Vascular Access Route Research Articles

An in-vitro method for comparative analysis of aspiration catheter tracking performance.

Mechanical thrombectomy (MT) for acute ischemic stroke (AIS) relies on efficient tracking of aspiration catheters through complex vascular anatomies. Differences in catheter design lead to variation in tracking performance which may only become apparent after use in patients. We developed an in-vitro methodology for evaluating aspiration catheter performance under a variety of pre-defined circumstances, that can be used during catheter development for design optimization. Validation of the in-vitro methodology involved testing four large bore aspiration catheters on recreated challenging vascular access routes derived from patient angiograms. Two experienced neurointerventionalists conducted the tests under controlled physiological and procedural conditions. Each catheter design was evaluated across 30 unique anatomy-procedural set-up combinations. A fifth, prototype large bore catheter was evaluated by trained engineers to assess the applicability of the in-vitro test. Results from statistical analysis using a general linear model demonstrated the methodology's effectiveness in detecting significant tracking differences among catheter designs (p < 0.01). Minimal inter-operator variability was observed (p = 0.304), while procedural techniques significantly influenced tracking performance (p < 0.01). The tortuosity of the arterial access route notably impacted catheter performance (p < 0.01), with anatomical features revealing varying degrees of influence on desirable and undesirable catheter design aspects. We successfully developed a test methodology for evaluating the trackability of large bore aspiration catheters intended for treating acute ischemic stroke with large vessel occlusions. This methodology offers a robust approach to pre-clinical design assessment, utilizing anatomical models that simulate real-world vascular challenges to enhance catheter optimization.

The association of intravenous vs. humeral-intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests

AimWhile intravenous (IV) vascular access for out-of-hospital cardiac arrest (OHCA) resuscitation is standard, humeral-intraosseous (IO) access is commonly used, despite few supporting data. We investigated the association between IV vs. humeral-IO and outcomes. MethodsWe utilized BC Cardiac Arrest Registry data, including adult OHCA where the first-attempted intra-arrest vascular access route performed by advanced life support (ALS)-trained paramedics was IV or humeral-IO. We fit a propensity-score adjusted model with inverse probability treatment weighting to estimate the association between IV vs. humeral-IO routes and favorable neurological outcomes (CPC 1–2) and survival at hospital discharge. We repeated models within subgroups defined by initial cardiac rhythm. ResultsWe included 2,112 cases; the first-attempted route was IV (n = 1,575) or humeral-IO (n = 537). Time intervals from ALS-paramedic on-scene arrival to vascular access (6.6 vs. 6.9 min) and epinephrine administration (9.0 vs. 9.3 min) were similar between IV and IO groups, respectively. Among IV and humeral-IO groups, 98 (6.2%) and 20 (3.7%) had favorable neurological outcomes. Compared to humeral-IO, an IV-first approach was associated with improved hospital-discharge favorable neurological outcomes (AOR 1.7; 95% CI 1.1–2.7) and survival (AOR 1.5; 95% CI 1.0–2.3). Among shockable rhythm cases, an IV-first approach was associated with improved favorable neurological outcomes (AOR 4.2; 95% CI 2.1–8.2), but not among non-shockable rhythm cases (AOR 0.73; 95% CI 0.39–1.4). ConclusionAn IV-first approach, compared to humeral-IO, for intra-arrest resuscitation was associated with an improved odds of favorable neurological outcomes and survival to hospital discharge. This association was seen among an initial shockable rhythm, but not non-shockable rhythm, subgroups.

Transumbilical Arterial Access for Embolization of a Hepatic Vascular Tumor in a Critically Ill Premature Neonate

AbstractCatheter-based interventions are relatively rare in the neonate population but serve as an invaluable tool in managing many pathologies. Here we present a case report of a neonate with a vascular hepatic tumor managed by embolization via transumbilical access. In neonates, the small size of the common femoral artery makes cannulation difficult and is thought to increase the risk of catheter-associated thrombosis and ischemia. Often, these patients reside in the neonatal intensive care unit (NICU) and already have an umbilical artery catheter (UAC) in place, which can be used as an effective alternative route of vascular access to carry out life-saving interventions.

