Long-term outcome of variety of techniques used to stabilize left ventricular lead in difficult coronary sinus anatomy- A single centre experience.

INTRODUCTION: Difficult coronary sinus (CS) anatomy may lead to difficulty in optimal left ventricular (LV) lead placement and lead displacements leading to nonresponse to cardiac resynchronization therapy (CRT). METHODS: In this retrospective study, we studied the CRT parameters of devices implanted by single operator during the time period from January 2014 till December 2021, where different off-label techniques were used to place/stabilize LV lead. The technique used to stabilize LV lead, CRT parameters at baseline and follow up were noted for each patient. RESULTS: Out of 133 CRTs implanted during the study period, 23 patients (17.29 %) required off-label techniques. Stylet and guidewire retaining techniques were used in 11/23 (47.82 %) and 7/23 (30.43 %) patients respectively. In two patients, LV lead was jailed using coronary stent to prevent displacement. Two patients had CS stenosis and required balloon dilation while one patient had tortuous posterolateral vein which was straightened using a coronary stent. There was technical failure of 6/23 LV leads (26.08 %) with loss of capture, at a median follow up of 44 months (Range: 06-114 months). Out of these 6 patients, stylet and guidewire retaining techniques were used in 4 and 2 patients respectively. CONCLUSION: Despite having acceptable parameters at implantation, these techniques particularly stylet and guidewire retention, may lead to non-capture of LV lead on long term follow ups. Better LV leads like active fixation leads and conduction system pacing (His Bundle/left bundle branch pacing) should be preferred in difficult CS anatomy.

Wire-in-needle versus conventional syringe-on-needle technique for ultrasound-guided central venous catheter insertion in the internal jugular vein: the WIN randomized trial.

PURPOSE: There are different techniques for ultrasound-guided central venous catheter (CVC) insertion. When using the conventional syringe-on-needle technique, the syringe needs to be removed from the needle after venous puncture to pass the guidewire through the needle into the vein. When, alternatively, using the wire-in-needle technique, the needle is preloaded with the guidewire, and the guidewire-after venous puncture-is advanced into the vein under real-time ultrasound guidance. We tested the hypothesis that the wire-in-needle technique reduces the time to successful guidewire insertion in the internal jugular vein compared with the syringe-on-needle technique in adults. METHODS: We randomized 250 patients to the wire-in-needle or syringe-on-needle technique. Our primary endpoint was the time to successful guidewire insertion in the internal jugular vein. RESULTS: Two hundred and thirty eight patients were analyzed. The median (25th percentile, 75th percentile) time to successful guidewire insertion was 22 (16, 38) s in patients assigned to the wire-in-needle technique and 25 (19, 34) s in patients assigned to the syringe-on-needle technique (estimated location shift: 2 s; 95%-confidence-interval: - 1 to 5 s, p = 0.165). CVC insertion was successful on the first attempt in 103/116 patients (89%) assigned to the wire-in-needle technique and in 113/122 patients (93%) assigned to the syringe-on-needle technique. CVC insertion-related complications occurred in 8/116 patients (7%) assigned to the wire-in-needle technique and 19/122 patients (16%) assigned to the syringe-on-needle technique. CONCLUSION: The wire-in-needle technique-compared with the syringe-on-needle technique-did not reduce the time to successful guidewire insertion in the internal jugular vein. Clinicians can consider either technique for ultrasound-guided CVC insertion in adults.

Analysis of recurrence factors after balloon compression for trigeminal neuralgia and the relationship between pear-shaped balloon and guidewire path.

