Ventricular Cannulation Research Articles

Atrial and Ventricular Cannulation for Biventricular Circulatory Support With Double-Ended Centrifugal Pump: InVitro Evaluation.

In patients with biventricular heart failure, a biventricular assist device (BVAD) may be necessary for hemodynamic support. BVAD inflows can be established through cannulation of the atrial (AC) and/or ventricular (VC) chambers, but no consensus exists on optimal cannulation techniques. This study aimed to characterize BVAD performance related to cannulation types (AC and VC) using a continuous-flow total artificial heart (CFTAH) as the BVAD. Both methods of cannulation (AC and VC) were tested on a mock loop using dual pulsatile ventricles with valves (AB5000; Abiomed) paired as the native ventricles and a double-ended centrifugal pump with two volutes, CFTAH, as a BVAD. Pressures were collected at the inlet and outlets of the AB5000 (LAP, RAP, AoP, and PAP) and the CFTAH (Lin, Rin, Lout, and Rout). The left and right flows exiting the CFTAH (LPF and RPF) and total flow (TF), exiting systemic resistance, were monitored. Several heart failure conditions were simulated with adjustment of the pneumatic pressures (AB5000). Trends between the AC and VC are similar where RAP, Lin, and Lout decreased, and AoP, PAP, TF, LPF, and RPF increased with increased support. The trends differ in LAP with an increase during AC as opposed to a decrease during VC. As a result, with this setup, left-right balance is more easily achieved during VC. TF is higher with AC, even though LPF and RPF are lower. This signifies the flow going through the aortic valve (TF-LPF) and pulmonary valve (TF-RPF) is higher with AC. The increased TF and valvular flow favored AC for introducing a CFTAH as BVAD to the native heart in these conditions.

Improving Successful Cannulation of External Ventricular Drain: 3D-Printed Surgical Guide for Inexperienced Neurosurgeons

ObjectiveExternal Ventricular Drain (EVD) is a fundamental neurosurgical procedure that is commonly performed by junior neurosurgeons. Expedient, successful cannulation of the ventricles can be lifesaving. Yet, the free-hand technique of EVD insertion is associated with significant mal-positioning rates. This study aims to improve EVD placement by junior neurosurgeons with the aid of a customized 3D printed surgical guide. MethodsA 3D printed surgical guide was developed and customized to our institution’s EVD insertion procedure. First year neurosurgical residents were taught how to perform pre-operative trajectory planning based on coronal brain images and how to use the surgical guide during standard EVD insertion procedure. Number of passes, accuracy of EVD placement, operative complications, need for revision, and surgeon’s experience with the guide were recorded. Results14 patients underwent guide-assisted EVD insertion by first year neurosurgical residents. Significantly, 6 (43%) patients had ventricular anatomy distorted by midline shift. All surgeons achieved successful ventricular cannulation using the EVD guide on first pass (100%). 13 out of 14 (93%) of the guide-assisted EVDs were optimally placed (Karkarla Grade 1). 1 (7%) guide-assisted EVD was suboptimally placed (Karkarla Grade 2). There was no intra or post-operative complication and there was no EVD revision. ConclusionsFor inexperienced surgeons, the 3D printed EVD guide can improve ventricular cannulation even in cases of altered ventricular anatomy. The benefit of 3D printing would also allow the guide to be widely adopted by other institutions worldwide.

The Celiac Artery in Gallus domesticus

Regarding the studied species, the literature has shown a variety of topographic, origin and distribution differences of the arterial supply compared to mammals, although they are not fully identified. The aim of this article is the macroscopical study of the arterial supply of the digestive tract of Gallus domesticus. The biological material was represented by 12 adult chicken bodies with an average weight of 2 kg. After procurement of the biological material, the feathers, skin, muscles and sternum were removed for easy access to the heart. After left ventricular cannulation, epoxy resin mixed with red dye was injected. The body was immersed in 5% formaldehyde for 24 hours. Next, stratigraphic dissection was performed. The celiac artery erupted from the right face of the descending aorta, on a level with the junction of the esophagus and the proventriculus. It gave off the Aa. esophageales, A. proventricularis dorsalis, then bifurcated into left and right branches. The left branch of the celiac artery gave off A. proventricularis ventralis and A. gastrica ventralis then continued with the A. gastrica sinistra.

