Ultrasound-guided Access Research Articles

Procedural and clinical outcomes according to ultrasound-guided access in TAVI: a propensity-matched comparative sub-analysis from the PULSE registry

Abstract Background Access-related vascular and bleeding complications during transcatheter aortic valve implantation (TAVI) are associated with significant morbidity and mortality. Ultrasound-guided (USG) puncture may reduce the incidence of these events, particularly in large-bore arterial access. However, large-scale data on this approach are limited and it has not yet fully been implemented into standard clinical practice during TAVI. Purpose We compared access-related vascular and bleeding complications in USG versus fluoroscopy-guided (FG) access from a large multicenter TAVI registry. Methods The PULSE registry (Plug or sUture based vascuLar cloSurE after TAVI) retrospectively evaluated data of 9,295 patients who underwent transfemoral TAVI at 10 high-volume German heart centers from 2016 to 2021. USG and FG access were performed in 1,992 (21.4%) and 7,303 (78.6%) patients, respectively. A propensity score was used to match 1,023 FG with 1,023 USG access patients in a 1:1 fashion. The primary endpoint was a composite of minor and major vascular complications at the TAVI-access site or bleeding type II-IV. Outcomes were evaluated in accordance with the Valve Academic Research Consortium (VARC-3) definitions. Results Mean age was 81.9±6.25 years and 48.0% of patients were female. Comorbidities and clinical variables were well-balanced in matched groups. The overall risk profile was comparable in USG vs. FG (mean EuroSCORE II: 3.4 [2.1, 6.4] vs. 3.6 [2.2, 5.7], p=0.54). The primary end point occurred in 12.0% in the USG and 17.7% in the FG group, p<0.001. While major large bore access-related vascular complications did not differ significantly (3.5% vs. 4.2%, p=0.49), there was a trend towards lower minor complications for USG compared to FG (5.9% vs. 7.8%, p=0.096). Large bore access-related bleeding occurred in 5.5% versus 7.8% (p=0.04) of patients. Endovascular balloon inflation was required in 0.6% and 3.3% (p<0.001) of all large-bore access vascular complications. Stroke (1.7% vs. 1.5%, p=0.86) and stage III/IV acute kidney injury (3.0% vs. 2.2%, p=0.42) were similar in both groups. Conclusion In patients treated with transfemoral TAVI, ultrasound-guidance for gaining access was associated with lower rates of access-related vascular complications or type II-IV bleeding. Endovascular treatment was required more frequently in case of a fluoroscopy-guided approach. These findings challenge the fact that most TAVI procedures were performed with fluoroscopy-guidance.

Development of a Cost-Effective and High-Fidelity Gel Model for Peripheral Ultrasound-Guided Intravenous Access Training.

Introduction Simulation tools are crucial in medical educationbut current commercial models for ultrasound-guided intravenous (IV) access lack complexity and can be prohibitively expensive. This article proposes a cost-effective gel model system that replicates realistic vein and artery interactions, addressing the limitations of traditional models. An advanced gelatin model was constructed that incorporates intricate vein and artery configurations and enhances medical training by providing a more authentic experience. Patient testing will further validate its efficacy, promising improved accessibility for skill refinement in resource-constrained environments. Methods In a controlled study at theKirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, 12 medical students with limited ultrasound experience participated in a workshop using novel and Blue Phantom™ models for ultrasound-guided IV catheter placement. The advanced gelatin model, created with Ziplock™ Tupperware®, ultrasonography gel-filled balloons, and gelatin, proved more effective, as assessed by participants' post-training comfort levels. The comparison of participants' pre- and post-training comfort levels with the models was the primary study objective. Participants were asked to complete a confidence survey based on a five-point Likert scale, and after using both models, this survey was re-administered to assess the participant's level of comfort after model use. The statistical analysis comparison of post-training survey data to the pre-training survey data was accomplished using SPSS version 29 (IBM Corp, Armonk, NY), where a paired t-test was set at a significance threshold of p <0.05. Results Analysis of data from both commercially made and advanced ultrasound-guided IV models using a paired t-test revealed a significant advantage for the advanced model. Participants, despite limited ultrasound experience, reported feeling over 4 points higher in skill confidence (p = 0.004) with the advanced model. Its popularity stems from diverse vasculature modeling, proving effective for both experienced practitioners and inexperienced individuals, maintaining value as user skill levels increase. Conclusion This study proposes an advanced model for ultrasound-guided peripheral IV access training, demonstrating a statistically significant increase in confidence levels. Despite limitations such as small sample size and single-site participation, the advanced model's adaptability and cost-effectiveness make it a strong contender for replacing current commercial models, potentially enhancing proficiency and confidence while reducing costs.