Hemodiyaliz Damar Erişim Yolları ve Bakımı

Hemodialysis remains the most widely used method for treating renal failure. Life expectancy and quality in hemodialysis are directly proportional to the quality of dialysis, and this quality depends on the reliability and integrity of the patient’s vascular access route. The ideal vascular access route provides reliable, uncomplicated access to dialysis and is also suitable for the patient’s needs. Hemodialysis vascular access options have not changed substantially over the past six decades, and arteriovenous fistula (AVF) remains the access of choice. Although AVF is a vascular intervention recommended and preferred in clinical practice guidelines for hemodialysis, it can develop into serious complications such as thrombosis, hematoma, edema, peripheral ischemia, bleeding, and infection. To prevent these complications, it is extremely important to educate patients about AVF care. This review has been prepared as a guide for healthcare professionals who care for hemodialysis patients.

Characterisation of Patients with Acute Coronary Syndrome: A 10-Year Experience

Introduction: Coronary intervention is a therapeutic method for acute coronary syndrome. Objectives: Characterise patients with acute coronary syndrome treated by percutaneous coronary intervention. Method: Analytical, observational, retrospective, and cross-sectional study of 1,469 patients with the diagnosis of acute coronary syndrome, treated with percutaneous coronary intervention at the Hermanos Ameijeiras Hospital, Havana, Cuba, between 2010–2019. Results: The mean age of the patients was 61.1±10.6 years, 72% were male, and 68.3% had acute coronary syndrome without persistent ST-segment elevation. The commonest risk factor was hypertension (69%). Radial access was used in 75.0% of procedures, and 82.0% had a single occluded epicardial coronary artery (42.4% anterior descending artery, 29.7% right coronary artery). One (63.3%) bare metal stent was implanted in 70.7% of patients, with a 96.0% angiographic success rate. There were complications in 1.1% of cases. Diabetes was significantly associated with the failure of the procedure. Conclusions: Most of the patients were middle-aged, with hypertension and a diagnosis of non-ST-segment elevation acute coronary syndrome, where the most frequently treated artery is the left anterior descending artery, and the radial artery is the most commonly used vascular access route with an elevated number of successful procedures. The presence of diabetes is significantly associated with the failure of the procedure.

THE EFFECTS OF CANCER’S METASTATIC STATUS AND CHEMOTHERAPY ON TOTALLY IMPLANTABLE VENOUS ACCESS PORT PATENCY AND PORT-RELATED VENOUS THROMBOEMBOLIC EVENTS

Objective: Totally implantable venous access port (TIVAP) is of great importance as a vascular access route in the treatment of cancer patients. In this study, we retrospectively researched the effects of cancer types, metastases, chemotherapeutic drugs, and intervention sites on port patency and TIVAP-related venous thromboembolism (VTE).&#x0D; Method: Demographics, cancer types, metastases, vascular access sites, chemotherapy drugs, TIVAP patency and TIVAP related complications were evaluated in 297 patients who had TIVAP implanted and 37 patients who underwent removal in our clinic between 2017-2021.&#x0D; Results: TIVAP implanted 297 patients were followed-up for a mean 17.7±16.6 months. TIVAPs were removed in 37 patients due to infection 14 (4.7%), occlusion 8 (2.7%), VTE 9 (3%), malposition 1 (0.3%), and treatment completion 10 (3.3%). TIVAPs of 270 (90.9%) patients were found to be usable for an average of 18.5±17.1 months. Complications of VTE, occlusion, infection and malposition developed in a total of 71 (23.9%) patients. In the comparison of develepment of these complications according to the presence of metastasis in patients, it was found to be that they were significantly higher in metastatic patients (47-27.9%/24-18.6%, p

Trends in use of intraosseous and intravenous access in out-of-hospital cardiac arrest across English ambulance services: A registry-based, cohort study

