Preservation Of Vessels Research Articles

Vessel Health and Preservation Framework: Use of the outcome logic model for evaluation.

Vascular access is an important part of many patient care management plans, but has unwanted risks. A working group led by the Infection Prevention Society (IPS) produced a Vessel Health and Preservation (VHP) Framework. Based on current evidence, a framework was developed for frontline staff to assess and select the best vascular access device to meet the individual patient's needs and to preserve veins for future use. Using the Outcome Logic Model, we conducted an evaluation of the short- and medium-term outcomes with regards to the impact and success of the VHP Framework. This evaluation found that many respondents were aware of the framework and were using it in a range of different ways. Participants saw the framework as being most beneficial to help decisions on device choice and peripheral vein assessment. However, the framework has not fully reached its intended audience. Many positive outcomes were reported as a result of using the VHP Framework including improving clinical practice as it relates to the VHP elements. However, further work is required to find the tools to extend the reach of the framework and assist healthcare teams to be able to fully implement it within their clinical settings.

Endovascular Repair of 40 Visceral Artery Aneurysms and Pseudoaneurysms with the Viabahn Stent-Graft: Technical Aspects, Clinical Outcome and Mid-Term Patency.

Endovascular repair of true visceral artery aneurysms (VAAs) and pseudoaneurysms (VAPAs) with stent-grafting (SG) can simultaneously allow aneurysm exclusion and vessel preservation, minimizing the risk of ischemic complications. Our aim was to report a single-center experience on SG of visceral aneurysms, focusing on technical aspects, clinical outcome and mid-term patency. Consecutive patients affected by VAAs-VAPAs and submitted to endovascular treatment were retrospectively reviewed, and SG cases with the self-expandable peripheral Viabahn stent-graft were analyzed (2003-2017). Aneurysm type, patient number, SG clinical setting, procedural data, peri-procedural complications, technical success, 30-day clinical success, 30-day mortality and follow-up period (aneurysm exclusion, stent-graft patency, ischemic complications) were analyzed. SG was performed in 40 patients (24 VAPAs/16 VAAs) and in 44 procedures (25 in emergency, 19 in elective treatments), via transfemoral in 37 cases (transaxillary in 7 cases). One peri-procedural complication was recorded (a splenic artery dissection successfully converted to transcatheter embolization). The overall technical and clinical success rates were, respectively, 96 and 84%, with excellent trend in elective treatments (both 100%). Overall 30-day mortality was 12.5% (septic shock after pancreatic surgery). Stent-graft thrombosis occurred in 2 patients within 3months, with aneurysm exclusion and without ischemic complications. Stent-graft patency and aneurysm exclusion were confirmed at 6, 12 and 36months in 18, 12 and 7 patients, respectively. SG of VAAs and VAPAs was safe and effective, particularly in elective treatments. The Viabahn stent-graft, flexible and without shape memory, is suitable for endovascular repair of tortuous visceral arteries.

Reducing catheter-related thrombosis using a risk reduction tool centered on catheter to vessel ratio.

In vascular access practices, the internal vessel size is considered important, and a catheter to vessel ratio (CVR) is recommended to assist clinicians in selecting the most appropriate-sized device for the vessel. In 2016, new practice recommendations stated that the CVR can increase from 33 to 45% of the vessels diameter. There has been evidence on larger diameter catheters and increased thrombosis risk in recent literature, while insufficient information established on what relationship to vessel size is appropriate for any intra-vascular device. Earlier references to clinical standards and guidelines did not clearly address vessel size in relation to the area consumed or external catheter diameter. The aim of this manuscript is to present catheter-related thrombosis evidence and develop a standardized process of ultrasound-guided vessel assessment, integrating CVR, Virchow's triad phenomenon and vessel health and preservation strategies, empowering an evidence-based approach to device placement. Through review, calculation and assessment on the areas of the 33 and 45% rule, a preliminary clinical tool was developed to assist clinicians make cognizant decisions when placing intravascular devices relating to target vessel size, focusing on potential reduction in catheter-related thrombosis. Increasing the understanding and utilization of CVRs will lead to a safer, more consistent approach to device placement, with potential thrombosis reduction strategies. The future of evidence-based data relies on the clinician to capture accurate vessel measurements and device-related outcomes. This will lead to a more dependable data pool, driving the relationship of catheter-related thrombosis and vascular assessment.