The Device for Intraventricular Entry guide: a novel solution to a perpetual problem.

The authors designed a low-profile device for reliable ventricular access and prospectively studied its safety, efficacy, and accuracy at a large academic center. A novel device for ventricular entry, the Device for Intraventricular Entry (DIVE) guide, was designed and created by the first and senior authors. Fifty patients undergoing external ventricular drainage (EVD) or shunt placement were prospectively enrolled for DIVE-assisted catheter placement at a single academic center. The primary outcome was the catheter tip location on postprocedural CT. Secondary outcomes included number of catheter passes, clinically significant hemorrhages, and procedure-related infections. Fifty patients were enrolled. Indications included subarachnoid hemorrhage, intraventricular hemorrhage, traumatic brain injury, hydrocephalus, pseudotumor, and postsurgical wound drainage. In total, 76% (38/50) of patients underwent right-sided placement and 24% (12/50) underwent left-sided placement. All 100% (50/50) of patients had successful cannulation with an average of 1.06 passes. Postprocedural head CT confirmed ipsilateral frontal horn or third ventricle placement (Kakarla grade 1) in 92% (46/50) of patients and placement in the contralateral lateral ventricle in 8% (4/50) (Kakarla grade 2). There were no clinically significant track hemorrhages or procedural infections. This single-center prospective study investigated the safety and efficacy of DIVE-assisted ventricular access. In total, 100% of procedures had successful ventricular cannulation, with 92% achieving Kakarla grade 1, with an average of 1.06 passes without any clinical complications.

The Effects of the Fraction Isolated from Iranian Buthotus shach Scorpion Venom on Synaptic Plasticity, Learning, Memory, and Seizure Susceptibility.

Epilepsy, as a neurological disease, can be defined as frequent seizure attacks. Further, it affects many other aspects of patients' mental activities, such as learning and memory. Scorpion venoms have gained notice as compounds with potential antiepileptic properties. Among them, Buthotus schach (BS) is one of the Iranian scorpions studied by Aboutorabi et al., who fractionated, characterized, and tested this compound using electrophysiological techniques in brain slices (patch-clamp recording). In the present study, the fraction obtained from gel electrophoresis was investigated through behavioral and electrophysiological assays. At first, ventricular cannulation was performed in rats, and then the active fraction (i.e., F3), carbamazepine, and the vehicle were microinjected into the brain before seizure induction by the subcutaneous (SC) injection of pentylenetetrazol (PTZ). Seizure behaviors were scaled according to Racine stages. Memory and learning were evaluated using the Y-maze and passive avoidance tests. Other groups entered evoked field potential recording after microinjection and seizure induction. Population spike (PS) and field excitatory postsynaptic potential (fEPSP) were measured. The F3 fraction could prevent the fifth stage and postpone the third stage of seizure compared to the control (carbamazepine) group. There was no significant improvement in memory and learning in the group treated with the F3 fraction. Also, PS amplitude and fEPSP slope increased significantly, and long-term potentiation was successfully formed after the high-frequency stimulation of the performant pathway. Our results support the antiepileptic effects of the F3 fraction of BS venom, evidenced by behavioral and electrophysiological studies. However, the effects of this fraction on memory and learning were not in the same direction, suggesting the involvement of two different pathways.

Intraoperative ultrasound-guided ventricular cannulation in patients with normal-sized ventricles