IntroductionThe optimum route for drug administration in cardiac arrest is unclear. Recent data suggest that use of the intraosseous route may be increasing. This study aimed to explore changes over time in use of the intraosseous and intravenous drug routes in out-of-hospital cardiac arrest in England. MethodsWe extracted data from the UK Out-of-Hospital Cardiac Arrest Outcomes registry. We included adult out-of-hospital cardiac arrest patients between 2015–2020 who were treated by an English Emergency Medical Service that submitted vascular access route data to the registry. The primary outcome was any use of the intraosseous route during cardiac arrest. We used logistic regression models to describe the association between time (calendar month) and intraosseous use. ResultsWe identified 75,343 adults in cardiac arrest treated by seven Emergency Medical Service systems between January 2015 and December 2020. The median age was 72 years, 64% were male and 23% presented in a shockable rhythm. Over the study period, the percentage of patients receiving intraosseous access increased from 22.8% in 2015 to 42.5% in 2020. For each study-month, the odds of receiving any intraosseous access increased by 1.019 (95% confidence interval 1.019 to 1.020, p < 0.001). This observed effect was consistent across sensitivity analyses. We observed a corresponding decrease in use of intravenous access. ConclusionIn England, the use of intraosseous access in out-of-hospital cardiac arrest has progressively increased over time. There is an urgent need for randomised controlled trials to evaluate the clinical effectiveness of the different vascular access routes in cardiac arrest.

Intravenous vs. intraosseous vascular access during out-of-hospital cardiac arrest – protocol for a randomised clinical trial

ObjectiveDuring cardiac arrest, current guidelines recommend attempting intravenous access first and to consider intraosseous access if intravenous access is unsuccessful or impossible. However, these recommendations are only based on very low-certainty evidence. Therefore, the “Intravenous vs Intraosseous Vascular Access During Out-of-Hospital Cardiac Arrest“ (IVIO) trial aims to determine whether there is a difference in patient outcomes depending on the type of vascular access attempted during out-of-hospital cardiac arrest. This current article describes the clinical IVIO trial. MethodsThe IVIO trial is an investigator-initiated, randomised trial of intravenous vs. intraosseous vascular access during adult non-traumatic out-of-hospital cardiac arrest in Denmark. The intervention will consist of minimum two attempts (if unsuccessful on the first attempt) to successfully establish intravenous or intraosseous vascular access during cardiac arrest. The intraosseous group will be further randomised to the humeral or tibial site. The primary outcome is sustained return of spontaneous circulation and key secondary outcomes include survival and survival with a favourable neurological outcome at 30 days. A total of 1,470 patients will be included. ResultsThe trial started in March 2022 and the last patient is anticipated to be included in the spring of 2024. The primary results will be reported after 90-day follow-up and are anticipated in mid-2024. ConclusionThe current article describes the design of the Danish IVIO trial. The findings of this trial will help inform future guidelines for selecting the optimal vascular access route during out-of-hospital cardiac arrest.

Epinephrine administration in adults with out-of-hospital cardiac arrest: A comparison between intraosseous and intravenous route

IntroductionThe benefits and risks of the intraosseous (IO) route for vascular access in patients with out-of-hospital cardiac arrest (OHCA) remain controversial. This study compares the success rates of establishing the access route, epinephrine administration rates, and time-to-epinephrine between adult patients with OHCA with IO access and those with intravenous (IV) access established by paramedics in the prehospital setting. MethodsThis was a retrospective study conducted by the San-Min station of Taoyuan Fire Department. Data for IV access were collected between January 1, 2020, and December 31, 2020. Data for IO access were collected between January 1, 2021, and March 10, 2021. Inclusion criteria were adult patients with OHCA who received on-scene resuscitation attempts and in whom either IV or IO route access was established by paramedics. Exclusion criteria were missing data, return of spontaneous circulation before establishing vascular access, cardiac arrest en route to hospital, patients not resuscitated, and OHCA unidentified by the dispatcher. Exposure was defined as IV route vs. IO route (EZ-IO®). The outcome measurements were per-patient based success rates of route establishment (successes/attempts), administration rates of epinephrine (epinephrine administered per case/enrolled OHCAs), and odds ratios of IV versus IO on epinephrine administration. We used nonparametric Mann-Whitney rank sum tests for the analysis in continuous variables and Fisher's exact tests for the analysis of categorical variables and the outcomes. Firth logistic regression method was used for sparse data. Factors associated with epinephrine administration other than vascular access were also analyzed. Time-to-epinephrine (defined as time from paramedic arrival to epinephrine injection) was reviewed and calculated by two independent observers and the Kaplan-Meier method was used to compare the two access routes. ResultsA total of 112 adult patients were enrolled in the analysis, including 71 men and 41 women, with an average age of 67 years. There were 90 IV access cases and 22 IO access cases. The groups were compared for median success rates of route establishment (33% vs. 100%, P < 0.001) and administration rates of epinephrine (52% vs. 100%, P < 0.001). The adjusted odds ratio of IO versus IV was 32.445, 95% confidence interval (CI) of 1.844–570.861. Time-to-epinephrine was significantly shorter in the cumulative time-event analysis by the Kaplan-Meier method (P < 0.001). ConclusionThe IO route was significantly associated with higher success rates of route establishment, epinephrine administration, and shorter time-to-epinephrine in the prehospital resuscitation of adult patients with OHCA.

