Cannulation Of Vessels Research Articles

Randomized study of teaching ultrasound-guided vascular cannulation using a phantom and the freehand versus needle guide-assisted puncture techniques.

The task of ultrasound-guided vessel cannulation can be technically difficult. Needle guides have been designed to facilitate vessel puncture. We aimed to identify and compare the learning curves of participants performing vessel puncture with conventional freehand (FH) and needle guide-assisted (NG) techniques. Thirty-six participants were randomly allocated to either the FH or the NG group. They were asked to consecutively perform as many as 30 vessel punctures on a simulated phantom model. Quantitative metrics (time taken and number of skin and posterior-wall punctures) were recorded and compared between the two groups. The cumulative sum and moving F-test statistical methods were used to delineate the learning curves. There was a significantly lower rate of posterior-wall punctures in the NG group than in the FH group (15% versus 26%; p < 0.0001). Participants in the NG group also performed significantly fewer skin punctures than did those in the FH group (mean, 405 versus 515; p < 0.0001). Cumulative sum statistical method analysis showed that participants in the NG group surmounted the learning curve earlier (13 attempts; interquartile range, 10.3-17.0) than did those in the FH group (19 attempts; interquartile range, 15.0-27.5). The number of attempts to surmount the learning curve was significantly less for the FH group (7.2 versus 16 attempts; p = 0.007) when using the moving F-test. The NG puncture allows a greater number of trainees to cross the learning threshold and offers the advantages of fewer posterior-wall punctures and skin punctures. The use of NG puncture may result in a shorter path to proficiency, allowing trainees to attempt needle puncture earlier and with a greater degree of safety.

Peripheral Intravenous Access Using Ultrasound Guidance: Defining the Learning Curve

BackgroundThe need for peripheral intravenous (IV) access in anatomically challenging patients is becoming a more commonly encountered clinical problem. The significant investment devoted to physician training for ultrasound-guided vascular access has not yet been matched by a similar commitment to nursing. Nurses, paramedics, and physicians are becoming more enthusiastic about peripheral IV access with ultrasound (PIVUS); however, institutional and clinician support has not yet been forthcoming. The learning curve for PIVUS has never been rigorously studied, and may be flatter than previously assumed. MethodsRegistered nurses were selected to participate as trainees. Training involved 1:1 sessions consisting of formal orientation to portable ultrasound, mentoring, and practice sessions with a nurse practitioner who has expertise in ultrasound-guided peripheral vascular access; hands-on, supervised practice cannulating vessels on a nonhuman tissue simulator; and supervised attempts on live patients. ResultsSeven of 8 trainees completed the training. The average number of patient encounters required to achieve 10 successful IV placements was 25 (range = 18-32). The average time required for successful vessel cannulation was 19.57 minutes (range = 5-62 minutes). An average of 25 attempts was required to achieve proficiency, and average of 50 cases was required to maintain consistency. ConclusionsIn today's practice environment, PIVUS skills are increasingly important. The results of our study demonstrate that, with appropriate hands-on training and supervision, these skills can be effectively taught to registered nurses.

Abstract No. 353 - Evaluation of robot-assisted catheterization using the Magellan system for embolization

No. 353 Evaluation of robot-assisted catheterization using the Magellan system for embolization G. Rao, S. Rao; Medicine, University of North Texas Health Science Center, Fort Worth, TX; SierraProvidence Health Network, El Paso, TX Purpose: To evaluate the safety and efficacy of robot-assisted catheter guidance by the Magellan (Hansen Medical, Mountain View, California, USA) robotic catheter for embolization procedures. The following four procedures were evaluated: uterine fibroid embolization, transarterial chemoembolization with drug-eluting beads for hepatocellular carcinoma, embolization for gastric hemorrhage and embolization of pulmonary arteriovenous malformation. Materials and Methods: Four patients underwent embolization using the remotely controlled Magellan catheter system. Documented performance metrics and data include: fluoroscopy time, success of target vessel cannulation, procedural time, contrast use, and overall technical success. Robotic manipulation routes included femoral and radial arterial access and femoral venous access. Assessment included evaluation of embolization ability using a variety of embolic materials. Results: Technical success was 100%. No complications seen. For the four cases: 1) UFE: 6Fr robotic catheter successfully accessed contralateral anterior branch of the internal iliac and ostium of the ipsilateral internal iliac. Further distal cannulation achieved with microcatheter. 2) 6Fr catheter for DEBTACE demonstrated successful catheterization of the right hepatic artery. Distal branches required microcatheter placement. 3) 6Fr catheter via radial access demonstrated successful catheterization of the gastroepiploic artery for particle and coil embolization for gastric bleed. Left gastric artery was poorly visualized and not accessed. 4) 9Fr catheter usage for embolization of pulmonary arteriovenous malformation demonstrated adequate access into right lower lobe pulmonary branch. Distal catheterization of feeding vessel required microcatheter for coil embolization. Reduction in radiation exposure to the operator was over 70% compared to control radiation monitor at patient bedside. Conclusion: Technical success without complication can be achieved during embolization procedures with the robotic system. Distal subselective target embolization may require the use of manual cannulation using a separate microcatheter. Usage of the remotely controlled catheter reduces radiation exposure to the operator.