Does the disruption of horizontal anterior ciliary vessels affect the blood-aqueous barrier function?

To investigate the significance of the anterior ciliary vessels (ACVs) preservation during the conventional horizontal strabismus surgery. Patients (≥ 8years) with horizontal strabismus were randomly allocated into group 1 (with ACV preservation) and group 2 (without ACV preservation). The surgical eyes in group 1 were further divided into group A (one rectus muscle operated) and group B (two rectus muscles operated). Similarly, eyes in group 2 were divided into group C (one rectus muscle operated) and group D (two rectus muscles operated). The success rate of ACV preservation was calculated. The anterior chamber flare measurements of each eye by laser flare photometry were recorded on the day prior to and after operation. The flare values between groups and between pre- and post-operation in each group were compared by one-way analysis of variance and a paired t-test respectively. In groups A and B, the success rate of ACV preservation was 82% (27/33) and 70% (28/40)respectively, and the flare values between pre- and post-operation showed no significant differences(4.378±1.527, 4.544±1.452, P=0.526; 4.625±1.090, 4.989±1.468, P=0.101 respectively). However, the postoperative values were significantly increased in group C and group D(4.661±1.031, 5.039±1.310, P=0.025; 4.933±1.691, 5.502±1.430, P=0.000 respectively). The postoperative flare readings of group D were significantly higher than group B, while group A and group C had no significant variation. ACV preservation probably has clinical significance in reducing the undesirable influence on the blood-aqueous barrier.

A tissue-specific, Gata6-driven transcriptional program instructs remodeling of the mature arterial tree.

Connection of the heart to the systemic circulation is a critical developmental event that requires selective preservation of embryonic vessels (aortic arches). However, why some aortic arches regress while others are incorporated into the mature aortic tree remains unclear. By microdissection and deep sequencing in mouse, we find that neural crest (NC) only differentiates into vascular smooth muscle cells (SMCs) around those aortic arches destined for survival and reorganization, and identify the transcription factor Gata6 as a crucial regulator of this process. Gata6 is expressed in SMCs and its target genes activation control SMC differentiation. Furthermore, Gata6 is sufficient to promote SMCs differentiation in vivo, and drive preservation of aortic arches that ought to regress. These findings identify Gata6-directed differentiation of NC to SMCs as an essential mechanism that specifies the aortic tree, and provide a new framework for how mutations in GATA6 lead to congenital heart disorders in humans.

Using the Vessel Health and Preservation framework to enhance vein assessment and vascular access device selection.

There is a range of risk factors that can lead to peripheral intravenous (IV) cannula failure, and several failed cannulation attempts can result in the patient experiencing increased pain, discomfort and delays in receiving IV therapy. The Vessel Health and Preservation (VHP) framework is a tool that can be used to improve clinical decision-making and the patient experience in relation to vascular access and IV therapy. Use of the VHP framework can ensure the right vein and right vascular access device (VAD) is selected at the right time for each patient. This article describes how healthcare practitioners can use the VHP framework to support and enhance vein assessment and VAD selection. It outlines the various types of VAD available, focusing on short-term peripheral IV cannulae, which are the most commonly used devices. It also explores the potential benefits of implementing the VHP framework in clinical areas.

Histopathological findings in colorectal liver metastases after electrochemotherapy.