Iliofemoral artery predilation prior to transfemoral transcatheter aortic valve implantation in patients with aortic valve stenosis and advanced peripheral artery disease

To investigate the feasibility and safety of percutaneous transluminal angioplasty (PTA) of the iliofemoral arteries (IFA) before transfemoral transcatheter aortic valve implantation (Tf-TAVI) in patients with advanced peripheral artery disease (PAD). Although Tf-TAVI represents the access of choice, alternative vascular access routes are preferred for patients displaying advanced PAD. PTA of the IFA represents a less invasive option, broadening the spectrum of patients eligible for Tf-TAVI. All patients requiring PTA of the IFA before Tf-TAVI, between 2012 and 2021, were included. Primary efficacy endpoint was the rate of successful transcatheter heart valve (THV) delivery and implantation. Primary safety endpoint was the rate of PTA and access-site-related vascular complications, procedural- and in-hospital complications. Among 2726 Tf-TAVI procedures, 59 patients required IFA predilation. Successful THV delivery and implantation was achieved in 57 (96.6%) patients, respectively. Sheath placement was achieved in 59 (100%) patients with only one minor dissection and no major vascular complications following iliofemoral PTA. Regarding access site complications, two (3.4%) vessel perforations and one (1.7%) vessel rupture were observed, with eight (13.5%) patients requiring unplanned endovascular interventions. There was one intraprocedural death due to THV-induced vessel laceration, while in-hospital all-cause mortality was 8.5% in the present high-risk patient cohort. Predilation of IFA is safe and effective in patients with advanced PAD. Careful preprocedural planning is paramount in improving procedural safety and efficacy. This strategy has the potential to broaden the spectrum of patients eligible for Tf-TAVI.

524 SAFETY OF HAND-HELD ULTRASOUND GUIDANCE FOR JUGULAR RIGHT HEART CATHETERIZATION IN ANTICOAGULATED PATIENTS: A TERTIARY CARE CENTER RETROSPECTIVE STUDY