Commentary on "Insertion of Totally Implantable Central Venous Access Devices by Surgeons" - What Is the Role of Surgeons When Implanting a Totally Implantable Venous Access Device to Prevent Immediate Complications?

To the editor: We have read with great interest the manuscript of An et al. [1], whose article focused on the safety of inserting a totally implantable central venous access device (TICVAD) by using a blind percutaneous approach. Although it is a method that has been used for many years and has been proven to be useful by many physicians familiar with this approach [2], risks remain. We offer some comments about the present article. In the section Procedure for the TICVAD insertion, the authors wrote that the venous was filled with about 10 mL of diluted heparin (50 IU/mL). Usually, the amount of saline mixed with heparin that can be placed in the of a TICVAD cannot be more than 2 mL. Also, the proportion of the mixed solution of saline and heparin was 9:1, meaning that for each 9 mL of saline, 1 mL of heparin (5,000 IU) was added. Thus, each milliliter contained 500 IU of heparin [3]-not 50 IU, as written by the authors. In the same paragraph, the authors wrote that they checked the tip of the after completing the procedure. The position of the should be checked during the procedure to avoid having to perform a second procedure, particularly in cancer patients who are already in an especially delicate state. In the RESULTS section, An et al. [1] differentiated the complications as early and late. This type of differentiation is not sufficiently precise. Generally, complications that appear within the first 24 hours are defined as immediate, between 24 hours and 30 days after the procedure as early, and after 30 days as late [4]. This classification is very important because the majority of the complications that occur during the first 24 hours are strictly related to the operator or to technical failures. Using this classification, late complications (e.g., pinch-off [5]) are fundamental and usually present after several months. In the same section, the authors wrote about a complication they called migration. Usually we hear of catheter migration. Perhaps the authors described port dislodgement as port migration [4]. This complication concerns a port that has been inserted into a subcutaneous space and is not well fixed to the fascia, causing it to become dislodged. In the DISCUSSION section, the authors focused on the differences in the incidence of pneumothorax in relation to the practitioner (surgeon or radiologist) who performed blind cannulation of the subclavian vein. In 2015, it is inconceivable that cannulation of a central vessel is performed in a blind manner. The fact that these authors did not experience any cases of pneumothorax or hemothorax is not a valid justification to continue to perform this technique without using an ultrasonography (US)-guided approach, which is currently recommended worldwide. Also, in the DISCUSSION section, the authors described the internal jugular vein as the safest access point for positioning a TIVAD catheter. We believe that the safest access remains the cephalic vein using the cutdown technique [6]. This technique is absolutely free of risk and immediate complications and does not require US support. Also, unless a skin incision is needed to position the port [7], surgeons should attempt the cutdown technique.

Cannulation in aortic surgery: subclavian and axillary cannulation.

Cannulation of peripheral vessels is being frequently used as a standard access for establishing cardiopulmonary bypass (CPB) in recent times. Apart from an increased use in patients requiring left ventricular circulatory support, i.e. either extracorporeal membrane oxygenation or long-term ventricular assist device systems, peripheral vessel cannulation is also beneficial in aortic surgery. The subclavian and axillary arteries are commonly used as sites for arterial cannulation to establish CPB during aortic surgery in many centres. Both cannulation sites enable safe implementation of CPB in patients requiring complex and difficult reoperations and those undergoing aortic surgery for acute type A aortic dissections or artherosclerotic aortic disease, in which cerebral perfusion is required. Here, we describe our techniques of direct cannulation of the subclavian and axillary artery for aortic arch surgery.