Feasibility of ultrasound-guided axillary vein access for implantation of cardiac implantable electronic device leads

BackgroundThe axillary vein is preferred over the subclavian vein, and the cephalic vein for cardiac implantable electronic device (CIED) lead insertion. However, studies on ultrasound-guided axillary vein access (US-AVA) in Asia are scarce. This study aims to evaluate the feasibility of US-AVA for CIED lead implantation in Korean patients.MethodsFrom September 2021 to September 2023, we employed US-AVA for CIED lead implantation procedures. Patients’ demographic and procedural data were collected and analyzed retrospectively.ResultsUS-AVA was successful in 301 patients (97.7%). There were no occurrences of pneumothorax or severe hematoma due to inadvertent arterial puncture, nor were there any other significant vascular access-related acute complications. During the median 1.7 years of follow-up, no CIED infection or lead-related problems have occurred. Compared to a historical cohort of patients who underwent fluoroscopy-guided axillary vein access (FL-AVA), US-AVA significantly reduced procedure and fluoroscopy time and showed a trend toward reduced radiation doses.ConclusionUS-AVA is a safe and effective technique for CIED lead implantation in Korean patients, with advantages over FL-AVA in terms of procedural efficiency and patient safety.

Collagen-Based Vascular Closure Device Multicenter Italian Experience in Endovascular Aortic Aneurysm Repair Compared With Suture-Mediated Closure Vascular Device.

The Manta Vascular Closure Device is a novel collagen-based vascular closure device that has been designed specifically for closure of large-bore percutaneous arterial accesses. The aim of this retrospective study is to evaluate the immediate and 30-day outcome of Manta at the completion of endovascular aneurysm repair (EVAR) or thoracic endovascular aortic repair (TEVAR). The hypothesis is that Manta is not inferior in obtaining hemostasis compared with the Perclose ProGlide Suture-Mediated Closure System device. We recruited all the percutaneous accesses for (T)EVAR performed from January 2021 to April 2023 by all the Italian Divisions of Vascular Surgery using Manta at the time of data collection (May 2023). The primary outcome is to evaluate the incidence of complications at the puncture site after Manta implantation and at 1 month, and compare this with ProGlide. We applied the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria for observational studies. Overall, 524 consecutive femoral accesses for (T)EVAR procedures were collected: 355 in the Manta cohort and 169 in the ProGlide cohort, respectively. The size of the sheath was 17.2±2.7 Fr for Manta, 15.7±2.3 Fr for ProGlide (p<0.001). No statistically significant differences between the groups regarding age, sex, body mass index, ultrasound-guided access, femoral calcifications, intraoperative, and 30-day complications. Successful arterial closure at groin puncture sites for (T)EVAR using Manta is 90.5% and 93.1% using ProGlide. Freedom for any reintervention for any complication is 95.5% for Manta and 96% for ProGlide. The 2 vascular closure devices have proved to be similar in terms of complications, without any statistically significant difference, although the median size of the sheaths for (T)EVAR was statistically significantly larger when Manta has been used, compared with ProGlide. Manta® is effective in the hemostasis of the access sites following the completion of (T)EVAR in this multicenter, retrospective, case-control study on 524 percutaneous femoral accesses. Compared to the more popular Proglide®, the average size of the introducers in the Manta® group was significantly larger than in the Proglide® group.

WP8.10 - Ultrasound Cannulation Training Programme: Quality Improvement Project

Abstract Aim Familiarisation with ultrasound skills can be very useful. This reduces stress for patients from multiple access attempts and preserves venous access. In our District General Hospital (DGH), no teaching on ultrasound-guided venous access was available. Our aim was to create a formal training programme on ultrasound-guided venous access for junior doctors. Methods Discussions were held with the medical education team at our DGH to understand how to organise a formal teaching programme. The interest of junior doctors was gathered through informal discussion. Those interested were then asked to complete course evaluation forms. Data was gathered on experience using ultrasound, confidence (out of 5) in performing ultrasound cannulation, and usefulness of the session (out of 5). Results Of the 49 participants, only 65% (n=32) filled in the course forms. Data was only analysed from these individuals. 47% (n=15) had previous experience using an ultrasound machine. Of the 32 participants analysed, 87.5% (n=28) felt the session was very useful and the other 12.5% (n=4) found the session to be useful. 100% (n=32) felt more confident performing ultrasound-guided access after the session. The average confidence score pre vs post-session was 1.59/5 vs 3.88/5, respectively. Conclusions This programme can improve confidence in procedural skills amongst junior doctors, whilst also minimising stress for patients of multiple access attempts. Though the sample obtained was small, it is clear to see increased confidence in participants, regardless of prior experience. The results obtained will be critical in continuing this programme in our hospital and hopefully roll out to a wider audience.