Electrochemotherapy of colorectal liver metastases has been proven to be feasible, safe and effective in a phase I/II study. In that study, a specific group of patients underwent two-stage operation, and the detailed histopathological evaluation of the resected tumors is presented here. Regressive changes in electrochemotherapy-treated liver metastases were evaluated after the second operation (in 8–10 weeks) in 7 patients and 13 metastases when the treated metastases were resected. Macroscopic and microscopic changes were analyzed. Electrochemotherapy induced coagulation necrosis in the treated area encompassing both tumor and a narrow band of normal tissue. The area became necrotic, encapsulated in a fibrous envelope while preserving the functionality of most of the vessels larger than 5 mm in diameter and a large proportion of biliary structures, but the smaller blood vessels displayed various levels of damage. At the time of observation, 8–10 weeks after electrochemotherapy, regenerative changes were already seen in the peripheral parts of the treated area. This study demonstrates regressive changes in the whole electrochemotherapy-treated area of the liver. Further evidence of disruption of vessels less than 5 mm in diameter and preservation of the larger vessels by electrochemotherapy is provided. These findings are important because electrochemotherapy has been indicated for the therapy of metastases near major blood vessels in the liver to provide a safe approach with good antitumor efficacy.

Midterm outcomes and evolution of gutter area after endovascular aneurysm repair with the chimney graft procedure

ObjectiveThe objective of this study was to describe our experience with endovascular aneurysm repair (EVAR) with the use of chimney grafts for branch vessel preservation. MethodsPatients treated with a chimney graft procedure between October 2009 and May 2015 were included for analysis. Patients who were not considered eligible for open surgical repair or for conventional, branched, or fenestrated endovascular repair were selected. A standardized operating procedure with left brachial or axillary artery cutdown access for the chimney grafts and bilateral femoral artery cutdown access for the aortic main device was used. Outcomes were noted according to the Society for Vascular Surgery reporting standards. In addition, evolution of gutter area over time was determined. Estimated rates of survival, freedom from aneurysm growth, and clinical success at 24 months of follow-up were calculated. ResultsThirty-three patients (mean age, 77.6 ± 6.8 years; 87.9% male) with a mean preoperative maximum aneurysm diameter of 71.7 ± 13.5 mm were included. A total of 54 of an intended 54 chimney grafts were deployed. Primary technical success and 30-day secondary clinical success rates were 87.9% and 84.8%, respectively. The early mortality rate was 6.1% (n = 2). The early type IA endoleak rate was 6.1% (n = 2), and the chimney graft occlusion rate was 6.1% (n = 2). Median follow-up duration was 26 months (interquartile range, 14.8-37.3 months). The estimated 2-year actuarial survival rate was 78.1% (standard error, ±7.4%). Late complications included type IA endoleak (n = 1), chimney graft occlusion (n = 2), type II endoleak with aneurysm growth (n = 4), and distal stent graft limb kinking and occlusion (n = 1). Late reinterventions included coil or glue embolization (n = 3), distal limb extension (n = 2), open endoleak ligation (n = 2), Palmaz stent placement (n = 1), repeated EVAR (n = 1), and femorofemoral bypass graft (n = 1). At 2 years, the estimated secondary clinical success and freedom from aneurysm growth rates were 80.5% (±7.2%) and 84.4% (±7.2%). Gutter size showed a small but significant decrease over time at the level of the proximal markers and at 10 mm distal from the markers. ConclusionsMidterm results show that a standardized procedure for EVAR using chimney grafts for branch vessel preservation is an acceptable option for high-risk patients with large, complex aneurysms who are unfit for open repair and who have been excluded from fenestrated EVAR. Gutter size decreases over time, but the rate of branch vessel loss and reinterventions demonstrate that this approach should remain reserved for those who are at truly prohibitive risk for open or fenestrated stent graft repair.

Robotic versus laparoscopic distal pancreatectomy: A propensity score-matched study.

Robotic distal pancreatectomy (RDP) is considered a safe and feasible alternative to laparoscopic distal pancreatectomy (LDP). However, previous studies have some limitations including small sample size and selection bias. This study aimed to evaluate whether the robotic approach has advantages over laparoscopic surgery in distal pancreatectomy. Demographics and perioperative outcomes among patients undergoing RDP (n = 102) and LDP (n = 102) between January 2011 and December 2015 were reviewed. A 1:1 propensity score matched analysis was performed between both groups. Both groups displayed no significant differences in perioperative outcomes including operative time, blood loss, transfusion rate, and rates of overall morbidities and pancreatic fistula. Robotic approach reduced the rate of conversion to laparotomy (2.9% vs 9.8%, P = 0.045), especially in patients with large tumors (0% vs 22.2%, P = 0.042). RDP improved spleen (SP) and splenic vessels preservation (SVP) rates in patients with moderate tumors (60.0% vs 35.5%, P = 0.047; 37.1% vs 12.9%, P = 0.025), especially in patients without malignancy (95.5% vs 52.4%, P = 0.001; 59.1% vs 19.0%, P = 0.007). RDP also reduced postoperative hospital stay (PHS) significantly (7.67% vs 8.58, P = 0.032). RDP is associated with less rate of conversion to laparotomy, shorter PHS, and improved SP and SVP rates in selected patients than LDP.