Ergonomic Investigation of Interventional Radiology

Interventional radiology (IVR) refers to a variety of minimally invasive procedures using small-caliber catheters under fluoroscopic or ultrasound guidance for the treatment of vascular and digestive diseases. Common IVR applications include dilatation, occlusion, and selective cannulation of vessels and the digestive canal without open surgery. Indications for IVR are rapidly increasing. However, ergonomic problems of IVR for physicians have not been considered. Such ergonomic problems and countermeasures were investigated in this study. Ergonomic problems during hepatic arterial catheterization and placement of a stent in the digestive canal, two frequent IVR procedures, were investigated. Ergonomic problems of IVR, problems induced by X-ray protectors, inadequate working postures and asthenopia induced by the apparatus, impaired maneuverability and neuro-muscular fatigue forced by small caliber catheter for intra-vascular catheterization, lacks of intuitive usability and standardization the devices and instruction documents are revealed in this study. For the continued safe development of IVR, outstanding ergonomic and technological problems must be resolved. Potential solutions include the development of adequate holding and accessory devices for small-caliber devices, improved educational software, and head-mounted displays. Further analyses of the workflow and ergonomic medical device design with input from end users are also critical.

Foregut reduplication cyst: Anaesthetic implications of the rare anomaly.

Sir, Congenital duplications can occur anywhere in the gastrointestinal tract and one-third of all duplications are foregut duplications.[1] A 6-month-old male child weighing 4 kg was admitted in our hospital with the history of recurrent productive cough with intermittent fever for 4 months. He was born full term by normal vaginal delivery. The child was apparently well till 2 months of age after which he started developing repeated episodes of cough and cold with fever. Child was febrile (102° F), lethargic with respiratory rate of 28-30/min. Breath sounds were markedly decreased on the right side of the chest. X-ray chest showed a homogenous opacity in mid-thoracic region compressing the right lung. The computed tomography [Figure 1] scan of chest revealed a large cystic mass (7 cm × 4 cm × 4 cm) in posterior mediastinum extending from the lung apex to base and reaching the opposite mediastinum posterior to oesophagus causing displacement of oesophagus and bronchus anteriorly. It also showed mild pleural effusion on the right side. A provisional diagnosis of foregut duplication cyst was made, and cyst excision via right thoracotomy was planned. Figure 1 Computed tomography scan of the thorax showing the cyst His pre-operative blood investigations were all normal. Once the patient arrived, monitors including electrocardiography (ECG), oxygen saturation (SpO2) and non-invasive blood pressure were placed. No sedative premedication was given. After pre-oxygenation, anaesthesia was induced with sevoflurane in graded concentration and an intravenous line secured. Intubation was performed under sevoflurane with a 4 mm uncuffed flexometallic endotracheal tube. Injection fentanyl 10 μg and injection vecuronium 0.4 mg were then given, and anaesthesia maintained with isoflurane and O2/N2O (50:50). Right internal jugular and right radial arterial cannulation were performed. Intraoperative monitoring included ECG, intra-arterial blood pressure, SpO2, nasopharyngeal temperature, end-tidal carbon dioxide, airway pressures, urine output, central venous pressure and intermittent arterial blood gas (ABG) analysis. The cyst was removed after mobilization that took 3 h. Warming mattress and radiant warmer were used to maintain normothermia. The estimated blood loss was around 300 ml, which was replaced with packed cells. Intercostal block was given with 6 ml of injection bupivacaine 0.125% and rectal suppository of paracetamol 80 mg inserted for post-operative analgesia. The patient was extubated uneventfully in the end and shifted to post-operative care unit. The post-extubation ABG was normal with pH - 7.4; pCO2-38 mmHg; HCO3-20 mmol/L; PaO2-98 mm Hg and SpO2-97% on oxygen by mask at 4 L/min. The post-operative course was uneventful, and the child was discharged after 15 days. The biopsy report later confirmed the diagnosis. Foregut malformation cysts are the second most common cause of posterior mediastinal mass after the neural tumours.[2] An embryonic defect in vacuolization of the oesophagus results in duplication and normally occurs in the 6th week of gestation.[1] The fusion anomalies of cervical and upper thoracic vertebral bodies are encountered in 80% of these cases due to the defect in their embryological development.[2] Although the mean age of onset of symptoms was 49.4 months in a study by Cohen et al., it ranges from 1 month to 18 years.[2] Most cases present with respiratory distress, which may be present from birth. Sometimes the symptoms may be delayed with sudden onset cough, wheeze or recurrent respiratory infections. In rare cases the cyst may perforate into the bronchial tree.[1] Extension of the cyst into the infradiaphragmatic area may cause gastrointestinal symptoms and extension into the neural canal can cause signs of spinal cord compression.[3] Cysts require total excision, to prevent cancer development or recurrence of symptoms.[2] The incidence of complications with the induction of anaesthesia in patients with mediastinal masses has been reported to be 7-18% including refractory cardio-respiratory collapse.[4,5] Inhalational induction with sevoflurane was chosen with a hope that the spontaneous ventilation will preserve the diaphragmatic movements in a caudal direction, and a normal transpleural pressure gradient will be maintained preventing airway collapse. Intubation was also carried out without muscle relaxants with a flexometallic tube to cause splinting of the trachea beyond the obstruction.[6,7] Successful use of femoro-femoral cardiopulmonary bypass (CPB) has been described in patients with mediastinal masses to restore the oxygenation in the event of severe life-threatening hypoxia.[4] Tempe et al. have recommended femoral vessel cannulation under local anaesthesia and CPB circuit primed and kept ready before induction of GA in symptomatic patients with a mediastinal mass.[8] Invasive haemodynamic monitoring is mandatory in these cases as severe cardiorespiratory embarrassments are noted. Good post-operative analgesia is a must after thoracotomy to hasten recovery. We used intercostal block, and rectal acetaminophen as thoracic epidural in infants is not a technique that is commonly practiced in our institution. We could successfully extubate the patient on the table after end of surgery, and he had an uneventful recovery.