The performance and complications of long peripheral venous catheters: A retrospective single-centre study.

Intravenous therapies are essential for hospitalised patients. The rapid dissemination of portable ultrasound machines has eased ultrasound-guided intravenous access and facilitated increased use of long peripheral venous catheters (LPCs). This study aimed to evaluate the clinical performance and complications of LPCs. Retrospective, observational single-site study. Data from all consecutively inserted LPCs during a period of 18 months was evaluated. The primary endpoint was the all-cause incidence rate of catheter removal. Secondary endpoints included specific reasons for the catheter removal and the associations between predefined characteristics of the patients, the infusions and the catheters with catheter failure. During the period, 751 PVCs were inserted in 457 patients. The reasons for catheter removal were recorded in 563 cases. The overall incidence rate of catheter removal was 95.8/1000 catheter days (95% CI 88.4-103.8). The median dwell time was 8 days (IQR 5-14), and the total dwell time was 6136 days. Catheter failure occurred in 283 (50.3%) cases, of which the most common cause was phlebitis (n = 101, 17.9%). In multivariable analyses, the use of the cephalic vein was significantly associated with both all-cause catheter failure (p < .001) and catheter failure due to phlebitis (p < .001). In multivariable analyses, vancomycin infusion was not significantly associated with all-cause catheter failure (HR 1.15 (0.55-2.42), p = .71) or catheter failure due to phlebitis (HR 1.49 (0.49-4.53), p = .49). The overall incidence rate of catheter removal was 95.8/1000 catheter days, and the most common causes of catheter failure were phlebitis, infiltration and unintended catheter removal. The use of the cephalic vein was significantly associated with catheter failure in multivariable analyses. We did not find an association between vancomycin infusion and catheter failure in multivariable analyses.

Ultrasound Guided Internal Jugular Vein Acesss: Comparison Between Short Axis And Long Axis Technique

Abstract Background: Percutaneous techniques have transformed vascular cannulation. It has reduced the need for open procedures and the associatedwoundcomplications, but percutaneous techniques have made physicians dependent on relationships between surface anatomic landmarks and deep anatomic structures. Now, percutaneous central venous catheter insertion by physicians has a lesser complication rate. During central venous catheterization, the complications include infection, occlusion, thrombosis and mechanical complications. Aims and Objective: To relate the inner course of cannulating needle, familiarity of surface anatomic landmarks excludes the complication. Deep anatomic relationships visualization does not only improves the efficacy and safety of the procedure but also supplements the operator’s ability to identify difficult cannulations. The safety of internal jugular cannulations increases with ultrasound visualization. Central venous cathetrization (CVC) is done for hemodynamic monitoring (such as central venous pressure) long-term administration of fluids, antibiotics, total parental nutrition, and hemodialysis. Material and Methods: Most commonly, the internal jugular vein (IJV) is cannulated because of its relatively less complications and easy accessibility. Seldinger technique is used for IJV cannulation. Landmark-guided IJV cannulation is associated with a more number of complications compared to ultrasound-guided cannulation. Ultrasound-guided cannulation improves success rate, reduces the number of needle passes, and decreases complications. Two different real-time ultrasound-guided cannulations of IJV using a short axis/out-of-plane (SA) approach and a long axis/in plane (LA) approach are compared in the study. Hence, the present study was done at our tertiary care center to compare ultrasound-guided IJV access between SA and LA technique method with the number of attempts and complications. Results: It was observed in the present study that 4 (10%) patients in Long axis group had posterior wall puncture while 9 (22.5%) patients in short axis group had posterior wall puncture. Conclusion: Posterior wall puncture incidence is lesser in long axis group than short axis group.

Adverse Events in Open Surgical vs. Ultrasound-Guided Percutaneous Brachial Access for Endovascular Interventions.