IntroductionMany pathologies require normal-sized ventricle cannulation, which may be technically challenging even with neuronavigation guidance. This study presents a series of ventricular cannulation of normal-sized ventricles using intraoperative ultrasound (iUS) guidance and the outcomes of patients treated by this technique, for the first time. MethodsThe study included patients who underwent ultrasound-guided ventricular cannulation of normal-sized ventricles (either ventriculoperitoneal (VP) shunting or Ommaya reservoir) between January 2020 and June 2022. All patients underwent iUS-guided ventricular cannulation from the right Kocher's point. The inclusion criteria for normal-sized ventricles were as follows: (1) Evans index <30%, and (2) widest third ventricle diameter <6mm. Medical records and pre-, intra- and post-operative imaging were retrospectively analyzed. ResultsNine of the 18 included patients underwent VP shunt placement; 6 had idiopathic intracranial hypertension (IIH), 2 had resistant cerebrospinal fluid fistula following posterior fossa surgery, and 1 had iatrogenic intracranial pressure elevation following foramen magnum decompression. Nine patients underwent Ommaya reservoir implantation, 6 of whom had breast carcinoma and leptomeningeal metastases and 3 hematologic disease and leptomeningeal infiltration. All catheter tip positions were achieved in a single attempt, and none were placed suboptimally. Mean follow-up was 10 months. One IIH patient (5.5%) had early shunt infection which necessitated shunt removal. ConclusioniUS is a simple and safe method for accurate cannulation of normal-sized ventricles. It provides an effective real-time guidance option for challenging punctures.

Radiological properties of neurological injury following acute type A aortic dissection repair

ObjectiveThe study objective was to assess the radiological properties of acute type A aortic dissection–related neurological injuries and identify predictors of neurological injury. MethodsOur single-center, retrospective, observational study included all patients who underwent acute type A aortic dissection repair between January 1998 and December 2021. Multivariable analyses and Cox regression were performed to identify predictors of embolic lesions, watershed lesions, neurological injury, 30-day mortality, and late mortality. ResultsA total of 538 patients were included. Of these, 120 patients (22.3%) experienced postoperative neurological injury; 74 patients (13.8%) had postoperative stroke, and 36 patients (6.8%) had postoperative coma. The 30-day mortality was 22.7% in the neurological injury group versus 5.8% in the no neurological injury group (P < .001). We identified several independent predictors of neurological injury. Cerebral malperfusion (odds ratio, 2.77; 95% confidence interval, 1.53-5.00), systemic hypotensive shock (odds ratio, 1.97; 95% confidence interval, 1.13-3.43), and aortic arch replacement (odds ratio, 3.08; 95% confidence interval, 1.17-8.08) predicted embolic lesions. Diabetes mellitus (odds ratio, 5.35; 95% confidence interval, 1.85-15.42), previous cardiac surgery (odds ratio, 8.62; 95% confidence interval, 1.47-50.43), duration of hypothermic circulatory arrest (odds ratio, 1.05; 95% confidence interval, 1.01-1.08), cardiopulmonary bypass time (odds ratio, 1.01; 95% confidence interval, 1.00-1.01), ascending aortic/arch cannulation (odds ratio, 5.68; 95% confidence interval, 1.88-17.12), and left ventricular cannulation (odds ratio, 17.81; 95% confidence interval, 1.69-188.01) predicted watershed lesions. Retrograde cerebral perfusion (odds ratio, 0.28; 95% confidence interval, 0.01-0.84) had a protective effect against watershed lesions. ConclusionsIn this study, we demonstrated that the radiological features of neurological injury may be as important as clinical characteristics in understanding the pathophysiology and causality behind neurological injury related to acute type A aortic dissection repair.