Carbon Dioxide Embolism Following Veress Needle Insertion Into the Liver During Laparoscopic Adrenalectomy

Although rare, complications can arise during the establishment of pneumoperitoneum during laparoscopic surgery. These include injury to blood vessels, hollow viscera, solid organs, and CO2 embolism. We report a case of trauma to the liver following the insertion of a Veress needle causing CO2 embolism during laparoscopic adrenalectomy. Opening pressures on insertion were high. Respiratory and cardiovascular changes alerted the anesthesiologists to the possibility of CO2 embolism. The patient was treated with inotropic drugs, placed in Durant’s position, and the operation was aborted. Ultrasound demonstrated gas bubbles within the liver parenchyma and the heart chambers. The patient was transferred to the surgical intensive care unit where she experienced a grand mal seizure. She was later taken to a nearby hospital for hyperbaric oxygen therapy during which she suffered 3 additional seizures. She had subsequent resolution of all neurological symptoms. The first entry into the peritoneum deserves the full attention of the operating room team, because this is when most CO2 embolisms occur. The team should be prepared to take immediate action on suspicion of embolism. Gas embolism can occur not only by direct cannulation of blood vessels, but also by injury to solid organs, especially the liver. All overweight patients should be suspected of having hepatomegaly and the location of initial entry into the peritoneum should shift accordingly. In selected patients, one should use a direct visualization approach, because this approach has fewer complications and they are more readily identified.

Minimally invasive aortic valve replacement.

Minimally invasive aortic valve replacement.

Postmortem angiography using femoral cannulation and postmortem microbiology.