Background: Advances in endovascular interventions have made endovascular approaches the first option for treating peripheral arterial diseases. Although radial artery access is commonly used for coronary procedures, the common femoral artery remains the most frequent site for endovascular treatments due to better ergonomics and proven technical success. Meanwhile, data on using upper extremity access via the brachial artery during complex endovascular aortic interventions are lacking. This study aimed to compare the incidence of access site complications between ultrasound-guided percutaneous brachial access (UPA) and open surgical incisional brachial access (OSA) in the management of peripheral arterial diseases. Methods: Patients who underwent treatment for peripheral arterial and aortic disease using brachial access from 2019 to 2023 were included in this study. The primary endpoint was the complication rate at the access site 30 days postoperatively. Access-related complications included bleeding requiring re-exploration, acute upper limb ischemia, thrombosis, pseudoaneurysm, arteriovenous fistula, and nerve injury associated with the brachial access. Results: Brachial access was performed on 485 patients (UPA, n = 320; OSA, n = 165). The mean operation time was 164.5 ± 45.4 min for the percutaneous procedure and 289.2 ± 79.4 min for the cutdown procedure (p = 0.003). Postprocedural hematoma occurred in 15 patients in the UPA group and 2 patients in the OSA group (p = 0.004). Thromboembolic events were observed in 9 patients in the percutaneous group and 3 patients in the OSA group. Reoperation was required for 23 patients in the percutaneous group and 8 patients in the cutdown group. Conclusions: The findings indicate that patients undergoing endovascular arterial interventions have a higher rate of brachial access complications in the UPA group compared to the OSA group.

Ultrasound-guided vs. Standard Coronary Access in Coronary Angiography: A Systematic Review and Meta-analysis.

Coronary angiography is a procedure performed during cardiac catheterization to define the coronary anatomy and determine the extent of coronary artery disease (CAD). The use of a cheap, relatively available tool like an ultrasound machine to assist in vascular access might reduce the risks associated with blind access. This study aimed to explore the efficacy and associated complications of ultrasound-guided coronary artery catheterization. This systematic review of randomized controlled trials (RCTs) was conducted according to the Preferred Reporting Item for Systematic Reviews and Meta-Analysis (PRISMA) and was registered in PROSPERO (CRD42022365518). A systematic search was performed for all published studies without language or country restrictions and all study variables were extracted into prefilled sheets by two independent reviewers. This meta-analysis identified 10 RCTs. The results confirmed statistically significantly reductions of total complications (RR = 0.53, 95% CI 0.39-0.72, P < .001), and hematoma >5 cm formation (RR = 0.43, 95% CI 0.25-0.75, P = 0.003) in patients who underwent ultrasound-guided coronary artery catheterization. Ultrasound with catheterization, as opposed to landmark-based catheterization, significantly improved the peri-catheterization operative outcomes, providing evidence for further research to be conducted and consideration for its implementation within the medical setting.

Ultrasound-guided versus fluoroscopy-guided large-bore femoral access in PCI of complex coronary lesions: the international, multicentre, randomised ULTRACOLOR Trial.

Transfemoral access is often used when large-bore guide catheters are required for percutaneous coronary intervention (PCI) of complex coronary lesions, especially when large-bore transradial access is contraindicated. Whether the risk of access site complications for these procedures may be reduced by ultrasound-guided puncture is unclear. We aimed to show the superiority of ultrasound-guided femoral puncture compared to fluoroscopy-guided access in large-bore complex PCI with regard to access site-related Bleeding Academic Research Consortium 2, 3 or 5 bleeding and/or vascular complications requiring intervention during hospitalisation. The ULTRACOLOR Trial is an international, multicentre, randomised controlled trial investigating whether ultrasound-guided large-bore femoral access reduces clinically relevant access site complications compared to fluoroscopy-guided large-bore femoral access in PCI of complex coronary lesions. A total of 544 patients undergoing complex PCI mandating large-bore (≥7 Fr) transfemoral access were randomised at 10 European centres (median age 71; 76% male). Of these patients, 68% required PCI of a chronic total occlusion. The primary endpoint was met in 18.9% of PCI with fluoroscopy-guided access and 15.7% of PCI with ultrasound-guided access (p=0.32). First-pass puncture success was 92% for ultrasound-guided access versus 85% for fluoroscopy-guided access (p=0.02). The median time in the catheterisation laboratory was 102 minutes versus 105 minutes (p=0.43), and the major adverse cardiovascular event rate at 1 month was 4.1% for fluoroscopy-guided access and 2.6% for ultrasound-guided access (p=0.32). As compared to fluoroscopy-guided access, the routine use of ultrasound-guided access for large-bore transfemoral complex PCI did not significantly reduce clinically relevant bleeding or vascular access site complications. A significantly higher first-pass puncture success rate was demonstrated for ultrasound-guided access. gov identifier: NCT04837404.