Delayed massive epistaxis from traumatic cavernous carotid false aneurysms: A report of two unusual cases

Introduction Blunt head trauma can injure the cavernous segment of the internal carotid artery (ICA). This may result in a carotid cavernous fistula (CCF). Rarely, a traumatic aneurysm may bleed medially causing massive epistaxis. Case presentation We present two cases of traumatic intracavernous carotid pseudoaneurysms with delayed massive epistaxis. The patients were managed with endovascular treatment involving coil embolization with parent vessel sparing and detachable balloon occlusion with carotid sacrifice. Early clinical outcome was good in both patients. Wherever possible, the CARE1 guidelines were followed in the reporting. Conclusion These cases illustrate the delayed nature of traumatic aneurysms and the need for a high index of suspicion in the presence of skull base fractures. The use of endovascular detachable balloon occlusion and coil embolization treatment with parent vessel preservation is shown.

The implementation of the Vessel Health and Preservation framework.

Vascular access is an important component of health care but is not without associated risks, some of which can be life-threatening. The Vessel Health and Preservation (VHP) framework was developed with the intention of providing frontline staff with a resource to assist in assessing and selecting the best vascular access device to meet individual patient needs and to preserve veins for future use. This article examines the impact of the introduction of the framework into a haematology ward in an acute hospital in the North West of England during a 3-month pilot study. The results indicate that the VHP framework gave nursing staff more autonomy to choose the appropriate vascular access device for their patients and improved staff knowledge around pH and osmolality of intravenous drugs. However it is clear that more in-depth evaluations need to be conducted to assess the impact of VHP on patient care and outcomes.

Retinal vessel delineation using a brain-inspired wavelet transform and random forest

This paper presents a supervised retinal vessel segmentation by incorporating vessel filtering and wavelet transform features from orientation scores (OSs), and green intensity. Through an anisotropic wavelet-type transform, a 2D image is lifted to a 3D orientation score in the Lie-group domain of positions and orientations R2⋊S1. Elongated structures are disentangled into their corresponding orientation planes and enhanced via multi-orientation vessel filtering. In addition, scale-selective OSs (in the domain of positions, orientations and scales R2⋊S1×R+) are obtained by adding a scale adaptation to the wavelet transform. Features are optimally extracted by taking maximum orientation responses at multiple scales, to represent vessels of changing calibers. Finally, we train a Random Forest classifier for vessel segmentation. Extensive validations show that our method achieves a competitive segmentation, and better vessel preservation with less false detections compared with the state-of-the-art methods.

Effect of vessel preservation on splenic volume and function in patients with spleen preserving distal pancreatectomies

Objective: The purpose of this study was to compare splenic function and volume between patients who underwent vessel sparing or vessel ligating (Warshaw) distal pancreatectomies with spleen preservation. Methods: A retrospective cohort study was conducted on patients who received distal pancreatectomies with splenic vessel preservation or ligation at the Toronto General Hospital from 2006–2015. Using Myrian 3-D volumetry software, spleen volumes and hematologic parameters were obtained from pre- and post-operative CT scans. Additional information concerning lesion histology, post-operative complications and laboratory blood values were analyzed. Outcomes included overall and disease free survival. Results: 83 patients received spleen preserving distal pancreatectomies, with volumes calculated on 44 patients. In patients whose spleen volumes were calculated, 8 had their splenic vessels preserved while 36 underwent the Warshaw procedure. Spleen volumes for the Warshaw group increased (mean 200–230 cm3 ANOVA p=0.69) as well as for the vessel sparing group (mean 225–235 cm3, ANOVA p=0.40). The average length of stay for patients undergoing the Warshaw procedure was 6.5 days and 10 days for those undergoing the vessel sparing procedure. 47% of patients who underwent the Warshaw procedure showed signs of splenic infarction within one year post-operatively. Conclusion: When comparing pre- and post-operative spleen volumes and hematologic parameters between vessel-preserving and Warshaw techniques, there is no significant difference in spleen size or function. Our results suggest that the resection of the splenic artery and vein during a Warshaw procedure maintains sufficient splenic perfusion to preserve volume and function.