Despite the undeniable advantages of postmortem angiography, numerous questions have arisen concerning the influence that the injected contrast media may exercise on biological fluids and tissues collected for toxicological and biochemical investigations. Moreover, cardiac blood for microbiological investigations cannot be obtained post-angiography. In this study, we examined whether the peripheral blood collected prior to postmortem angiography, using percutaneous access to femoral vessels after skin surface disinfection, could be suitable for microbiological investigations when postmortem angiography with femoral vessel cannulation is also performed. A total of 66 cases were included in the study and were divided into two subgroups (angiography and bacteriology group, 33 cases and control group, 33 cases). Autopsies, histology, toxicology, bacteriology, and biochemical investigations (procalcitonin, C-reactive protein, interleukin-6, and soluble triggering receptors expressed on myeloid cells type 1) were performed in all cases. No statistically significant differences between the two groups were noted, and identified category distribution (death unrelated to infection, true infection, false positive, and undetermined) was rather similar in both studied populations. These preliminary results suggest that postmortem angiography using a femoral approach does not constitute an impediment to the collection of peripheral blood for microbiology and vice versa. Moreover, the use of femoral blood for microbiology does not lead to an increased risk of doubtful results.

Ultrasound-guided small vessel cannulation: long-axis approach is equivalent to short-axis in novice sonographers experienced with landmark-based cannulation.

IntroductionOur primary objective was to describe the time to vessel penetration and difficulty of long-axis and short-axis approaches for ultrasound-guided small vessel penetration in novice sonographers experienced with landmark-based small vessel penetration.MethodsThis was a prospective, observational study of experienced certified emergency nurses attempting ultrasound-guided small vessel cannulation on a vascular access phantom. We conducted a standardized training, practice, and experiment session for each participant. Five long-axis and five short-axis approaches were attempted in alternating sequence. The primary outcome was time to vessel penetration. Secondary outcomes were number of skin penetrations and number of catheter redirections. We compared long-axis and short-axis approaches using multivariable regression adjusting for repeated measures, vessel depth, and vessel caliber.ResultsEach of 10 novice sonographers made 10 attempts for a total of 100 attempts. Median time to vessel penetration in the long-axis and short-axis was 11 (95% confidence interval [CI] 7–12) and 10 (95% CI 6–13) seconds, respectively. Skin penetrations and catheter redirections were equivalent and near optimal between approaches. The median caliber of cannulated vessels in the long-axis and short-axis was 4.6 (95% CI 4.1–5.5) and 5.6 (95% CI 5.1–6.2) millimeters, respectively. Both axes had equal success rates of 100% for all 50 attempts. In multivariable regression analysis, long-axis attempts were 32% (95% CI 11%–48%; p=0.009) faster than short-axis attempts.ConclusionNovice sonographers, highly proficient with peripheral IV cannulation, can perform after instruction ultrasound-guided small vessel penetration successfully with similar time to vessel penetration in either the long-axis or short-axis approach on phantom models.

DEEP VERSUS MILD HYPOTHERMIA FOR LIMITED AORTIC ARCH SURGERY

Deep hypothermic circulatory arrest is the most frequently used organ protective strategy for aortic arch surgery. However, mild to moderate hypothermia with antegrade cerebral perfusion is increasingly being used to minimize the adverse effects of deep hypothermia. We compared these two strategies in a contemporary cohort of patients undergoing partial aortic arch resection. Sixty-three consecutive patients undergoing partial aortic arch resection were included. Patients were divided into deep hypothermia (DH, n = 33) and mild hypothermia (MH, n = 30) based on lowest cardiopulmonary bypass (CPB) temperature. Acute type A aortic dissections were excluded from this study. Antegrade cerebral perfusion was performed either through axillary artery cannulation or direct cannulation of arch vessels. Data on clinical outcomes and blood product use was obtained. The primary endpoint was a composite of mortality and major morbidity including stroke, need for dialysis, and deep sternal wound infection. The baseline characteristics including age, gender, LV function, renal function and prior sternotomies were similar between both groups. There were 22 elective cases, 9 urgent cases and 2 emergent cases in the DH group. In the MH group, there were 27 elective cases, 3 urgent cases and no emergent cases. The circulatory arrest time in the DH and MH groups were 32.7 ± 20.4 min and 18.7 ± 5.8 min respectively (p < 0.001). The lowest CPB temperature in the DH and MH groups were 19.5 ± 2.8 °C vs. 31.4 ± 2.3 °C respectively (p < 0.001). CPB times were significantly longer in DH patients (264 ± 107 vs. 141 ± 59 min, p < 0.001). The incidence of all major clinical adverse outcomes was higher in the DH group (see Table). The primary endpoint occurred in 42% of DH and 10% of MH patients (p = 0.005). The proportion of patients requiring any blood products in the DH and MH groups was 97% vs. 47% (p < 0.001). The number of units of blood products needed was substantially higher in the DH group (see Table). In patients undergoing partial aortic arch resection, mild hypothermia with antegrade cerebral perfusion is associated with lower morbidity and decreased need for blood products compared to deep hypothermia. These findings require further validation in larger, prospective clinical trials.