BACKGROUND: Percutaneous balloon compression (PBC) is widely used to treat trigeminal neuralgia due to its significant efficacy and low treatment cost. However, there is considerable variation in postoperative pain recurrence among patients. Currently, the factors influencing pain recurrence after PBC are under discussion. This study aims to explore the impact of individual patient parameters and surgical parameters on postoperative pain recurrence following PBC. The goal is to provide clinicians with a reference for preoperative assessment of pain recurrence risk and to offer insights for effectively intervening in controllable influencing parameters. METHODS: A analysis was conducted on 114 patients who underwent PBC in the Department of Neurosurgery at Hebei General Hospital. Univariate Kaplan-Meier analysis and multivariate Cox regression analysis were performed on the general and surgical data of the patients to identify factors potentially associated with postoperative pain recurrence. RESULTS: The results of the multivariate Cox regression analysis showed that a history of hypertension, MRI indicating trigeminal nerve compression and a non-ideal pear-shaped balloon were statistically significant factors for pain recurrence after PBC. Additionally, the guidewire path during the procedure had a statistically significant impact on the rate of achieving a pear-shaped balloon (P<0.05). CONCLUSION: A history of hypertension, MRI indicating trigeminal nerve compression and a non-ideal pear-shaped balloon shape are independent risk factors for pain recurrence after PBC. Additionally, to avoid pain recurrence due to an unfavorable balloon shape, it is recommended to use 3D-slicer for preoperative guidewire path simulation and 3D reconstruction of Meckel's cavity.

Development of a Scoring System for Predicting the Difficulty of Bile Duct Cannulation and Selecting the Appropriate Cannulation Method.

BACKGROUND: Selective biliary cannulation in endoscopic retrograde cholangiopancreatography can be challenging due to factors like papillary morphology. Various patterns indicate cannulation difficulty, but the combinations causing difficulty and the optimal cannulation method for each scenario are unclear. AIMS: This study aimed to identify cannulation difficulty patterns and develop a predictive scoring system for selecting the appropriate cannulation method. METHODS: We retrospectively compared 776 patients with naïve papilla, dividing them into conventional contrast cannulation (N = 510) and salvage technique (N = 266) groups. The salvage group included patients using pancreatic duct guidewire placement and/or wire-guided cannulation due to difficulties with the contrast method. Papillary morphology (Haraldsson's classification), periampullary diverticulum (PAD), and scope operability were analyzed using multiple regression to identify risk factors for cannulation difficulties. Factors were scored based on hazard ratios to access combinations causing difficulties. RESULTS: The salvage group had more older patients and higher frequencies of type 2 (small), type 3 (protruding or pendulous), type 4 (creased or ridged) papillae, PAD, and poor scope operability. Significant risk factors in the multivariate analysis included type 2 [odds ratio (OR) 6.88], type 3 (OR 7.74), type 4 (OR 4.06) papillae, PAD (OR 2.26), and poor scope operability (OR 4.03). Pattern recognition scores were significantly higher in the salvage group (1.31 vs. 3.43, P < 0.0001). CONCLUSIONS: Type 2-4 papillae, PAD, and poor scope operability are significant risk factors for cannulation difficulty. Pattern recognition scores based on these factors can predict cannulation difficulty and aid in selecting between conventional and salvage methods.

Central venoplasty followed by 'double guidewire railroad technique' as a bailout strategy in difficult tunnelled dialysis catheter insertion.

End-stage renal disease (ESRD) patients frequently encounter challenges at the time of dialysis catheter insertion from concomitantly associated with thoracic central venous obstruction (TCVO). TCVO complicates the placement of tunnelled dialysis catheters (TDCs). In cases where TCVO is unexpectedly encountered and TDC insertion becomes difficult, central venoplasty followed by catheter reinsertion is required. This report details a novel technique to salvage a TDC that was trapped at the TCVO site after removal of the peel-away sheath. We describe the case of a 67-year-old diabetic male ESRD patient on haemodialysis since 2017, with history of multiple prior accesses, who presented with acute thrombosis of his arteriovenous fistula. TDC placement was attempted via the left internal jugular vein (IJV). Angiography revealed severe stenosis at the left brachiocephalic vein-superior vena cava confluence, necessitating venoplasty. Post-venoplasty, the TDC could not be advanced past the IJV venous entry site due to unfavourable catheter tip profile. Utilising a double guidewire railroad technique, the TDC was successfully reinserted, ensuring functional dialysis. The technique carries potential risks, which mandates careful hemodynamic monitoring and prophylactic measures. In conclusion, percutaneous placement of a TDC following a central venoplasty is at times life-saving in patients with exhausted peripheral vascular access and concomitant TCVO. In the absence of a peel-away sheath, TDC reinsertion using a double guidewire railroad technique is a helpful technique for salvaging the catheter, especially in financially-constrained settings.

