access, and fewer visible plastic shavings.Clinical Trial RegistrationURL: http://www.clinicaltrials.gov. Unique identifier: NCT01209260.

Pulmonary Artery Perforation by Plug Anchoring System After Percutaneous Closure of Left Appendage

Patients receiving oral anticoagulant therapy for atrial fibrillation who are at high risk of bleeding are increasingly referred for percutaneous left atrial appendage exclusion. Although effective, this procedure is not free from risk. We report a case of pericardial tamponade due to pulmonary artery tear caused by a trespassing anchoring hook of an AGA plug. Intraoperatively, no actual bleeding was found from the left appendage, a proof of its complete occlusion by the device. The patient underwent successful surgical repair and radio-frequency ablation of atrial fibrillation was performed by pulmonary veins encircling.

Relevant Ventricular Septal Defect Caused by Steam Pop During Ablation of Premature Ventricular Contraction

A 62-year-old female patient with highly symptomatic, idiopathic, monomorphic, premature ventricular contraction presented at our institution for further treatment (Figure 1A). Previous medical antiarrhythmic treatment has failed. She had a history of mitral valve repair attributable to rheumatic heart disease 2 years before and paroxysmal atrial fibrillation. Aside from that, transthoracic echocardiogram revealed no structural heart disease. Indication was set for catheter ablation. After transseptal puncture (BRK-0 transseptal needle, St. Jude Medical, St. Paul, MN) a left ventricular electroanatomic activation map of the premature ventricular contraction was done using the CARTO-3 RMT system (Biosense-Webster, Diamond Bar, CA). The site of earliest activation was found in an inferoseptal apical position (Figure 1B and 1C). During radiofrequency ablation at this site with a 3.5-F external irrigated tip …

Antegrade In Situ Stent-Graft Fenestration for the Renal Artery Following Inadvertent Coverage During EVAR

To report the use of antegrade in situ fenestration as a bailout technique to rescue a renal artery after inadvertent coverage during endovascular aneurysm repair (EVAR). The technique is demonstrated in a patient with a 6-cm infrarenal abdominal aortic aneurysm (AAA) and a short, angulated proximal neck. A type I endoleak persisted on completion angiography after implantation of a bifurcated Zenith stent-graft despite dilation with a compliant balloon. A Giant Palmaz stent mounted on a large compliant balloon successfully resolved the endoleak. After placing the stent, the left renal artery was covered completely by the main aortic graft material, leading to only marginal opacification on angiography. To preserve flow to the renal artery, a transseptal sheath and transseptal needle were introduced from the right femoral artery and used to puncture the abdominal stent-graft antegrade at the site of the left renal artery. A 0.018-inch guidewire could then be introduced into the left renal artery; following a number of maneuvers, a balloon-expandable stent was placed through the fenestration into the target vessel. On computed tomographic angiography 4 days postoperatively, the AAA remained excluded and both renal arteries were patent, with all side branches fully preserved. Renal function was completely restored. Antegrade in situ fenestration can facilitate immediate revascularization of inadvertently covered side branches in EVAR using a transseptal sheath and needle. If the anatomical features are supportive, antegrade in situ fenestration can be a useful bailout technique.

Subintimal Recanalization of Peripheral Chronic Occlusive Arterial Disease with Modified Transseptal Needle

PurposeTo report an alternative technique of subintimal recanalization of chronically occluded lower-extremity arteries using a modified transseptal needle (MTSN) to reenter the true lumen. Materials and MethodsFrom December 2008 to December 2010, 98 patients with chronic arterial occlusions were treated with endovascular techniques. True lumen reentry with conventional subintimal techniques failed in 23 of these patients (24%). Retrospective review of medical records and procedure data was performed, and clinical presentation, lesion location, Trans-Atlantic Inter-Society Consensus II classification, amount of calcification, procedure time, recanalization time with conventional subintimal technique, recanalization time with the MTSN, and complications were recorded. During the 24-month period, 11 common iliac arteries (CIAs), three external iliac arteries (EIAs), one combined CIA/EIA, six superficial femoral arteries (SFAs), and two combined SFA/popliteal arteries were treated with MTSNs. ResultsSuccessful recanalization with the MTSN was obtained in 21 patients (91%). There was one complication of pseudoaneurysm formation in the EIA. The average occlusion length of the CIA was 6.7 cm; that of the SFA was 15.9 cm. The average procedure time was 73 minutes, with 20 minutes used to attempt to reenter the true lumen and 6.3 minutes used to reenter the true lumen with the MTSN. ConclusionsThe MTSN technique is safe and effective and offers another approach to reenter the true lumen of chronic total arterial occlusions during subintimal recanalization in difficult cases.