Totally robotic atrial septal defect closure: 7-year single-institution experience and follow-up.

Robotic technology has been applied to atrial septal defect (ASD) repair for more than 10 years, but the number of cases reported is limited and results of long-term follow-up are not clear. This study reports on a large group of patients who underwent totally robotic ASD repair on an arrested or beating heart at a single institution with a 7-year follow-up. From 2007 to 2013, 160 patients (median age, 36 years; range, 11-66 years) at our centre underwent selective repair of secundum-type ASD using the da Vinci robotic system. The first 54 cases were performed on an arrested heart (arrested-heart group, n = 54) and the remainder on a beating heart (beating-heart group, n = 106). The mean diameter of defects was 2.9 cm (range, 1.1-4.1 cm). Cardiopulmonary bypass was achieved via cannulation of the femoral vessels and the right internal jugular vein. Blood cardioplegic arrest was induced using a transthoracic Chitwood clamp in the arrested-heart group. With the assistance of a robotic surgical system, atrial septal defect repairs were performed with or without tricuspid valvuloplasty via three 8-mm ports, a camera port and a working port in the right chest. Transoesophageal echocardiography was used to evaluate surgical results and follow-up. Complete ASD closure was verified by intraoperative transoesophageal echocardiography in all patients. None of the procedures was converted to an alternate technique and there were no major complications. There were significant learning curves for cross-clamp time, operative duration and cardiopulmonary bypass time. The beating-heart group had significantly shorter operative and cardiopulmonary bypass durations than the arrested-heart group (P = 0.000). The two groups had similar durations of mechanical ventilation and intensive care unit and hospital stays, and similar drainage volumes. During the 39 ± 21 months of follow-up, no patient required reoperation because of a residual shunt or tricuspid valve regurgitation. ASD can be performed safely and effectively on an arrested or beating heart with the assistance of robotic technology. This totally endoscopic approach represents an option for patients seeking a reliable, minimally invasive ASD repair with an excellent long-term result.

Learning curve of vessel cannulation in rats using cumulative sum analysis

BackgroundIntravascular access routes are widely used for administering agents or taking blood samples in rodents. Vessel cannulation in rats is a technically challenging procedure with a risk for significant complications. The use of cumulative sum (CUSUM) analysis allows continuous monitoring of the performer's outcomes to evaluate the learning curve for a particular procedure. The aim of the present study was to assess a researcher's learning curve in the cannulation of the jugular and femoral vein in rats using CUSUM analysis. Materials and methodsA single researcher performed two hundred microsurgical operations between September 2012 and September 2013. The animals (male Wistar rats) were anesthetized with isoflurane whereas the right jugular vein and the left femoral vein were catheterized. Prospective data were collected and analyzed using CUSUM analysis. For the purposes of the study, the rat population was divided in four groups based on the order of studies; group 1 represents the first 50 animals cannulated, group 2 the next batch of 50 animals, and so forth. ResultsThe operating times required for cannulation of the jugular vein for groups 1, 2, 3, and 4 were 24.6 ± 4.8, 15.9 ± 2.5, 15.2 ± 3.2, and 15.7 ± 3.3 min, respectively. Group 1's operating time was significantly longer than all the other groups (P < 0.001 compared with all other groups). The operating times for groups 2, 3, and 4 did not differ significantly (P > 0.05). The cannulation of the femoral vein required a mean of 32 ± 5.3 min for group 1, 24.9 ± 5.7 min for group 2, 18.4 ± 4 min for group 3, and 17.2 ± 3.4 min for group 4. The operating time of group 1 was significantly longer when compared with all groups (P < 0.001 for all groups). Group 2 also had a longer operating time than groups 3 and 4 (P < 0.001 compared with both groups). Groups 3 and 4 did not show any statistical significant difference when their operating time was compared (P > 0.05). CUSUM analysis suggested that the number of cases required to achieve the required experience to most effectively cannulate the jugular and femoral vein is approximately 50 and 100 cases, respectively. The adverse effects of the procedure included two unexpected deaths, both of which occurred in group 1 (0.5% in total). ConclusionsThe authors' experience regarding the learning curve of the cannulation of the femoral and jugular vein in rats from 200 animals operated over a period of 1 y for the evaluation of the pharmacokinetic properties of drug candidates suggests significant experience is required to optimize the operating time required for the procedure.