Injury of the superficial femoral artery and posterior tibial artery associated with an atherectomy device.

OBJECTIVES: Rotational atherectomy can offer a viable treatment for occlusive peripheral artery disease; maintaining the minimal invasiveness of an endovascular procedure, while allowing for a more complete lesion debridement compared with balloon angioplasty. This case report outlines a complication of guidewire entrapment associated with rotational atherectomy in the superficial femoral artery (SFA). METHODS: A 57-year-old male underwent an atherectomy with Rotorex for left lower limb foot pain. During the procedure, the guidewire was suctioned into the atherectomy device, preventing any further advancement of the device and damaging the SFA and posterior tibial artery (PTA). RESULTS: The atherectomy device was withdrawn and a new vascular access site was gained in the left PTA. A covered stent was inserted to treat the original SFA lesion, and balloon angioplasty was used to repair the device-induced damaged to the PTA. CONCLUSION: While guidewire complications have been previously reported, this case report details the first reported case, to our knowledge, of guidewire entrapment while using a rotational atherectomy device. Knowledge of this possible complication of rotational atherectomy can aid in clinical decision making when choosing between treatments for peripheral vascular disease.

[How to solve difficult side branch access: case report and literature review]. / Je n'arrive pas à passer mon guide dans la branche fille ; cas clinique et revue de la littérature.

We present the case of a 53-year-old patient with history of hypertension and dyslipidemia, admitted for effort-induced angina. Coronary angiography revealed two-vessel disease with severe stenosis of the LAD- Diagonal bifurcation (MEDINA 1-1-1). This lesion was considered complex regarding the severe stenosis of the bifurcation core, the angulation <45°, and the severity and length of the diagonal lesion. The procedure was planned according to a TAP technique. The flow in the diagonal was however lost after stenting the main vessel causing an ST elevation with chest pain. It was subsequently recovered using the rescue jailed balloon technique before re-crossing the stent struts of the LAD using a Gaia First® (Asahi) guidewire. The aim of this case report is to illustrate some pitfalls that can be encountered in bifurcation percutaneous interventions and to present technical solutions to solve difficult side branch access issues through a literature review.

Consequences and management of guidewire fracture-entrapment in the left circumflex artery: a case report.

Background: Entrapment and fracture of the coronary guidewire are rare but major complications of percutaneous coronary intervention (PCI). The incidence of these complications is reported to be <1%. Case summary: A 52-year-old male patient with diabetes and dyslipidaemia presented with posterior wall myocardial infarction. An angiogram revealed occlusion in the left circumflex (LCX) artery. Attempts to pass a guidewire through the lesion led to its entrapment and eventual fracture. Several techniques and manoeuvres failed to retrieve the fractured guidewire, which remained lodged in the LCX. An endovascular snare catheter also proved unsuccessful. The fragment was eventually removed using the triple-wire technique, although this caused coronary perforation and dissection. The perforation was identified and stented. A subsequent stent addressed a dissection in the left main/left ascending artery area, likely caused by the coronary snare. These interventions were crucial in stabilizing the patient's condition, leading to recovery with a left ventricular ejection fraction of 50% and a viable LCX artery. The patient exhibited an uneventful progression at the 1-year follow-up. Discussion: Coronary guidewire fracture during PCI is a rare event often associated with coronary calcifications. Percutaneous removal remains the mainstay treatment for fragment removal; however, it carries risks. The triple-wire technique, a newer method that entangles and extracts the fractured guidewire without specialized equipment, was effective in removing the fragmented guidewire. If asymptomatic, leaving the wire in situ is documented as a favourable approach. This case highlights that the triple-wire technique can effectively be used for the extraction of fractured guidewire fragments from the coronary vessels.