Ultrasound-Guided Transfemoral Access for Coronary Procedures: A Pooled Learning Curve Analysis From the FAUST and UNIVERSAL Trials.

The learning curve for new operators performing ultrasound-guided transfemoral access (TFA) remains uncertain. We performed a pooled analysis of the FAUST (Femoral Arterial Access With Ultrasound Trial) and UNIVERSAL (Routine Ultrasound Guidance for Vascular Access for Cardiac Procedures) trials, both multicenter randomized controlled trials of 1:1 ultrasound-guided versus non-ultrasound-guided TFA for coronary procedures. Outcomes included the composite of major bleeding or vascular complications and successful common femoral artery cannulation. Participants were stratified by the operators' accrued case volume. We used adjusted repeated-measurement logistic regression, with random intercepts for operator clustering, for comparison against the non-ultrasound-guided TFA group and to model the learning curve. The FAUST and UNIVERSAL trials randomized a total of 1624 patients, of which 810 were randomized to non-ultrasound-guided TFA and 814 to ultrasound-guided TFA (cases 1-10, 391; 11-20, 183; and >20, 240). Participants who had operators who performed >20 ultrasound-guided TFAs had a decreased risk for the primary end point (5/240 [2.1%] versus 64/810 [7.9%]; adjusted odds ratio, 0.26 [95% CI, 0.09-0.61]) compared with non-ultrasound-guided TFA. Operators who performed >20 ultrasound-guided procedures had increased odds of successfully cannulating the common femoral artery (224/246 [91.1%] versus 327/382 [85.6%]; adjusted odds ratio, 1.76 [95% CI, 1.08-2.89]) compared with non-ultrasound-guided TFA. The learning curve plots demonstrated growing competence with increasing accrued cases. New operators should perform at least 20 ultrasound-guided TFA to decrease access site complications and increase proper cannulation compared with non-ultrasound-guided TFA. Additional accrued cases may lead to increased proficiency. Training programs should consider these findings in the transradial era.

Ultrasound guided arterial access for combat medics: A blinded proof-of-concept study using echogenic needles.

Obtaining percutaneous vascular access in hemodynamically unstable patients with constricted vessels can be challenging. Training combat medics in this procedure is necessary for administration of fluid and blood products and introducing endovascular bleeding control tools in pre-hospital settings. Echogenic coated needles might provide better ultrasound visibility in invasive procedures and hereby lower complications. The primary aim was to evaluate the efficacy of a microteaching program for obtaining ultrasound-guided femoral artery access for ultrasound inexperienced combat medics. The secondary aim was to assess the additional value of innovative echogenic coated needles in ultrasound-guided vascular access. Combat medics participated in a four-step microteaching program. The program consisted of a theoretical and step-by-step practical part with three different models including live and dead tissue & a REBOA Access Task Trainer. During the final test, all participants had to obtain femoral artery access on a pressurized post-mortem human specimen model with both echogenic coated and conventional needles. Self-perceived and observed performance as well as procedure times were scored. All nine participants succeeded in blood vessel visualization and obtaining vascular access in the two models within 3 minutes and were significantly faster during the second attempt on the pressurized post-mortem human specimen model. Scoring comparison and usability preference by ultrasound inexperienced personnel showed a significant difference in favor of the echogenic coated needles. Microteaching may be an effective approach to train combat medics in obtaining ultrasound-guided percutaneous femoral artery access. The use of echogenic coatings on needles could be a valuable adjunct and provide advantage in obtaining vascular access. Future research should focus on realistic simulation of austere situations and further evaluation of the use of echogenic coated instruments for vascular access in these pre-hospital settings.

Improving healthcare professionals' ultrasound-guided peripheral vascular access ability utilizing self-assembled ultrasound phantoms: A prospective, observational quality improvement project.