768 The Device for Intraventricular Entry (DIVE) Guide: A Novel Solution to a Perpetual Problem

INTRODUCTION: Safe and reliable access to the ventricular system is a necessary skill in the neurosurgical armamentarium. The freehand technique for catheter placement remains an accepted method, yet the inaccuracy rate can be as high as 40%, with as many as 3 passes per procedure, and complication rates between 10-40%. A number of devices have been developed to assist with catheter placement, however, these devices inhibit ergonomics or require larger incisions and expensive navigation technology. METHODS: A novel device for ventricular entry, the DIVE guide, was designed by the first and senior author. 50 patients undergoing extra ventricular drain (EVD) or shunt placement were prospectively enrolled for DIVE assisted catheter placement under an IRB approved study with a non-significant risk (NSR) device designation. The primary outcome is catheter location on CT. Secondary outcomes include number of catheter passes, clinically significant hemorrhages and procedure-related infections. RESULTS: 50 patients were enrolled at a single academic center for ventricular access with DIVE assistance. Indications included subarachnoid or intraventricular hemorrhage, TBI, hydrocephalus, pseudotumor and post-surgical wound drainage. 76% (38/50) underwent right sided placement and 24% (12/20) underwent left. 100% (50/50) had successful cannulation in an average of 1.06 passes. Post procedure head CT confirmed ipsilateral frontal horn or 3rd ventricle placement (Kakarla Grade 1) in 92% (46/50) and 8% (4/50) in the contralateral lateral ventricle (Grade 2). There were no significant tract hemorrhages or procedural infections. CONCLUSIONS: This a prospective study to investigate the safety and efficacy of DIVE-assisted ventricular access. 100% of procedures had successful ventricular cannulation, with 92% achieving Kakarla Grade 1, in an average of 1.06 passes.

Emodin protects against homocysteine-induced cardiac dysfunction by inhibiting oxidative stress via MAPK and Akt/eNOS/NO signaling pathways

Elevated levels of plasma homocysteine (Hcy) causes severe cardiac dysfunction, which is closely associated with oxidative stress. Emodin, a naturally occurring anthraquinone derivative, has been shown to exert antioxidant and anti-apoptosis activities. However, whether emodin could protect against Hcy-induced cardiac dysfunction remains unknown. The current study aimed to investigate the effects of emodin on the Hcy-induced cardiac dysfunction and its molecular mechanisms. Rats were fed a methionine diet to establish the animal model of hyperhomocysteinemia (HHcy). H9C2 cells were incubated with Hcy to induce a cell model of Hcy-injured cardiomyocytes. ELISA, HE staining, carotid artery and left ventricular cannulation, MTT, fluorescence staining, flow cytometry and western blotting were used in this study. Emodin significantly alleviated the structural damage of the myocardium and cardiac dysfunction from HHcy rats. Emodin prevented apoptosis and the collapse of MMP in the Hcy-treated H9C2 cells in vitro. Further, emodin reversed the Hcy-induced apoptosis-related biochemical changes including decreased Bcl-2/Bax protein ratio, and increased protein expression of Caspase-9/3. Moreover, emodin suppressed oxidative stress in Hcy-treated H9C2 cells. Mechanistically, emodin significantly inhibited the Hcy-activated MAPK by reducing ROS generation in H9C2 cells. Furthermore, emodin upregulated NO production by promoting the protein phosphorylation of Akt and eNOS in injured cells. The present study shows that emodin protects against Hcy-induced cardiac dysfunction by inhibiting oxidative stress via MAPK and Akt/eNOS/NO signaling pathways.

Correlation of palpation anterior fontanometry and cerebrospinal fluid opening pressure in early childhood hydrocephalus.

The anterior fontanelle (AF) tension has been a traditional clinical method of indirect assessment of intracranial pressure (ICP). How does this time-tested bedside assessment technique compare with an objective ventricular cerebrospinal fluid (CSF) opening pressure? To determine the correlation of palpation anterior fontanometry and CSF opening pressure in early childhood hydrocephalus. Children diagnosed with hydrocephalus who were planned for CSF diversion using ventriculo-peritoneal (V-P) shunt were prospectively studied over 18 months. The AF tension was assessed by palpation preoperatively and graded. The CSF opening pressure was measured using sterile disposable plastic manometers after ventricular cannulation intraoperatively. Data obtained were analysed using SPSS version 21. Student's t-test, Mann-Whitney U test and ANOVA were used to determine associations based on normality tests. A P < 0.05 was considered significant for associations. Fifty-two children were operated on with AF patency rate of 88.5%. Their age ranged between 2 weeks and 18 months with a mean age of 7.1 ± 5.1 months. The fontanelle tension was tense, full and normal in 63.0%, 26.1% and 10.9% of patients, respectively. The mean CSF opening pressure of 20.5 ± 8.5 cm of H2O was higher than the expected ICP for the age group (t-test 4.754, P = 0.000). All 28 patients with CSF opening pressure >15 cm of H2O had a tense fontanelle, but 10.9% of children with raised ICP have normal AF tension. The mean ICP increases as palpation AF tension increases, but a normal AF tension does not rule out raised ICP.