494 - Tips and Tricks of Splenic Vessel Preservation During Laparoscopic Distal Pancreatectomy

494 - Tips and Tricks of Splenic Vessel Preservation During Laparoscopic Distal Pancreatectomy

Low-profile Visualized Intraluminal Support Junior Device for the Treatment of Intracranial Aneurysms.

Objective: Early case series suggest that the recently introduced Low-profile Visualized Intraluminal Support Junior (LVIS Jr.) device (MicroVention-Terumo, Inc., Tustin, CA) may be used to treat wide-necked aneurysms that would otherwise require treatment with intrasaccular devices or open surgery. We report our single-center experience utilizing LVIS Jr. to treat intracranial aneurysms involving 1.8-2.5 mm parent arteries.Methods: We retrospectively reviewed records of patients treated with the LVIS Jr. device for intracranial aneurysms at a single center. A total of 21 aneurysms were treated in 18 patients. Aneurysms were 2-25 mm in diameter; one was ruptured, while three had recurred after previous rupture and treatment. Lesions were distributed across the anterior (n=12) and posterior (n=9) circulations. Three were fusiform morphology.Results: Stent deployment was successful in 100% of cases with no immediate complications. Seventeen aneurysms were treated with stent-assisted coil embolization resulting in immediate complete occlusion in 94% of cases. Two fusiform aneurysms arising from the posterior circulation were further treated with elective clip ligation after delayed expansion and recurrence; no lesions required further endovascular treatment. Four aneurysms were treated by flow diversion with stand-alone LVIS Jr. stent, and complete occlusion was achieved in three cases. Small foci of delayed ischemic injury were noted in two patients in the setting of antiplatelet medication noncompliance. No in-stent stenosis, migration, hemorrhage, or permanent deficits were observed. Good functional outcome based on the modified Rankin Scale score (mRS ≤ 2) was achieved in 100% of cases.Conclusion: Our midterm results suggest that the LVIS Jr. stent may be used for a variety of intracranial aneurysms involving small parent arteries (1.8-2.5 mm) with complete angiographic occlusion, parent vessel preservation, and functional clinical outcomes. This off-label expansion would increase the number of aneurysms amenable to endovascular treatment. Future studies may build upon our experiences with flow diversion and treatment of complex or multiple lesions.

Locating difficult veins for venepuncture and cannulation.

Vein location and assessment are essential to improve the success rates for vascular access. However, problems remain with first attempt success rates for peripheral cannulation and locating difficult veins. Practitioners may not be aware of developments in technology and aids to assist in the location and assessment of veins to achieve vascular access. This article provides an overview of two vein location aids that can be used to locate difficult veins: the IV-eye vein imager and the Vacuderm tourniquet. It discusses the patient factors that can increase the difficulty of vein assessment and location, and emphasises the importance of vessel health and preservation, and vein palpation. Practitioners should be experienced and skilled in the assessment of veins, and they are encouraged to revisit how they locate and assess veins.