Abstract Background RHC is currently the gold standard in the assessment of diagnosis, prognostic evaluation, and decision-making of pulmonary hypertension patients. Internal jugular vein (IJV) access is the preferred option among the available vascular access routes in most of pulmonary hypertension centers; furthermore, ultrasound (US) guidance is strongly recommended for the IJV access (IA) since it reduces the number of access complications. Many patients requiring RHC are on long-term oral anticoagulant therapy. Continuation of direct oral anticoagulant (DOAC) has been shown to be safe in patients undergoing percutaneous coronary intervention (PCI) and cardiac implantable electronic device implantation (CIED). However only few data in the literature are available in the setting of RHC. Objectives To compare the feasibility and safety of ultrasound (US)-guided IJV access for RHC procedure in pulmonary hypertension's patients anticoagulated vs non-anticoagulated. Methods This is a retrospective observational single–center study, including a cohort of 114 consecutive patients undergoing RHC via IJV assess by US guidance RHC at our tertiary care center between February 2018 and February 2022. The primary outcome was a composite of general (defined as overall success rate, patient discomfort, syncope, mortality) and access site complications (defined as significant hematoma formation greater than 5 cm in diameter, thrombosis, embolism, arterial puncture, pneumothorax, haemotomediastinum and hydro mediastinum, subcutaneous emphysema and nerve injury) after adequate hemostasis, at the access site at 6-hour post procedure. Results Of the 114 patients, 50 (44%) were on anticoagulation and 64 (56%) were not. Mean age was 71 ± 13 and 59 ± 16 years, respectively. The main indication for anticoagulation was atrial fibrillation in 40 (80%) patients. 43 (86%) patients were on DOAC, only 7 (14%) on Warfarin. 13 patients were on single antiplatelet therapy and 8 were on double antiplatelet therapy. Mean INR value was 1.25 ± 0.33 in the anticoagulated population and 1.08 ± 0.11 in the non-anticoagulated one. HAS-BLED score was equal or greater than 3 in 29 (25%) patients. Indication for RHC was mainly confirmation of PH class I diagnosis (54% of patients). None of the patients enrolled developed general or access site complications, except for 1 (2%) non-anticoagulated patient who develop a significant hematoma (defined as &amp;gt;5 cm in diameter) at the puncture site. All patients underwent day-hospital regimen, were able to mobilize immediately following the procedure, and were discharged as planned at 6 hours. Conclusions To the best of our knowledge this is the first study in the literature supporting the feasibility and safety of US guided IJV approach to RHC in anticoagulated patients when compared to non-anticoagulated patients affected by pulmonary hypertension. Keywords: Right heart catheterization, catheterization, anticoagulation, internal jugular vein, US-guidance, access site complications

Prediction of the anastomosis angle of arteriovenous fistula in hemodialysis to standardize the surgical technique.

Arteriovenous fistula (AVF) is the preferred route of vascular access in hemodialysis. The primary reason of fistula failure is intimal hyperplasia (IH), which leads to stenosis. Wall shear stress (WSS) and disturbed flow are the critical parameters in the formation of IH. The primary goal of this study is to explore the influence of anastomosis angle on WSS and venous outflow rate, as well as to find the ideal angle of anastomosis for AVF to standardize surgical technique. Three-dimensional idealized geometries of end-to-side type AVF for the five various angles of anastomosis are considered in this study. The WSS, blood flow rate at the venous outlet for non-Newtonian, pulsatile blood flow are calculated using a numerical simulation technique. The WSS is higher at 75° compared to other angles and least at 45° for pulsating arterial inflows. The WSS is moderate at 30°, 60° and 90°. On the arterial bed and outer wall of the vein, immediately after the anastomosis, the recirculation zone is observed. At an angle of 45° and 90° anastomosis, the outflow rate is greater at distal venous end. If one believes that high wall shear stress causes IH within the AVF, the results suggest that the AVF should be formed at a 45° angle to avoid IH. However, if one believes that low wall shear stress causes IH within the AVF, the results suggest that AVF should be formed at either 30° or 75° to avoid IH. The findings spotlight the importance of anastomosis angle in determining AVF hemodynamics.

Randomized Clinical Trial on Prevention of Radial Occlusion After Transradial Access Using Nitroglycerin: PATENS Trial.

The aim of this study was to evaluate whether administration of nitroglycerin at the beginning or end of a transradial approach (TRA) procedure would preserve radial patency. The TRA is becoming the preferred vascular access route in coronary interventions. Radial artery occlusion (RAO) is the most frequent complication. Routine vasodilator treatment aims to reduce spasm and possibly prevent RAO. The authors designed a prospective, multicenter, randomized, double-blind, 2-by-2 factorial, placebo-controlled trial encompassing patients undergoing the TRA. Patients were randomized to either 500μg nitroglycerin or placebo; each arm was also subrandomized to early (upon sheath insertion) or late (right before sheath removal) nitroglycerin administration to evaluate the superiority of nitroglycerin in the prevention of RAO with 24 hours on Doppler ultrasound. A total of 2,040 patients were enrolled. RAO occurred in 49 patients (2.4%). Fifteen of these patients (30.6%) showed re-establishment of flow at 30days. Nitroglycerin, compared with placebo, did not reduce the risk for RAO at either of the 2 time points (early, 2.5% vs 2.3% [P=0.66]; late, 2.3% vs 2.5% [P=0.66]). By multivariable analysis, the presence of spasm (OR: 3.53; 95%CI: 1.87-6.65; P< 0.001) and access achieved with more than 1 puncture attempt (OR: 2.58; 95%CI: 1.43-4.66; P=0.002) were independent predictors of RAO. The routine use of nitroglycerin was not associated with a reduction in the rate of RAO, regardless ofthe time of administration (at the beginning or end of the TRA procedure).