Human in vivo baseline intrarenal pressure, peristaltic activity and response to ureteric stenting.

OBJECTIVES: To assess human in vivo intrarenal pressure (IRP) and peristaltic activity at baseline and after ureteric stent placement, using a narrow calibre pressure guidewire placed retrogradely in the renal pelvis. PATIENTS AND METHODS: A prospective, multi-institutional study recruiting consenting patients undergoing ureteroscopy was designed with ethical approval. Prior to ureteroscopy, the urinary bladder was emptied and the COMET™ II pressure guidewire (Boston Scientific) was advanced retrogradely via the ureteric orifice to the renal pelvis. Baseline IRPs were recorded for 1-2 min. At procedure completion, following ureteric stent insertion, IRPs were recorded for another 1-2 min. Statistical analysis of mean baseline IRP, peristaltic waveforms and frequency of peristaltic contractions was performed, thereby analysing the influence of patient variables and ureteric stenting. RESULTS: A total of 100 patients were included. Baseline mean (±SD) IRP was 16.76 (6.4) mmHg in the renal pelvis, with maximum peristaltic IRP peaks reaching a mean (SD) of 25.75 (17.9) mmHg. Peristaltic activity generally occurred in a rhythmic, coordinated fashion, with a mean (SD) interval of 5.63 (3.08) s between peaks. On univariate analysis, higher baseline IRP was observed with male sex, preoperative hydronephrosis, and preoperative ureteric stenting. On linear regression, male sex was no longer statistically significant, whilst the latter two variables remained significant (P = 0.004; P < 0.001). The mean (SD) baseline IRP in the non-hydronephrotic, unstented cohort was 14.19 (4.39) mmHg. Age, α-blockers and calcium channel blockers did not significantly influence IRP, and no measured variables influenced peristaltic activity. Immediately after ureteric stent insertion, IRP decreased (mean [SD] 15.18 [5.28] vs 16.76 [6.4] mmHg, P = 0.004), whilst peristaltic activity was maintained. CONCLUSIONS: Human in vivo mean (SD) baseline IRP is 14.19 (4.39) mmHg in normal kidneys and increases with both hydronephrosis and preoperative ureteric stenting. Mean (SD) peristaltic peak IRP values of 25.75 (17.9) mmHg are reached in the renal pelvis every 3-7 s and maintained in the early post-stent period.

Focal alveolar hemorrhage following guide-wire progression into the pulmonary arterial circulation during fibrin sheath angioplasty and catheter exchange: Case report.

Central venous catheters are a frequently used vascular access for hemodialysis. Fibrin sheath formation is a common complication and is associated with catheter malfunction. Although fibrin sheath angioplasty with catheter exchange is a frequently employed procedure, it can be associated with mechanical complications. An important technical step in this procedure is progression of the guide-wire into the inferior vena cava. Focal alveolar hemorrhage is a very rare complication of this procedure. We report a case of a 70-year old patient on dual antiplatelet therapy who underwent fibrin sheath angioplasty with guide-wire catheter exchange and experienced focal alveolar hemorrhage presenting as hemoptysis and acute type 1 respiratory failure. Progression of the guide-wire into the pulmonary circulation and antithrombotic therapy played a significant role in the development of this complication. This report aims to call attention to a poorly described and potentially serious yet avoidable complication of fibrin sheath angioplasty with guide-wire catheter exchange.

Endoscopic ultrasound-guided rendezvous techniques for difficult biliary cannulation: Technical review.

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard procedure for the diagnosis and treatment of biliary diseases. However, selective biliary cannulation, the essential first step in ERCP, can sometimes fail due to anatomical variations or technical limitations. In these cases, the endoscopic ultrasound-guided rendezvous technique (EUS-RV) offers a valuable salvage option. Nevertheless, it is crucial to be aware of potential adverse events associated with bile duct puncture. To optimize the success rate and safety of EUS-RV, understanding the basic techniques, technical tips for each procedural step, and troubleshooting strategies for potential difficulties is essential. This review article summarizes the clinical outcomes and technical considerations of EUS-RV, including a comprehensive analysis of the current evidence.