Evaluation of centrifugal blood pump performances for biventricular support in the virtual simulation model.

Despite the advances in the left ventricular assist device (LVAD), there are still situations that require a biventricular assist device (BVAD) system. The purpose of this study was to explore and compare the system performance interactions with the HeartMate3 (HM3) and HeartWare (HVAD) in a BVAD configuration using the virtual mock loop (VML) simulation tool. The VML simulation tool is an in silico implementation of a lumped parameter model of the cardiovascular system with mechanical circulatory support. Patients with ejection fractions of 60%, 20%, and 15% were simulated in VML, and the HVAD and HM3 in a BVAD with ventricular cannulation were applied to simulated conditions. Pump speeds that restored baseline normal hemodynamics were determined. To determine the optimal speeds for BVAD, the left and right arterial pressures (LAP, RAP) were plotted. In the HVAD, LAP and RAP are balanced at 11mm Hg with LVAD 3500rpm, right ventricular assist device (RVAD) 2200rpm; at 13mm Hg with LVAD 3000rpm, RVAD 1700rpm; and at 14mm Hg with LVAD 2500rpm, RVAD 1300rpm. For the HM3, at 8mm Hg with LVAD 7000rpm, RVAD 5000rpm; at 9mm Hg with LVAD 6000rpm, RVAD 4300rpm; and at 9.5mm Hg with LVAD 5000rpm, RVAD 3500rpm. The RVAD/LVAD speed ratios required for atrial balance were approximately 0.6 for the HVAD and 0.7 for the HM3. However, the HVAD required RVAD speeds below its range of operation.

Ventricular Infusion and Nanoprobes Identify Cerebrospinal Fluid and Glymphatic Circulation in Human Nerves.

Background:Growing evidence suggests that cerebrospinal fluid circulates in human nerves. Several conditions encountered by the plastic surgeon may be related to dysregulation of this system, including nerve transection, stretch injuries, and peripheral neuropathy. The purpose of this study was to show how ventricular infusion and nanoprobes identify CSF and glymphatic circulation in neural sheaths of human nerves.Methods:The technique of ventricular infusion using buffered saline was developed in 2017. The technique was used in a series of eight fresh cadavers before dissection of the median nerve, and combined with fluorescent imaging and nanoprobe injections in selected specimens.Results:Eight cadaver specimens underwent ventricular infusion. There were six female and two male specimens, ages 46–97 (mean 76.6). Ventricular cannulation was performed successfully using coordinates 2 cm anterior to coronal suture and 2.5 cm lateral to sagittal suture. Depth of cannulation ranged from 44 to 56 mm (mean 49.7). Ventricular saline infusion complemented by nanoprobe injection suggests CSF flows in neural sheaths, including pia meninges, epineurial channels, perineurium, and myelin sheaths (neurolemma).Conclusions:Ventricular infusion and nanoprobes identify CSF flow in neural sheaths of human nerves. CSF flow in nerves is an open circulatory system that occurs via channels, intracellular flow, and cell-to-cell transport associated with glial cells. Neural sheaths, including neurolemma, may participate in glucose and solute transport to axons. These techniques may be used in anatomic dissection and live animal models, and have been extended to the central nervous system to identify direct ventricle-to-pia meninges CSF pathways.

A Morphometric Analysis of Commonly Used Craniometric Approaches for Freehand Ventriculoperitoneal Shunting.