Incidence of Tissue Coring During Transseptal Catheterization When Using Electrocautery and a Standard Transseptal Needle

The application of radiofrequency electrocautery to a standard, open-ended transseptal needle has been used to facilitate transseptal puncture (TSP). The purpose of this study was to determine the incidence of cardiac tissue coring when this technique is used. A model using excised swine hearts submerged in a saline-filled basin was developed to simulate TSP with electrocautery and a standard transseptal needle. Punctures were performed without the use of electrocautery and by delivering radiofrequency energy to the transseptal needle using a standard electrocautery pen at 3 target sites (fossa ovalis, non-fossa ovalis septum, and aorta). The tissue of the submerged heart was gently tented, and the needle was advanced on delivery of radiofrequency. The devices were retracted, and the needle was flushed in a collection basin. None of the TSPs without cautery caused tissue coring. For TSPs using electrocautery, the frequency of coring was at least 21% for any puncture permutation used in the study and averaged 37% at septal sites (P<0.001 compared with punctures without cautery). Tissue coring occurred in 33 of 96 (35%) punctures through the fossa ovalis and in 38 of 96 (40%) punctures through non-fossa ovalis septum. The frequency of tissue coring at aortic sites was 62 of 96 (65%), which was significantly higher than at the septal sites (P<0.001). In an animal preparation, TSP at the level of the fossa ovalis using electrocautery and a standard open-ended Brockenbrough needle resulted in coring of the septal tissue in 35% of cases (33 of 96 punctures).

Abstract 17060: Incidence of Tissue Coring during Transseptal Catheterization When Using Electrocautery and a Standard Transseptal Needle

Introduction. The application of radiofrequency (RF) electrocautery to a standard, open-ended transseptal needle has been used to facilitate transseptal puncture (TSP). The purpose of this study was to determine the incidence of cardiac tissue coring when this technique is used. Methods. A model using excised swine hearts submerged in a saline-filled basin was developed to simulate TSP with electrocautery and a standard transseptal needle. Four types of adult Brockenbrough needles and two different size swine hearts were used. Punctures were performed without the use of electrocautery, and by delivering RF energy to the transseptal needle using a standard Bovie electrocautery pen and an RF generator set to 10W and 15W, in both “pure” and “blend” cut settings, at three target sites (Fossa Ovalis [FO], non-Fossa Ovalis septum [Non-FO], and Aortic [AO]). The tissue of the submerged heart was gently tented, and the needle was advanced on delivery of RF. The devices were retracted, and the needle was flushed in a collection basin. The basin was inspected for tissue. Results. See Figure. None of the TSPs without cautery caused tissue coring. For TSP's using electrocautery, the frequency of coring was at least 21% for any puncture permutation used in the study, and averaged 37% at septal sites (p &lt; 0.05 compared to punctures without cautery). Tissue coring occurred in 33/96 (35%) punctures through the FO, and 38/96 (40%) punctures through non-FO septum (Figure 3a). The frequency of tissue coring at aortic sites was 62/96 (65%), which was significantly higher than at the septal sites (p&lt;0.001). Conclusions. In an animal preparation, TSP at the level of the fossa ovalis using electrocautery and a standard open-ended Brockenbrough needle resulted in coring of the septal tissue in one third of cases. These results raise concern about the risk of systemic embolism of cardiac tissue when this technique is used in humans.