Ultrasound guidance can reduce the number of attempts to gain peripheral IV access while improving the success rate and satisfaction in patients with difficult IV access. Education and simulation are effective tools for improving the skills and knowledge related to ultrasound-guided peripheral IV access. Ultrasound phantom models allow for skill development without the risk of patient harm. Twenty-nine registered nurses and nurse practitioners were recruited for education and simulation regarding ultrasound-guided peripheral IV (USGPIV) placement. Participants completed a survey evaluating the efficacy of the phantom models in addition to pre- and post-intervention confidence, perceived competence, knowledge surveys, and a Directly Observed Procedural Skills Evaluation (DOPSE). The intervention included an educational PowerPoint and open practice session using the phantom models. Statistically significant improvements were found in participants' confidence (p < 0.001; 95% CI: 5.287, 9.499; d = 1.31), perceived competence (p < 0.001; 95% CI: 1.231, 2.742; d = 1.20), knowledge (p < 0.001; 95% CI: 1.079, 2.163; d = 1.47), and skills (p < 0.001; 95% CI: 2.499; 5.501; d = 1.29). Participants improved in maintaining needle visualization (p < 0.001; 95% CI: 0.272, 0.9; d = 0.79) and decreasing their cannulation attempts (0.045; 95% CI: 0.013, 1.022; d = 0.48). Participants with no and novice experience saw statistically significant improvement across all categories (p < 0.02) compared to those with intermediate, advanced, or expert experience with ultrasound. 96.5% of participants could perform ultrasound-guided peripheral IV cannulation independently or with indirect supervision following the intervention. At $36.52 per model, the self-assembled ultrasound phantom models provided a cost-effective and sustainable solution to teaching ultrasound-guided peripheral IV cannulations. Education and simulation for ultrasound-guided peripheral vascular access may benefit individuals with no or novice ultrasound experience.

Feasibility and outcomes of ultrasound-guided transcutaneous access to the axillary vein for implantation, revision, and upgrade of cardiac electronic devices

Abstract Background Implanting leads for cardiac implantable electronic devices (CIED) requires venous access. Venous access is commonly established through the cephalic and subclavian vein. For CIED upgrades or revisions, the preferred cephalic vein access is often not viable. Several reports suggest that fluoroscopy-guided axillary vein puncture may reduce thoracic complications. Purpose This study reports on procedural outcomes of ultrasound-guided axillary vein access for CIED implantation, revision, or upgrade in a large tertiary care centre. Outcomes were compared to the traditional subclavian vein approach. Methods This retrospective, single-center non-randomized study, conducted from January 2021 to August 2023, analyzed patients undergoing CIED implantation, revision, or upgrade. Axillary access, initially introduced by one operator, was increasingly adapted by additional operators. The axillary access was obtained by ultrasound-guided visualization of the axillary vein at the deltopectoral groove (Figure 1A and B). Subsequently, the wire(s) were transcutaneously inserted. An adjacent skin incision allowed for threading the wire(s) followed by standard lead implantation (Figure 1C). The study evaluated the acute success of each venous access method and the incidence of adverse events. Those were defined as pneumothorax, hemothorax, and pocket hematoma. An intention-to-treat analysis was performed. A p-value assessed the comparative outcomes between the axillary and subclavian access methods. Results In this study, 986 patients (mean age 74, IQR 64-82 years, 35% women) underwent CIED implantation, revision, or upgrade with 1636 lead implants. Axillary access was used in 578 patients with 532 (92%) successful implantations. Subclavian access yielded a higher success rate with 394/408 patients (97%) (p=0.003). For device upgrades or revisions specifically, axillary access was successful in 68/79 patients (86%), versus 44/47 patients (94%) with subclavian access (p=0.193). Acute complications were less frequent with axillary access (0.3%, 2/578 patients) and consisting of two cases of pneumothorax requiring intervention. In CIED implantations via subclavian access, complications occurred in 17/408 patients (4.2%) (p&amp;lt;0.001) including pneumothorax in 12 patients (2.9%, with 2% requiring intervention), hemothorax in three patients (0.7%), and pocket hematoma in two patients (0.5%). No additional complications were observed in the axillary group. Conclusion The implementation of transcutaneous, ultrasound-guided axillary access for CIED implantations, revisions and upgrades in a major CIED training centre is feasible. Complication rates were low compared to subclavian venous access.Figure 1

Endoscopic ultrasound-guided access using a lumen-apposing metal stent for the management of duodenal bleeding in a Roux-en-Y anatomy after gastric bypass.

Endoscopic ultrasound-guided access using a lumen-apposing metal stent for the management of duodenal bleeding in a Roux-en-Y anatomy after gastric bypass.