Ultrasound-guided transversus abdominis plane/genitofemoral blocks for a patient receiving extracorporeal life support.

Extracorporeal life support may be used in patients with refractory cardiogenic shock. The femoral venoarterial route can be used for implanting cannulae in patients who are hemodynamically unstable. Here we describe the use of an ultrasound-guided transversus abdominis plane block supplemented with the femoral component of the genitofemoral nerve as the anesthesia technique for peripheral cannulation of the femoral vessels in a patient with severe acute heart failure after myocardial infarction with ST-segment elevation. The procedure was performed using 40 mL of a 50:50 mixture of 0.5% levobupivacaine and 2% lidocaine (30 mL for transversus abdominis plane and 10 mL for genitofemoral block) associated with low-dose remifentanil infusion during spontaneous breathing. A left ventricular assist device was successfully implanted 4 days later.

PC.88 National survey of the usage of percutaneous femoral arterial and venous catheterisation in Level 3 NICU units

BackgroundFemoral vessel cannulation in neonates is more difficult and done when other forms of access are not available.AimThe aim of this study was to analyse the usage pattern of Percutaneous...

Hybrid arch repair in chronic B dissection.

Since its introduction in 1983 by Hans Borst, numerous variations of the classic elephant trunk technique have been introduced. Among them, the ‘frozen elephant trunk technique’ (FET) certainly represents the most innovative (1). The FET technique, involving arch replacement and concomitant stenting of the descending thoracic aorta, has been developed as a hybrid operation to treat patients with complex pathologies of the thoracic aorta in a single stage (2). Management of chronic type B aortic dissection is challenging. Thoracic endovascular aortic repair (TEVAR), or alternatively, open surgery through a left thoracotomy, is usually indicated in the presence of complications including dilatation or rupture (3). In addition, an uncomplicated type B dissection which dilates over time in the chronic setting can be treated during operations primarily addressing more proximal aneurysms or pathological aortic conditions. Based on our growing experience with FET surgery, we have extended its use to selected patients with chronic type B aortic dissection. In particular, we have used this approach in patients with concomitant pathologies of the proximal aorta and when TEVAR was deemed unfeasible. Here we show a FET procedure in a patient with a chronic type B aortic dissection and concomitant aneurysm of the aortic arch (Video 1). Video 1 Hybrid arch repair in chronic B dissection. The case A 53-year-old man with migrating back pain was admitted to our hospital. Medical history revealed hypertension, smoking, dyslipidemia, and family history of ischemic heart disease. Computed tomography (CT) angiogram showed an acute type B aortic dissection extending to the iliac bifurcation, involving the celiac trunk and left renal artery. The entry tear was located at the proximal descending thoracic aorta, distal to the offspring of the left subclavian artery. A wide abdominal re-entry was identified at the level of the renal arteries, with the maximal diameter at the descending thoracic aorta and the aortic arch being 34 and 46 mm, respectively. Without clinical and imaging signs of impending aortic rupture, medical management was initiated and after 2 weeks, the patient was uneventfully discharged. A CT angiogram was scheduled at 4 months. This revealed a 5 mm growth of the aortic arch, a perfused false lumen without significant dimensional modifications, and obliteration of the celiac trunk (Figure 1). Coronary angiogram ruled out a significant coronary artery disease. Arch replacement with the FET technique was scheduled. Figure 1 The pre-operative CT angiogram scan showed a 50 mm aortic arch aneurysm, a chronic type B aortic dissection with the intimal tear located at the proximal descending thoracic aorta. CT, computed tomography. Surgical techniques A median sternotomy was performed to approach the aorta, the arch vessels, and the heart. After systemic heparinization, a guide wire was inserted through the femoral artery in the true lumen of the descending thoracic aorta, under transesophageal echocardiographic control. The ascending aorta and the right atrium were cannulated for cardiopulmonary bypass (CPB) institution. A left ventricle drainage was inserted through the right superior pulmonary vein and cooling was initiated at nasopharyngeal temperature of 26 °C. The ascending aorta was clamped and myocardial protection achieved by means of antegrade infusion of crystalloid cardioplegia (Custodiol, Koehler Chemie, Alsbach-Haenlein, Germany). Circulatory arrest was subsequently instituted, the aortic arch was opened and antegrade selective cerebral perfusion established (10 mL/kg/min) by means of endoluminal cannulation of the arch vessels (4). The arch was completely resected and the proximal descending aorta was prepared with obliteration of the false lumen using an external Teflon felt fixed with four internal pledgetted U-stitches. The E-vita open plus delivery system was then introduced and appropriately advanced into the descending thoracic aorta over the previously positioned stiff guide-wire. The 30-mm stent graft was carefully deployed into the true lumen. The incorporated Dacron graft was pulled back and sutured to the previously prepared descending aorta using a 2/0 polypropylene running suture. After 10 minutes of lower body reperfusion, the arch vessels were re-implanted ‘en bloc’ to the E-vita open plus prosthesis. Antegrade reperfusion of the arch and thoracoabdominal aorta was then obtained by cannulating the clamped vascular graft. Rewarming was started. The proximal anastomosis to the native ascending aorta completed the aortic repair. Subsequently, CPB was easily weaned off with no need for inotropic support.