Abstract P2-01-14: Lymphatic microsurgical preventive healing approach (LYMPHA) for the primary prevention of lymphedema

Abstract Background/Objective The incidence of breast cancer related lymphedema is as high as 40% in patients undergoing axillary lymph node dissection (ALND) and radiation. We report our experience performing lymphatic-venous anastomoses (LVA) using Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) at the time of axillary node dissection performed in patients at highest risk for developing lymphedema. This preventative microsurgical procedure was first described by Boccardo, Campisi et al in 2009. Methods Female patients with node positive breast cancer requiring ALND were offered LYMPHA beginning January 2013. Exclusion criteria included allergy to lymphazurin blue dye, pregnancy and pre-existing lymphedema. Immediately following ALND a LVA was performed with optical magnification. Axillary reverse mapping (ARM) using blue dye injected in the ipsilateral upper arm allowed for the identification and preservation of afferent lymphatic vessels, 1-3 (mean 1.5) were sutured into a branch of the axillary vein distal to a competent valve. Limb volume was assessed via circumferential arm measurements and (L-Dex®) bio-impedance spectroscopy. Limb volumes and clinical exam were used to define lymphedema (LE). Results Over 42 months, 52 patients were consented for LYMPHA and 42 completed the LYMPHA procedure. The majority had locally advanced disease, 96% receiving chemotherapy (54% receiving neoadjuvant chemotherapy) and 63% receiving adjuvant radiation. In the 10 patients unable to undergo LYMPHA, all were early in each surgeon's experience. Among these patients, 6 had no suitable lymphatic identified, 3 had no suitable vein and one had extensive axillary disease precluding anastomosis. Of the 42 patients who successfully underwent LVA, 32 had modified radical mastectomy, and 10 patients had breast conserving therapy with ALND. Mean current follow-up is 22 months (range 2-42). 3 of the 42 LYMPHA patients (7.14%) developed clinically-apparent LE. Among the 10 patients without completed LYMPHA, persistent LEdeveloped in 3 (30%). Two patients from each cohort had transient LE which resolved by their 6 month follow up visit. A retrospective review of our historic LE rate from 2009-2014 for patients undergoing ALND demonstrated a LE rate of 31.3%. All patients (32) who had post-operative lymphoscintigraphy demonstrated patency of their LVA. We estimate that performing LYMPHA added 30-45 minutes to operative time. No procedure-related complications were reported. Conclusion Data in our high-risk cohort of patients undergoing ALND shows that LYMPHA is feasible, safe, and practical method for the primary prevention of clinical lymphedema. This technique serves to significantly reduce the rate of clinical LE (7.1 vs 31.3 %) in breast cancer patients. Follow up is ongoing to evaluate the significance of transient lymphedema and bio-impedence measurement abnormalities in our patient population. As our experience grows, we anticipate that the majority of patients undergoing ALND would benefit from the LYMPHA procedure. Larger multi-institution and randomized trials are warranted to further evaluate the effectiveness of LYMPHA. Citation Format: Gomberawalla A, Vandenberge J, Borden B, Rohde C, Ascherman J, Taback B, Chen M, Feldman S. Lymphatic microsurgical preventive healing approach (LYMPHA) for the primary prevention of lymphedema [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-14.

Clinical study on splenic infarction after spleen-preserving distal pancreatectomy

Objective To compare splenic infarction incidence and clinical outcome of spleen-preserving distal pancreatectomy (SPDP) with splenic vessel preservation (SVP, Kimura procedure) or splenic vessel resection (SVR, Warshaw procedure). Methods We retrospectively reviewed clinical data of 181 patients who underwent SPDP for benign and low-grade malignant tumors occurred in pancreatic body and cauda between January 2007 and December 2013. Cases were divided into SVP (n=146) and SVR (n=35) groups. Safety and postoperative complications were compared to evaluate splenic infarction between the two groups. Results There were no significant differences in operation duration, intraoperative blood loss between the two groups (P>0.05). With CT study performed 3 days after operation, splenic infarction incidence was 15.1% (22/146) in SVP group and 60.0% (21/35) in SVR group, all the patients from two groups recovered within 12 months after operation, which were (3.2±3.0) months and (4.8±3.3) months in SVP and SVR groups, respectively. Conclusions Splenic infarction is the main complication resulted from SPDP with SVP and SVR. Nevertheless, the incidence of postoperative splenic infarction is significantly lower in SVP than SVR. Spleen-preserving distal pancreatectomy with splenic vessel preservation is preferred. Key words: Spleen-preserving; Splenic vessel preservation; Splenic vessel resection; Distal pancreatectomy; Kimura procedure; Warshaw procedure