Ventricular catheter tip position is a predictor for ventriculoperitoneal shunt survival. Cannulation is often performed freehand, but there is limited consensus on the best craniometric approach. To determine the accuracy of localizing craniometric entry sites and to identify which is associated with optimal catheter placement. This is a retrospective analysis of adult patients who underwent ventriculoperitoneal shunting. The approaches were categorized as Kocher's, Keen's, Frazier's and Dandy's points as well as the parieto-occipital point. An accurately sited burr hole was within 10 mm from standard descriptions. Optimal catheter tip position was defined as within the ipsilateral frontal horn. A total of 110 patients were reviewed, and 58% (65/110) of burr holes were accurately sited. Keen's point was the most correctly identified (65%, 11/17), followed by Kocher's point (65%, 37/57) and Frazier's point (60%, 3/5). Predictors for accurate localization were Keen's point (odds ratio 0.3; 95% CI: 01-0.9) and right-sided access (odds ratio 0.4; 95% CI: 0.1-0.9). Sixty-three percent (69/110) of catheters were optimally placed with Keen's point (adjusted odds ratio 0.04; 95% CI: 0.01-0.67), being the only independent factor. Thirteen patients (12%) required shunt revision at a mean duration of 10 ± 25 mo. Suboptimal catheter tip position was the only independent determinant for revision (adjusted odds ratio 0.11; 95% CI: 0.01-0.98). This is the first study to compare the accuracy of freehand ventricular cannulation of standard craniometric entry sites for adult patients. Keen's point was the most accurately sited and was a predictor for optimal catheter position. Catheter tip location, not the entry site, predicted shunt survival.

P.202 Image-Guidance for Ventricular Drains Insertion: A Systematic Review and Metanalysis

Background: The use of Image-guidance to improve the accuracy during ventricular drain insertion has been attempted. We aim to assess the effect of use of Image-guidance on accuracy, drain failure rate and number of ventricular cannulation attempts. Methods: MEDLINE, EMBASE and Cochrane Library databases were searched from inception to February 2021 looking for studies comparing image-guided versus freehand ventricular drain insertion. Two reviewers independently screened studies, extracted data and assessed risk of bias and quality of evidence. Metanalysis was conducted in compliance with PRISMA guidelines using a random-effects model and GRADE tool was used to assess quality of evidence. Results: 17 studies with 3404 patients were included, all of which were of non-randomized design. Pooled data on drain accuracy and drain failure rates showed favourable effect of image-guidance with risk ratio of 1.31 (95% CI of 1.13 – 1.51, low quality evidence) and 0.63 (95% CI 0.48 – 0.83, moderate quality evidence), respectively. Pooled data were equivocal for number of attempts with mean difference score of -0.11 times (95% CI -0.31 – 0.09, very low-quality evidence). Conclusions: Image-guidance likely enhances drain accuracy and reduces drain failure rate. No clear recommendation can be drawn on the benefit of intervention on number of drain insertion attempts.

Atrial Cannulation in Pediatric Mechanical Circulatory Support

Purpose Several centers have considered the potential benefits of atrial inflow cannulation to provide mechanical circulatory support (MCS) among pediatric patients with small or restrictive ventricles particularly in those with potential for myocardial recovery. Limited pediatric data are available on contemporary outcomes of atrial cannulation. We sought to describe the characteristics, complications, and outcomes of children supported with atrial cannulation using the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) ventricular assist device (VAD) database. Methods Data were collected from the ACTION VAD database for all patients who underwent VAD implantation via atrial cannulation from 8/16/2012 to 9/8/2020. Patient characteristics, VAD types, complications, and outcomes were analyzed. Results Forty-one patients met the study criteria with 52 implants. Median age was 3.6 years (range 0.02 - 25.32), weight 13.6 kg (2.7-106), and BSA 0.6 (0.15 - 2.2). Diagnoses included dilated cardiomyopathy (42%), congenital heart disease (37%), transplant graft dysfunction (7%), restrictive and hypertrophic cardiomyopathies (5% each). VAD indications were bridge to decision (42%), bridge to transplant (42%), and bridge to recovery (17%). Eighty-four percent of patients were INTERMACS 1 or 2, 44% were on ECMO, and 63% were mechanically ventilated. Devices utilized included Berlin Heart Excor (40%), paracorporeal continuous flow devices (38%), Heartware (19%) and one Heartmate 3. Median support duration was 43.5 days (range 0-307). Overall mortality was 22%. Twenty patients (49%) were successfully transplanted, 7 (17%) recovered, and 5 (12%) are still alive on the device. Adverse events included major bleeding (24%), stroke (12%), sepsis (10%), right heart failure requiring RVAD (5%), and one instance of pump thrombosis. Conclusion Atrial cannulation in pediatric MCS can be performed across a variety of anatomic substrates and age ranges with outcomes and complication rates that are comparable to left ventricular cannulation strategies. This method may be advantageous in certain circumstances including patients with small or restrictive ventricles, potential for myocardial recovery, or multiple prior sternotomies to minimize surgical dissection. Further studies are needed to delineate the ideal patient population and benefits of varying atrial cannulation techniques.