Use of Therapeutic Plasma Exchange in the Pediatric Intensive Care Unit.

Objective: Therapeutic plasma exchange has been used as a primary or supportive treatment in many diseases in recent years and has achieved satisfactory results in lots of diseases in children. Therapeutic plasma exchange procedure is changing plasma component of a patient's blood with the new plasma as a replacement solution. The aim of this study is to share our experience of therapeutic plasma exchange on varying indications in critically ill children who were accepted to our pediatric intensive care unit.Materials and Methods: We conducted this study between December 2010 and February 2020, retrospectively. Patients’ data such as age, sex, indication, number of sessions, vascular access route, and type of replacement fluid used were obtained from medical records. Indications for therapeutic plasma exchange were classified according to the 2019 American Society for Apheresis categorization. The patient’s follow-up, clinical courses, therapeutic plasma exchange season count, complications, and outcome were evaluated according to each indications and their overall condition.Results: This study included a total of the 84 patients who underwent therapeutic plasma exchange, and their median (minimum-maximum) ages were 7.07 years (0.2-18), 57.1% were male (n = 48) and 42.9% were female (n = 36). A total of 463 sessions of therapeutic plasma exchange were performed in 84 patients. The most common indication was thrombocytopenia-associated multi-organ failure with sepsis (40.4%, n = 34) followed by liver failure/hepatic encephalopathy (28.5%, n = 24) and autoimmune encephalitis (9.5%, n = 8), and according to The American Society for Apheresis 2019 category, patients distributions were as follows: 15.4% of the patients were placed in category 1 (n = 13), 5.9% in category 2 (n = 5), 77.3% in category 3 (n = 65), and 1.1% in category 4 (n = 1). Therapeutic plasma exchange was combined to extracorporeal membrane oxygenation in 10 patients (11.9%) and continuous renal replacement therapies in 39 (46.4%) patients. Finally, the survival rate was 50% in all patients, and the lowest survival rate was 41.5% (n = 27) in category 3 group. Conclusion: Therapeutic plasma exchange is enlarging to varying indications and showing to be more effective on a lot of disorders in children. Also, it is available in pediatric age groups and in different states like combined with other extracorporeal therapies.

Fluoroscopy and CT guided translumbar tunneled dialysis catheter for hemodialysis access failure in a case of autosomal dominant polycystic kidney disease

Vascular access in hemodialysis is essential to end-stage renal disease (ESRD) patients' survival. Unfortunately, even after years of recent advances, a significant number of patients may develop multi-access failure for many reasons. In this situation, arterial-venous fistula (AVF) or catheters placement in traditional vascular sites (jugular, femoral, or subclavian) are not feasible. In this scenario, translumbar tunneled dialysis catheters (TLDCs) may be a salvage option. The use of central venous catheters (CVC) is associated with an increased incidence of venous stenosis that can progressively limit future vascular access routes. The common femoral vein can be used for temporary access in patients in whom traditional approaches for permanent central venous access may not be feasible because of either chronically occluded or not accessible vasculature; however, this location is not preferred for long-term venous access because of the high rate of catheter related blood stream infections (CRBSI). In these patients, a direct translumbar approach to the inferior vena cava is a lifesaving alternative. This approach has been described by several authors as a bail-out option. Fluoroscopy-guided access via a translumbar approach into the inferior vena cava bares the risk of hollow-organ perforation or severe bleeding from the inferior vena cava or even the aorta. To minimize the risk of complications caused by a translumbar central venous access, we hereby present a hybrid approach with CT-guided translumbar access of the inferior vena cava followed by a conventional implantation of the permanent central venous catheter. CT scan-guided access of IVC that further helps in our case as patient has large bulky kidneys secondary to autosomal dominant polycystic kidney disease.

