Vascular Access Route Research Articles

The Safety of Tirofiban Therapy in Patients with Acute Coronary Syndrome

Background and Objectives:Recent randomized studies have shown a significant reduction in the rate of recurrent cardiac events with adjunctive pharmacotherapy, using Glycoprotein IIb/IIIa inhibitors (GPI), in patients undergoing percutaneous coronary intervention (PCI) procedures. However, in Korea, there is a paucity of data concerning complications of tirofiban therapy in patients with acute coronary syndrome (ACS). Therefore, this study was performed to evaluate the safety of tirofiban therapy. Subjects and Methods:ACS patients who underwent tirofiban administration between May 2002 and October 2003 were reviewed. The rates of bleeding, transfusion, and thrombocytopenia were analyzed, and the rates of complications by ages, gender and PCI compared with medical treatment, renal function and vascular access route. Results:A total of 261 ACS patients (male/female=150/111) underwent tirofiban therapy. The mean ages of the subjects was 64.5 years, the rates of minor bleeding, major bleeding, transfusion and thrombocytopenia were 8.1% (n=21), 2.3% (n=6), 4.6% (n=12) and 1.2% (n=3), respectively. Minor bleeding occurred at similar rates in both sexes (8 vs. 8.1%) and to a greater extent in old age (≥65) (12.5 vs. 2.6%, p=0.093), but major bleeding occurred to a greater extent in females and old age (5.4 vs. 0% and 4.2 vs. 0%, p=0.25 and 0.093, respectively). The rates of thrombocytopenia and transfusion were greater in old age (2.1 vs. 0% and 8.3 vs. 0%, p=0.052 and 0.087, respectively). In-hospital days were greater in old age (14.7±9.5 vs. 11.9±4.4 days, p=0.065). The rates of complications were similar in both groups when compared by PCI or medical treatment and vascular access route. The serum creatinine was 3.3 mg/dL in those with major bleeding, which was higher than in the other groups (p= 0.000). Conclusion:The tirofiban therapy in patients with ACS did not induce an increase in the bleeding rates, in-hospital days and it was safe and well tolerated in old age. (Korean Circulation J 2004;34(6):558-564)

Percutaneous femoral arterial and venous catheterisation during neonatal intensive care

BACKGROUNDFemoral vessel catheterisation is generally avoided in the neonatal period because of technical difficulties and the fear of complications.AIMTo review the use of femoral arterial and venous catheters inserted percutaneously...

Transumbilical catheterization of cerebral arteries.

For neonates requiring cerebral endovascular procedures, an alternative route of arterial access, the umbilical artery, is described. Transfemoral catheterization, with its attendant risks, can thus be avoided. Six neonates with severe cardiac failure secondary to aneurysmal malformations of the vein of Galen underwent transarterial embolization in an effort to reduce flow through the intracranial arteriovenous malformations and therefore improve control of the high output cardiac failure. The transumbilical route was used in each case, with successful devascularization of some of the malformations in all patients. The femoral arteries were preserved for future staged embolizations. No complications related to the umbilical artery catheterization were encountered. Femoral artery cannulation in neonates is technically challenging and may result in stenosis or thrombosis of the vessel. The umbilical artery provides an alternative route of vascular access for cerebral artery catheterization and embolization in these patients, preserving the femoral arteries for future interventions.

Complications and Side Effects Associated with Large‐Bore Catheters in the Subclavian and Internal Jugular Veins

Since the introduction of large-bore catheters for acute hemodialysis 30 years ago, many problems with handling, material, and contamination of these catheters exist. Nevertheless, catheterization of the inferior and superior vena cava with a large-bore catheter has proved to be suitable as a rapid connection process for hemodialysis, hemofiltration, hemoperfusion, plasmapheresis, plasmaperfusion, among others. In a retrospective study with 2,741 large-bore catheters in 1,716 patients, the frequency of infections, thrombosis, bleeding, and other side effects was investigated. All complications and side effects are presented dependent on vascular access route. In total, the complication rate was 48.9% higher in subclavian puncture than in internal jugular puncture (24.8%). The highest complication rates for both vascular access routes were infections or septicemia; infections were observed in 19.5% of subclavian catheters versus 10% of internal jugular catheters.

Improved technique for rodent microarteriography.