The Branching Pattern of the Aortic Arch in Gallus Domesticus

In birds, in contrast to mammals, two brachiocephalic trunks are the origin in the arch of aorta and give rise to the subclavian arteries and common carotid. The aim of this study was to investigate the vascular branching morphology of the aortic arch in Gallus Domesticus with the purpose of providing accurate data with regards to the arterial supply of these segments to researchers and clinicians. The biological material was represented by 10 adult chicken bodies with an average weight of 2 kg, females. After procurement of the biological material, the feathers, skin, muscles and sternum were removed for easy access to the heart. After left ventricular cannulation, epoxy resin mixed with red dye was injected. The body was immersed in 5% formaldehyde for 24 hours. Next, stratigraphic dissection was performed. Two brachiocephalic trunks branched continually from aortic arch caudoventral to the primary bronchi. The left subclavian artery gave rise to sternoclavicular, thoracic, axillary and intercostal and the same was observed to the right side. Due to this method we could observe the aortic arch of Gallus Domesticus being different from mammals in that the left and right brachiocephalic trunks are detached from it.

Optimizing accuracy of freehand cannulation of the ipsilateral ventricle for intracranial pressure monitoring in patients with brain trauma.

Intracranial pressure (ICP) monitoring in traumatic brain injury (TBI) usually requires the placement of a catheter into the ipsilateral ventricle. This surgical procedure is commonly performed via a freehand method using surface anatomical landmarks as guides. The current accuracy of the catheter placement remains relatively low and even lower among TBI patients. This study was undertaken to optimize the freehand ventricular cannulation to increase the accuracy for TBI. The authors hypothesized that an optimal surgical plan of cannulation should give an operator the greatest degrees of freedom, which could be measured as the range of operation angle, range of catheter placement depth, and size of the target area. An imaging simulation was first performed using the computed tomography (CT) images of 47 adult patients with normal brain anatomy. On the reconstructed 3D head model, four different coronal planes of ventricular cannulation were identified: a 4-cm anterior, a 2-cm anterior, a standard (central), and a 2-cm posterior plane. The degrees of freedom during the cannulation procedure were determined, including the relevant angles, lengths of cannulation, cross-sectional area, and bounding rectangle of the lateral ventricle. Next, a retrospective assessment was performed on the CT scans of another 111 patients with TBI who underwent freehand ventricular cannulation for ICP monitoring. Postoperative measurements were also performed based on CT images to calculate the accuracy and safety of catheter placement between coronal planes in practice. Our simulation results showed that the 2-cm anterior plane had more extensive degrees of freedom for ventricular cannulation, in terms of length of catheter trajectory (7% longer, P<0.001), cross-sectional area of the lateral ventricle (14% larger, P=0.046), and length of the lateral ventricle (17% wider, P<0.001) than that of the standard plane, while both the 4-cm anterior and 2-cm posterior planes did not offer advantages over the standard plane in these ways. The mean length range of catheter trajectory in the 2-cm anterior plane was 41 to 58 mm. Retrospective assessment of TBI patients with ICP monitor placement also confirmed our simulation data. It showed that the accuracy of ipsilateral ventricle cannulation in the 2-cm anterior plane was 70.6%, which was a significant increase from 42.9% in the standard plane (P=0.007). Our imaging simulation and retrospective study demonstrate that different coronal planes could provide different degrees of freedom for cannulation, the 2-cm anterior plane has the greatest degrees of freedom in terms of larger target area and greater length range of the trajectory. The optimized surgical plan in this manner could improve cannulation accuracy and benefit a significant number of TBI patients.