Ultrasound-Guided Venous Axillary Access Versus Standard Fluoroscopic Technique for Cardiac Lead Implantation: ZEROFLUOROAXI Randomized Trial

BackgroundAxillary vein puncture (AVP) and cephalic vein surgical cutdown are recommended in international guidelines because of their low risk of pneumothorax and chronic lead complications. Directly visualizing and puncturing the axillary vein under ultrasound guidance reduces radiation exposure, provides direct needle visualization, and lowers periprocedural complications. Our hypothesis is that ultrasound-guided axillary access is safer and more feasible than the standard fluoroscopic technique. ObjectivesThe purpose of this study was to assess the efficacy and safety of ultrasound-guided axillary venous access during cardiac lead implantation for pacemakers (PMs) and implantable cardioverter-defibrillator (ICD) implantations. MethodsPatients were randomized in a 1:1 fashion to either axillary venous access under fluoroscopic guidance or ultrasound-guided axillary venous access. The composite outcome, including pneumothorax, hemothorax, inadvertent arterial puncture, pocket hematoma, pocket infection, lead dislodgement, and death, was evaluated 30 days after implantation. ResultsWe randomized 270 patients into 2 groups: the standard group for fluoroguided AVP (n = 134) and the experimental group for ultrasound-guided AVP (n = 136). No disparities in baseline characteristics were observed between the groups. The median age of the patients was 81 years, with women comprising 41% of the population. The majority of patients received single- and dual-chamber PMs (87% vs 88%; P = 1.00), and slightly over 10% in both groups received ICDs (13% vs 12%; P = 0.85). In total, we placed 357 leads in PMs and 48 leads in ICDs. Among these, 295 leads were inserted via axillary vein access and 110 via cephalic vein access. Notably, the subclavian vein was never used as a vascular access. The composite outcome was lower in the ultrasound group according to intention-to-treat analysis (OR: 0.55; 95% CI: 0.31-0.99; P = 0.034). The main difference within the composite outcome was the lower incidence of inadvertent axillary arterial puncture in the experimental group (17% vs 6%; P = 0.004). The ultrasound group also exhibited lower total procedural x-ray exposure (10,344 μGy × cm2 vs 7,119 μGy × cm2; P = 0.002) while achieving the same rate of success at the first attempt (61% vs 69%; P = 0.375). ConclusionsUltrasound-guided AVP is safer than the fluoroscopy-guided approach because it achieves the same rate of acute success while maintaining low total procedural radiation exposure. Ultrasound AVP should be considered the optimal venous access method for cardiac lead implantation. (Ultrasound Guided Axillary Access vs Standard Fluoroscopic Technique for Cardiac Lead Implantation [ZEROFLUOROAXI]; NCT05101720)

Training ultrasound-guided percutaneous nephrostomy technique with porcine model.

There is increasing interest in the use of ultrasound for endoscopic and percutaneous procedures. Access can be achieved without radiation exposure under ultrasound guidance. Our aim was to develop a porcine-based training model for ultrasound-guided percutaneous renal access that could also be personalized to a specific patient. The Institutional Animal Care and Use Committee of Severance Hospital approved the study protocol. An anesthetized pig was placed in the dorsal lithotomy position. For the nephrostomy puncture, a Chiba biopsy needle with an echo tip was used under ultrasound guidance. Eight residents and three consultants in urology participated. Puncture time was defined as the nephrostomy time to confirm the flow of irrigation via the needle. After training, satisfaction survey results for clinical usability and procedural difficulty were evaluated. The 5-point Likert scale satisfaction survey for clinical usability and procedural difficulty found mean results of 4.64 and 4.09 points, respectively. There were no differences between residents and consultants for either variable. For all participants combined, there was a significant difference for nephrostomy time between the first and second trials (278.8±70.6 s vs. 244.5±47.0 s; p=0.007). The between-trial difference was greater for residents (291.5±71.2 s vs. 259.1±41.9 s; p=0.039). The difference for the consultant was not significant (245.0±69.4 s vs. 205.7±42.5 s; p=0.250). We developed a porcine-based ultrasound-guided nephrostomy puncture training model. Satisfaction survey results indicated high clinical usability and procedural difficulty. For nephrostomy time, the model was more effective for urology residents than for consultants.

Should we routinely use ultrasound-guided transfemoral access for coronary procedures? High-quality evidence from an individual participant data meta-analysis.

Should we routinely use ultrasound-guided transfemoral access for coronary procedures? High-quality evidence from an individual participant data meta-analysis.