We have developed new techniques in rodent microarteriography which provide excellent two-plane views of the rat femoral artery. These techniques employ routine mammography film and equipment for imaging as well as standard intravenous catheters for vascular access. The use of mammographic equipment provides high quality, finely detailed, orthogonal X-ray images. The elective outpatient nature of mammography allows microsurgical investigators convenient access to the necessary equipment without interfering with patient care. The standard intravenous catheters permit easy and inexpensive vascular access via the contralateral femoral artery. The technique avoids the more invasive thoracic and abdominal aortic approaches without compromising X-ray image quality. Additionally, the same rat can be imaged multiple times if care is taken to repair the vascular access route.

Frequency, Therapy, and Prevention of Infections Associated with Large Bore Catheters

Since the introduction of large bore catheters for acute hemodialysis 30 years ago, many problems with handling, material, and contamination of these catheters existed. Nevertheless, the catheterization of the inferior and superior vena cavae with a large bore catheter has proved to be suitable as a rapid connection process for hemodialysis, hemofiltration, hemoperfusion, plasmapheresis, plasmaperfusion, etc. In a retrospective study with 2,626 large bore catheters in 1,627 patients, the frequency of infections, thrombosis, bleeding, and other side effects was investigated. All complications and side effects are presented dependent upon vascular access route. In total, the complication rate was 44.2% higher in subclavian puncture than in internal jugular puncture at 23.9%. The highest complication rates in both vascular access routes were infections or septicemia; infections were observed in 22.8% of subclavian catheters versus 9.5% of internal jugular catheters. Three different catheter materials (Teflon, polyurethane, and polypropylene) were investigated with scanning electron microscopy after removal. The advantages and disadvantages of the different materials are presented.

Intraosseous infusion: A re-discovered procedure as an alternative for pediatric vascular access

The intraosseous infusion has numerous advantages over other techniques that provide vascular access during emergencies. It is a rapid and safe alternate route for fluid and certain drug administration in the infant or child. Few contra-indications or restrictions exist and the success rate for the technique is very high, even when performed by paramedical personnel, and the rate of complications is very low. At this time the technique should be reserved for children in crisis such as cardiac arrest, shock, trauma, life threatening status epilepticus, or any situation in which the potential benefit of rapid venous access outweighs the low incidence of complication. Intraosseous infusion is intended only for emergency resuscitation and stabilization, after which another route of vascular access should be sought. The technique may offer even more promise for those who rarely care for critically ill children, because this skill is easily mastered with even limited opportunity for practice.

Triple lumen venous access for pediatric bone marrow transplantation candidates.

Multiple routes of vascular access are required in children undergoing bone marrow transplantation to facilitate total parenteral nutrition (TPN); blood withdrawal; and administration of blood products, antibiotics, fluids, and immunosuppressive drugs. Placement of multiple catheters frequently requires multiple venotomies in separate vessels. We have found that both a Broviac catheter and pediatric dual-lumen Raaf catheter can be placed through separate venotomies in the external jugular vein, which provides sufficient routes of vascular access without complications. This technique places only one vessel at risk while minimizing the chance for infection by utilizing two exit sites. We consider this to be the procedure of choice in young patients requiring multiple routes of vascular access.

Vascular access through the femoral vessels: indications and complications.

A prospective study was performed to assess the indications for and complications of femoral vascular access in burn patients. In the study, 1655 femoral catheters (one-third arterial) were inserted in 232 patients; 136 of the catheters were inserted in 29 children (18 were younger than five years of age; the youngest was four months old). Insertion was "easy" in 83.9% of the insertions and "difficult" in 7.6%, with no difference noted between arterial and venous insertions. There were six significant complications: local abscess requiring drainage (2), arterial occlusion (3), and extravasation (1). No septic arthritis, deep infections, catheter erosions, venous thrombosis, embolisms, or late complications were noted. Venous and arterial access through the femoral vessels is an appropriate route for vascular access in burn patients when care is taken to minimize complications. This area is usually free of burn, provides ready access to central vessels, is technically easy, and has few complications.

Central, high flow subclavian artery-internal jugular vein fistula for venous access.

A subclavian artery--internal jugular vein shunt was created for intermittent parenteral infusions in six patients who had undergone extensive intestinal resection because of Crohn's disease or ulcerative colitis. The flow rates through the shunt were initially around 1000 ml/min. In three patients the flow later increased, giving rise to mild cardiac symptoms. Slight disturbance from arm ischemia during work was experienced by two patients. Some patients were disturbed by murmurs from the shunt when the flow increased. Narrowing of the vein at the end-to-side anastomosis diminished excessive flow and relieved symptoms. There was no perioperative mortality, and no septic, hemorrhagic or wound healing complications occurred in connection with the six primary and nine secondary operations. The patency rate of fistula was 100% after one year, 83% after two years and 66% after three years. The shunt was well accepted by patients and by personnel. This type of A-V fistula for intermittent parenteral infusions seems to be a feasible alternative to other A-V shunts when the usual vascular access routes have been exhausted.