Craniometrics and Ventricular Access: A Review of Kocher's, Kaufman's, Paine's, Menovksy's, Tubbs', Keen's, Frazier's, Dandy's, and Sanchez's Points.

Intraventricular access is frequently required during neurosurgery, and when neuronavigation is unavailable, the neurosurgeon must rely upon craniometrics to achieve successful ventricular cannulation. In this historical review, we summarize the most well-described ventricular access points: Kocher's, Kaufman's, Paine's, Menovksy's, Tubbs', Keen's, Frazier's, Dandy's, and Sanchez's. Additionally, we provide multiview, 3-dimensional illustrations that provide the reader with a novel understanding of the craniometrics associated with each point.

Single Ventricular Assist Device Support for the Failing Bidirectional Glenn Patient

Given poor outcomes, strategies to improve ventricular assist devices (VADs) for single-ventricle patients with bidirectional Glenn (BDG) palliation are needed. This retrospective review describes an institutional experience with VAD support for patients with BDG from April 2011 to January 2019. Surgical strategies, complications, and causes of death are described. Survival to heart transplantation for various strategies are compared. A total of 7 patients with BDG (weights, 5.6 to 28.8 kg; ages, 7 months to 11 years) underwent VAD implantation. Three patients underwent implantation of Berlin Heart EXCOR devices (Berlin Heart, Inc, Spring, TX), 2 had HeartWare HVADs (Medtronic, Minneapolis, MN) implanted, and 2 patients underwent implantation of paracorporeal continuous flow devices. Four patients underwent ventricular inflow cannulation, and 3 underwent atrial inflow cannulation. At the time of VAD implantation, the BDG was left intact in 3 patients, taken down in 3 patients, and created de novo in 1 patient. Over a total of 420 VAD support days, 2 patients survived to heart transplantation, 1 patient with HeartWare ventricular cannulation and intact BDG (after 174 days) and another with Berlin Heart atrial cannulation and BDG take-down (after 72 days). There were 3 deaths within 2 weeks of VAD implantation (2 from respiratory failure, 1 from infection) and 2 deaths after 30 days as a result of strokes. The surgical strategy and postoperative management of VAD with BDG are still evolving. Successful support can be achieved with (1) both pulsatile and continuous flow pumps, (2) atrial or ventricular cannulation, and (3) with or without BDG take-down. Surgical strategy should be determined by individual patient anatomy, physiology, and condition.

Freehand Insertion of External Ventricular Drainage Catheter: Evaluation of Accuracy in a Single Center.

Introduction:External ventricular drain (EVD) placement is the gold standard for managing acute hydrocephalus. Freehand EVD, using surface anatomical landmarks, is performed for ventricular cannulation due to its simplicity and efficiency. This study evaluates accuracy and reason(s) for misplacements as few studies have analyzed the accuracy of freehand EVD insertion.Patients and Methods:Preoperative and postoperative computed tomography scans of patients who underwent EVD insertion in 2014 were retrospectively reviewed. Diagnosis, Evans ratio, midline shift, position of burr hole, length of the catheter, and procedural complications were tabulated. The procedures were classified as satisfactory (catheter tip in the frontal horn ipsilateral lateral ventricle) and unsatisfactory. Unsatisfactory cases were further analyzed in relation to position of burr hole from midline and length of the catheter.Results:Seventy-seven EVD placements in seventy patients were evaluated. The mean age of the patients was 57.5 years. About 83.1% were satisfactory placements and 11.7% were unsatisfactory in the contralateral ventricle, corpus callosum, and interhemispheric fissure. Nearly 5.2% were in extraventricular locations. Almost 2.6% EVD placements were complicated by hemorrhage and 1 catheter was reinserted. Suboptimal placements were significantly associated with longer intracranial catheter length. The mean length was 66.54 ± 10.1 mm in unsatisfactory placements compared to 58.32 ± 4.85 mm in satisfactory placements. Between the two groups, no significant difference was observed in Evans ratio, midline shift, surgeon's experience, distance of burr hole from midline, and coronal suture.Conclusion:Freehand EVD insertion is safe and accurate. In small number of cases, unsatisfactory placement is related to longer catheter length.