Combined cCTA and TAVR Planning for Ruling Out Significant CAD: Added Value of ML-Based CT-FFR

ObjectivesThe purpose of this study was to analyze the ability of machine-learning (ML)-based computed tomography (CT)-derived fractional flow reserve (CT-FFR) to further improve the diagnostic performance of coronary CT angiography (cCTA) for ruling out significant coronary artery disease (CAD) during pre-transcatheter aortic valve replacement (TAVR) evaluation in patients with a high pre-test probability for CAD. BackgroundCAD is a frequent comorbidity in patients undergoing TAVR. Current guidelines recommend its assessment before TAVR. If significant CAD can be excluded on cCTA, invasive coronary angiography (ICA) may be avoided. Although cCTA is a very sensitive test, it is limited by relatively low specificity and positive predictive value, particularly in high-risk patients. MethodsOverall, 460 patients (age 79.6 ± 7.4 years) undergoing pre-TAVR CT were included and examined with an electrocardiogram-gated CT scan of the heart and high-pitch scan of the vascular access route. Images were evaluated for significant CAD. Patients routinely underwent ICA (388/460), which was omitted at the discretion of the local Heart Team if CAD could be effectively ruled out on cCTA (72/460). CT examinations in which CAD could not be ruled out (CAD+) (n = 272) underwent additional ML-based CT-FFR. ResultsML-based CT-FFR was successfully performed in 79.4% (216/272) of all CAD+ patients and correctly reclassified 17 patients as CAD negative. CT-FFR was not feasible in 20.6% because of reduced image quality (37/56) or anatomic variants (19/56). Sensitivity, specificity, positive predictive value, and negative predictive value were 94.9%, 52.0%, 52.2%, and 94.9%, respectively. The additional evaluation with ML-based CT-FFR increased accuracy by Δ+3.4% (CAD+: Δ+6.0%) and raised the total number of examinations negative for CAD to 43.9% (202/460). ConclusionsML-based CT-FFR may further improve the diagnostic performance of cCTA by correctly reclassifying a considerable proportion of patients with morphological signs of obstructive CAD on cCTA during pre-TAVR evaluation. Thereby, CT-FFR has the potential to further reduce the need for ICA in this challenging elderly group of patients before TAVR.

Pushing the limits for interventional treatment of aortic valve stenosis.

As we approach 20years of clinical experience with transcatheter aortic valve replacement (TAVR), avast portfolio of high-quality clinical data has accumulated, confirming the safety and efficacy of TAVR across the entire spectrum of surgical risk. Although many aspects of this innovative therapy have been thoroughly studied, several challenges remain. As TAVR is expanding to include younger low-risk patients, with longer life expectancy, one major unsolved issue is represented by transcatheter heart valve (THV) durability, since robust THV durability data are currently limited to approximately 5-6years. Additionally, steric interactions between THV components and coronary ostia may render coronary access particularly difficult, and thus personalized decisions regarding THV type and implanting techniques are of paramount importance to secure future coronary access. Since bicuspid aortic valve (BAV) stenosis may be associated with unfavorable anatomic factors, it has represented an exclusion criterion in major randomized TAVR trials. Albeit promising data are available from multicenter registries, results of specifically designed randomized trials are eagerly needed to inform use of TAVR for BAV stenosis. Although valve-in-valve (ViV) TAVR has emerged as an effective treatment option for degenerated aortic bioprostheses, ViV procedures are associated with specific risks, which mandated the development of specific techniques aimed at reducing the occurrence of periprocedural adverse events. Despite the transfemoral approach represents the access of choice for TAVR, asignificant proportion of patients have significant peripheral artery disease and alternative vascular access routes have been increasingly evaluated with encouraging data regarding their safety and feasibility.