Experience with subclavian vein for vascular access.

We report our experience with the subclavian vein as a route for temporary vascular access. By modifying the technique described by Uldall one can place these catheters at the bedside without the need of a separate exit tunnel. They are easily maintained in place and allow for early discharge home while awaiting permanent vascular access maturation. The results of approximately 600 dialysis treatments showed adequate clearence with a mean postdialysis drop in creatinine of 5.0mg./dl. and BUN of 46mg./dl. Complication rates were minimal with no hemo or pneumothorax. The rate of complications between bedside and operating room placement was not different. We feel the low complication rate, the ease of insertion, and the patency at home makes this an attractive alternative to other means of temporary dialysis such as: peritoneal dialysis, repeat femoral vein catheterization or arteriovenous shunts.

Total parenteral nutrition (TPN) with complete nutritive mixtures: An artificial gut in cancer patients

Abstract A new technique in total parenteral nutrition (TPN), involving a deep vein indwelling catheter as a vascular access route, was applied to cancer patients in order to obtain a positive nitrogen balance. Various complete nutritive mixtures were administered; all were aseptic and apyrogenic; normonutrition mixtures contained 2000, 25000 and 3000 ml of solvent, while hyper‐nutrition mixtures contained 600 and 1200 ml of solvent. TPN (average duration 1.4 months) was used in 2122 cancer patients: 74.6% of patients underwent surgery, 15.8% had radiotherapy and 9.6% received only chemotherapy. A significant increase in the rate of operability of tumors was noted as a result of preoperative TPN, as well as an increase in the number of procedures involving extensive visceral resection. The results of a randomized study involving 81 patients with pelvic and/or abdominal irradiation revealed a significant increase in the degree to which radiotherapy was tolerated by the patients when TPN was administered du...

Angiography of chronic hemodialysis arteriovenous grafts

The arteriovenous graft has become an accepted vascular access route for chronic hemodialysis. Angiography plays in important role in the demonstration of graft abnormalities and in the management of graft malfunction. We describe the two basic techniques of graft angiography and classify graft abnormalities and factors associated with graft malfunction. The role of angiography in each category is analyzed, and representative cases are presented. Pertinent clinical material is also presented to provide information concerning the relative frequency of graft complications. In addition, the role of arteriovenous grafts in chronic maintenance hemodialysis and highlights in the development of graft technology are reviewed.

Renal and Cardiac Failure

SINCE THE original description by Brescia et al¹in 1966, arteriovenous fistulas have become the vascular access route of choice for patients undergoing hemodialysis. There are few complications attributable to these fistulas. To our knowledge, this is a previously unreported complication of prerenal azotemia associated with high-output cardiac failure, secondary to an arteriovenous fistula that occurred in a recipient of a renal allograft. <h3>Report of a Case</h3> A 20-year-old man was admitted to the University of California Hospital at San Francisco seven weeks after an uncomplicated cadaver renal transplant. The patient's complaints included progressive leg edema, a 4.6 kg weight-gain, increasing abdominal girth, and progressive dyspnea on exertion, with a greatly decreased exercise tolerance. Prior to transplantation, he had had no history of cardiac symptoms. The patient had two functioning arteriovenous fistulas: a right arm side-to-side distal radial artery-cephalic vein fistula, and a left upper forearm side-to-side brachial artery-anticubital

Renal and cardiac failure. Complications of an arteriovenous fistula in a renal transplant recipient

SINCE THE original description by Brescia et al 1 in 1966, arteriovenous fistulas have become the vascular access route of choice for patients undergoing hemodialysis. There are few complications attributable to these fistulas. To our knowledge, this is a previously unreported complication of prerenal azotemia associated with high-output cardiac failure, secondary to an arteriovenous fistula that occurred in a recipient of a renal allograft. Report of a Case A 20-year-old man was admitted to the University of California Hospital at San Francisco seven weeks after an uncomplicated cadaver renal transplant. The patient's complaints included progressive leg edema, a 4.6 kg weight-gain, increasing abdominal girth, and progressive dyspnea on exertion, with a greatly decreased exercise tolerance. Prior to transplantation, he had had no history of cardiac symptoms. The patient had two functioning arteriovenous fistulas: a right arm side-to-side distal radial artery-cephalic vein fistula, and a left upper forearm side-to-side brachial artery-anticubital