Vessel Health and Preservation: Selection Rights and Dashboard

To assess the technical success of ultrasound (US)-guided peripherally inserted central catheter (PICC) placement at a large academic medical center and evaluate the direct and indirect costs associated with malpositioned catheters.This retrospective chart review consisted of 250 consecutive inpatients and 150 consecutive outpatients (N = 400, aged 58 ± 17 years, 225 men and 175women) who underwent US-guided PICC placement at a single center. Repositioning rates were compared between high-complexity (inpatient) and low-complexity (outpatient) groups using a χ2 test and phi coefficient. Initial and final catheter tip position was assessed by radiography. Direct costs of repositioning were estimated using Medicare reimbursement rates. Indirect costs, including additional staff time, imaging, and delays in treatment, were assessed via a survey of PICC nurses and chart reviews.Initial PICC placement resulted in an optimal tip position in 34% of patients and an optimal or acceptable position in 84% of patients. Repositioning rates were significantly higher for inpatients with a low to moderate association between inpatient PICC placement and the need for repositioning (χ2 = 9.603, P = .002; ϕ = 0.155, P = .002). In total, 77 catheters required repositioning, costing on average an additional $186.03 and 50 minutes of staff time per catheter as well as delaying catheter use in 23 patients for at least 24 hours.PICC malpositioning is a significant source of inefficiency, especially for inpatient services, that should be addressed to reduce expenditures and maximize patients' perceptions of quality health care.

Pulsed laser-induced liquid jet: evolution from shock/bubble interaction to neurosurgical application

The high-speed liquid (water) jet has distinctive characteristics in surgical applications, such as tissue dissection without thermal damage and small blood vessel preservation, that make it advantageous over more conventional instruments. The continuous pressurized jet has been used since the first medical application of water jets to liver surgery in the 1980s, but exhibited drawbacks partly related to the excess water supply required and unsuitability for application to microsurgical instruments intended for deep, narrow lesions (endoscopic instrumentation and catheters) due to limitations in miniaturization of the device. To solve these issues, we initiated work on the pulsed micro-liquid jet. The idea of the pulsed micro-liquid jet originated from the observation of tissue damage by shock/bubble interactions during extracorporeal shock wave lithotripsy and evolved into experimental application for recanalization of cerebral embolisms in the 1990s. The original method of generating the liquid jet was based on air bubble formation and microexplosives as the shock wave source, and as such could not be applied clinically. The air bubble was replaced by a holmium:yttrium-aluminum-garnet (Ho:YAG) laser-induced bubble. Finally, the system was simplified and the liquid jet was generated via irradiation from the Ho:YAG laser within a liquid-filled tubular structure. A series of investigations revealed that this pulsed laser-induced liquid jet (LILJ) system has equivalent dissection and blood vessel preservation characteristics, but the amount of liquid usage has been reduced to less than 2 $$\upmu $$ l per shot and can easily be incorporated into microsurgical, endoscopic, and catheter devices. As a first step in human clinical studies, we have applied the LILJ system for the treatment of skull base tumors through the transsphenoidal approach in 9 patients (7 pituitary adenomas and 2 chordomas), supratentorial glioma (all high grade glioma) in 8 patients, including one with fine perforating vessel involvement, and cerebrovascular disease (1 arteriovenous malformation and 2 intracerebral hemorrhages) in 3 patients. Precise dissection and mass reduction of the tumor were obtained in all tumor cases except for one chordoma with significant fibrosis. Small arteries down to 100 $$\upmu \hbox {m}$$ were preserved, allowing subsequent microsurgical devascularization. Veins were also preserved occasionally. The arachnoid membrane and the tumor capsule were resistant to the LILJ except for one case with prolonged exposure. No complications related to use of the LILJ system were observed. No disturbance of the surgical field by splashing, aerosol, or dissemination of pathological tissue occurred with placement of the optimal suction system. The Ho:YAG LILJ system enhances the advantages of commercialized pressure-driven continuous liquid jet instrumentation in terms of small vessel preservation and accessibility in confined spaces for minimally invasive neurosurgery, and solves some of the drawbacks involved with excessive liquid use and size.