The association of intraosseous vascular access and survival among pediatric patients with out-of-hospital cardiac arrest

IntroductionIn pediatric out-of-hospital cardiac arrest (OHCA) the effect of intraosseous (IO) or intravenous (IV) access on outcomes is unclear. MethodsWe analyzed prospectively collected data of non-traumatic OHCA in the Resuscitation Outcomes Consortium registry from 2011 to 2015. We included EMS-treated patients ≤17 years of age, classified patients based on vascular access routes, and calculated success rates of IO and IV attempts. After excluding patients with obvious non-cardiac etiologies and those with unsuccessful vascular access or multiple routes, we fit a logistic regression model to evaluate the association of IO vascular access (reference IV access) with the primary outcome of survival, using multiple imputation to address missing data. We analyzed a subgroup of patients at least 2 years of age. ResultsThere were 1549 non-traumatic OHCA: 895 (57.8%) patients had an IO line attempted with 822 (91.8%) successful; 488 (31.5%) had an IV line attempted with 345 (70.7%) successful (difference 21%, 95% CI 17 to 26%). Of the 761 patients included in our logistic regression, 601 received IO (30 [5.2%] survived) and 160 received IV (40 [25%] survived) vascular access. Intraosseous access was associated with a decreased probability of survival (adjusted OR 0.46; 95% CI 0.21–0.98). Patients at least 2 years of age showed a similar association (adjusted OR 0.36; CI 0.15–0.86). ConclusionsIntraosseous access was associated with decreased survival among pediatric non-traumatic OHCA. These results are exploratory and support the need for further study to evaluate the effect of intravascular access method on outcomes.

Central line placement at ECMO decannulation: A missed opportunity

IntroductionECMO is a support modality for refractory critical illness. This study reviews the incidence and utility of central venous line (CVL) placement at pediatric ECMO decannulation. MethodsA single-institution retrospective study of patients undergoing open neck decannulation from 2015 to 2019. Patients were divided into two groups: ≤ 28-days and > 28-days. ResultsOf 65 patients, 31% had a CVL placed at decannulation. Sepsis and pneumonia were the most common indications for ECMO in the older-group compared to CDH in neonates. The most common indications for CVL were hemodialysis (45%), monitoring (25%), and access (25%). 89% of neonates had an access line placed, whereas 73% of the older group received hemodialysis catheters. Median CRRT requirement was 20 days. 85% of lines were functional at time of removal or death. None were removed for infection. 40% of the patients not receiving a CVL at decannulation required one within 30 days. Conclusion69% of patients did not have a CVL placed at decannulation, however 40% required a CVL within 30 days. Most lines placed at decannulation remained functional and none were removed for infection. Decannulation removes the circuit as a route for vascular access, but it also presents an opportunity to safely place an essential CVL.

Occupational Blood Exposure of Nursing Staff During Dialysis Connection and Disconnection Procedures: A Quantitative Assessment

Background: Hemodialysis patients are at high risk for developing healthcare-associated infections and acquiring multidrug-resistant microorganisms. The importance of hand hygiene in the prevention of healthcare-associated infections is well known. To date, no quantitative study has been undertaken to verify hand hygiene and nosocomial infection management prevention and control. Methods: This quantitative, exploratory, descriptive, observational study used the pyramidon semi-quantitative examination method to detect hemoglobin on the fingers of enrolled nursing staff. We sampled all the fingers of participants who had just finished operating vascular access routes during randomly selected 15-min detection periods that covered all steps of a hemodialysis session (connection and disconnection). Findings: In all the periods that were investigated, numerous residual blood-exposure positive results were found on the fingers of the nurses. Among a total of 454 samples, 273 were found to be residual blood positive and 181 were negative on semi-quantitative examination. The processes where significant differences were found included connection and disconnection of the vascular access routes to the hemodialysis machine (p<0.001). Interpretation: The novel detection method provides direct evidence for hand-based exposure to blood by hemodialysis nurses during the operation of the patient’s vascular access route for hemodialysis. Pyramidon semi-quantitative examination is an excellent method for the evaluation of blood exposure in a hemodialysis unit. Enhanced hand hygiene can be achieved through immediate and intuitive feedback. Clinical Trial Registration Details: This study has been registered with the China Clinical Trial Center, and the number is: ChiCTR2100051448. Funding Information: This study did not receive any funding or financial support. Declaration of Interests: All other authors do not declare any conflict of interest related to the results of this study. Ethics Approval Statement: This research project was approved by the ethical review board of the Affiliated Hospital of Inner Mongolia Medical University (No. KY2020027).