Noninvasive Hemodynamic Monitoring Devices

Noninvasive Hemodynamic Monitoring Devices

Does a novel method of PICC insertion improve safety?

Placing a central venous access device via the internal jugular or subclavian vein entails significant risks to both patient and healthcare worker. The purpose of this randomized, prospective study was to determine whether the accelerated Seldinger technique (AST) offers significant safety advantages over the modified Seldinger technique (MST) for peripherally inserted central catheter insertion. Patients were randomly assigned to undergo introducer sheath insertion by means of either MST or AST. Primary outcome measures included time to completion of introducer sheath insertion, estimated blood loss, and success rate. Secondary outcome measures included vessel-to-air exposure events and unprotected sharps exposure. While both insertion methods proved equivalent for successful vessel cannulation, AST was significantly faster (P = 0.0048) and resulted in less blood loss (P = 0.0295) than MST. Additionally, AST resulted in significantly fewer vessel-to-air exposure events (P < 0.0001) and unprotected sharps exposures (P < 0.0001). Although this was a relatively small and unblinded study, the high degree of statistical significance of the study results suggests that, for both patients and healthcare workers, AST is faster and safer than MST for PICC peelable introducer sheath insertion.

Comparison of fenestrated endografts and the snorkel/chimney technique

Recent approval by the Food and Drug Administration of custom fenestrated endografts has increased endovascular options for patients with short-neck or juxtarenal abdominal aortic aneurysms (AAAs). We sought to compare the early learning curve at a single institution of fenestrated repair vs the snorkel technique. From 2009 to 2013, we performed 57 consecutive snorkel procedures for juxtarenal AAAs in an Institutional Review Board-approved prospective cohort, and since the summer of 2012, we gained access to the Food and Drug Administration-approved custom fenestrated device. Patient demographics, imaging, and operative techniques were compared between the first 15 cases for each of the snorkel (sn-EVAR) and fenestrated (f-EVAR) endovascular aneurysm repair (EVAR) techniques. Patient demographics and AAA morphology on preoperative imaging were similar between the groups. Operative time tended to be similar in the 3- to 4-hour range, with more fluoroscopy time and less contrast material used in f-EVAR than in sn-EVAR (P< .05) because of differing strategies of renal premarking. Larger delivery systems for f-EVAR required a higher rate of iliac conduits (40% vs 0%). Perioperative complications, short-term renal patency rates, and evidence of acute kidney injury were similar. The early experience of f-EVAR was similar to that of sn-EVAR in terms of patient demographics, case selection, and procedural characteristics. A significant portion of the learning curve for both procedures, particularly for f-EVAR, lies in the preoperative planning of fenestrations and the cannulation of branch vessels. Similar short-term postoperative outcomes between these two particular techniques indicate that both will have utility in the treatment of high-risk patients with complex anatomy.