Adapted chicken model for training percutaneous arterial access

ObjectiveEndovascular approaches within vascular surgery have grown substantially over the past two decades. As general surgery trainees gain exposure to these approaches, innovative simulation methods to train basic endovascular skills are needed. The purpose of this study was to pilot an existing low-cost model for percutaneous femoral arterial access and examine its effect on resident simulation performance and procedural interest. MethodsA percutaneous arterial access simulation was designed using an adapted chicken breast model. Exiting postgraduate year 1 and 2 general surgery residents participated in sessions with these models for ultrasound-guided arterial access simulation using 5F micropuncture kits. Vascular surgery faculty and fellows provided didactic introductions and proctoring during sessions. Residents also completed skill self-assessments before and after participating in the simulation and rated the model and simulation as a whole. Paired t tests and descriptive statistics were applied in analyses. ResultsTwenty-six residents participated in the simulation in May 2022. Mean resident confidence in overall ability to complete steps required for percutaneous femoral arterial access increased from 3.1 ± 1.0 to 4.4 ± 0.6 (P < .001) when assessed on a 5-point rating scale. Most improved individual steps were identification of arterial cannulation sites using ultrasound (mean difference, +1.4; 95% confidence interval, 1.0-1.8; P < .001) and advancement of hemostatic sheaths over the guidewire into position (mean difference, +1.5; 95% confidence interval, 1.0, 1.9; P < .001). Residents also reported increased comfort level asking to vascular surgery fellows and faculty to participate in subsequent percutaneous access procedures (mean before, 2.7 ± 1.0; mean after, 3.2 ± 0.7; P = .015). On session evaluations, the majority of residents (n = 19 [86%]) strongly agreed that the model was realistic for training purposes and could be used for future skill assessments (n = 16 [73%]). The average material cost required for creation of one chicken model was estimated at $10.32. ConclusionsGeneral surgery trainees require opportunities for low-stakes, independent practice of basic endovascular skills, particularly those with applicability beyond vascular surgery. In this study, use of a simple, a low-cost chicken model promoted increases in procedural confidence and was sufficiently realistic for further training with residents. In the future, this model will be incorporated into standardized assessments to ensure translation of simulated skills to live operative settings.

Efficacy of Magnesium Sulfate and Dexmedetomidine as Adjuvants to Ropivacaine in Supraclavicular Brachial Plexus Block: A Randomised Clinical Study

Introduction: Peripheral nerve blocks have recently proven to be extremely promising in terms of patient satisfaction. In upper limb procedures, rapid and deep anaesthesia can be achieved with supraclavicular ultrasound-guided access to the brachial plexus. To improve the quality of local anaesthesia, adjuvants such as magnesium sulfate and dexmedetomidine have been added to the local anaesthetic. Aim: To evaluate the efficacy of magnesium sulfate and dexmedetomidine as adjuvants to ropivacaine in supraclavicular Brachial Plexus Blockade (BPB). Materials and Methods: A prospective randomised doubleblind study was conducted in the Department of Anaesthesiology from June 2016 to November 2017 ( 1 year and 6 months) at King George's Medical University, Lucknow, Uttar Pradesh, India. A total of 60 patients were divided into two groups using a computer-generated random number for upper limb surgeries (below the mid-humerus) under supraclavicular brachial plexus block. Group A (n=30) received ropivacaine 0.5% (30 mL) plus dexmedetomidine 50 µg for the supraclavicular block, and Group B received ropivacaine 0.5% (30 mL) plus magnesium sulfate 150 mg in 1 mL Normal Saline (NS) 0.9% for the same block. A comparison of these two groups was conducted for the time of onset, duration of sensory and motor block, haemodynamic stability, postoperative analgesia, and complications. Statistical analyses such as Student’s t-test, Chi-square test, and MannWhitney U-test were used. Results: The mean age of Group A was 28.03±5.86 years and Group B was 31.07±7.06 years. The sensory block and motor block onset were significantly faster among patients of Group A (6.47±1.43 min and 8.50±1.46 min) compared to Group B (9.57±1.22 min and 11.77±1.19 min). The mean duration of analgesia was significantly longer (p&lt;0.001) in Group A (1034.10±61.07 min) compared to Group B (460.00±35.82 min). The duration of sensory block and motor block was also significantly higher (p&lt;0.001) in Group A compared to Group B. Both groups were haemodynamically stable, but sedation was significantly higher in Group A. Conclusion: Dexmedetomidine 50 µg is a superior adjuvant compared to magnesium sulfate 150 mg with ropivacaine 0.5% in supraclavicular brachial plexus block as it significantly hastens onset time and prolongs the duration of sensory and motor blocks and the duration of analgesia.