Salvaging intraluminal peritoneal dialysis catheter obstruction from blood clot with a targeted thrombolytic agent: an innovation.

Peritoneal dialysis (PD) catheter malfunction commonly leads to the removal of the catheter and eventually to a transfer to hemodialysis. The most common cause is intraluminal obstruction caused by blood and fibrin clots. Recommended interventions include irrigation of the catheter with heparinized saline; if this method fails, thrombolytic agents may be used. Mechanical methods such as intraluminal brushing are also utilized, typically after medical treatment fails. Here, we present a case of a patient who developed an intraluminal blood clot that persisted despite attempts with intraluminal thrombolytic drugs and intraluminal brushing. To salvage the catheter, targeted thrombolysis was performed using an endoscopic retrograde cholangiopancreatography (ERCP) guidewire to reinforce the coiled PD catheter and puncture the clots. Additionally, a Swing Tip cannula was employed for direct injection of the thrombolytic agent. These interventions successfully preserved the catheter, resolving the clot and ensuring continued functionality.

Needle-free, Novel Fossa Ovalis Puncture with Percutaneous Transluminal Coronary Angioplasty Guidewire and Microcatheter in Pigs and a Human with an Extremely Tortuous Inferior Vena Cava.

Background: Transseptal puncture (TSP) performed with the Brockenbrough (BRK) needle is technically demanding and carries potential risks. The back end of the percutaneous transluminal coronary angioplasty (PTCA) guidewire is blunt and flexible, with good support, it can puncture the right ventricle-free wall, which is thicker than the atrial-septum. The guidewire is thin and easy to manipulate. This study evaluated the performance of TSP with a PTCA guidewire and microcatheter without a needle. Methods: The back end of a PTCA guidewire was advanced into the Tiger (TIG) catheter, within the SL1 sheath, to puncture the fossa ovalis (FO) under fluoroscopy. Subsequently, the microcatheter was inserted into the left atrium (LA) above the guidewire, and the front end of the guidewire was exchanged in the LA. After the puncture site was confirmed by contrast, the TIG catheter and a 0.032 inch wire were advanced into the LA. Finally, the sheath, with the dilator, was advanced over the wire into the LA. The safety margin of this method was tested in a pig model. Results: The puncture was successful in all seven pigs tested with a puncture-to-sheath entry time of < 20 minutes and no procedure-related complications. The method was successfully used to perform a difficult TSP in a patient with an extremely tortuous inferior vena cava, in whom puncture with a BRK needle had repeatedly failed. Conclusions: Cardiologists may use the PTCA guidewire and microcatheter as an alternative to the needle while performing TSP in special conditions, such as an extremely tortuous inferior vena cava.

2D array imaging system for mechanically-steered, forward-viewing ultrasound guidewire.

Approximately 4 million people with peripheral artery disease (PAD) present with critical limb ischemia each year, requiring urgent revascularization to avoid loss of limb. Minimally-invasive (i.e. endovascular) revascularization is preferable due to increased recovery time and increased risk of complications associated with open surgery. However, 40% of people with PAD also have chronic total occlusions (CTOs), resulting in > 20% of revascularization procedures failing when CTOs are present. A steerable robotic guidewire with integrated forward-viewing imaging capabilities would allow the guidewire to navigate through tortuous vasculature and facilitate crossing CTOs in revascularization procedures that currently fail due to inability to route the guidewire. The robotic steering capabilities of the guidewire can be leveraged for 3D synthetic aperture imaging with a simplified, low element count, forward-viewing 2D array on the tip of the mechanically-steered guidewire. Images can then be formed using a hybrid beamforming approach, with focal delays calculated for each element on the tip of the guidewire and for each physical location to which the robotically-steered guidewire is steered. Unlike synthetic aperture imaging with a steerable guidewire having only a single element transducer, an array with even a small number of elements can allow estimation of blood flow and physiological motion in vivo. A miniature, low element count 2D array transducer with 9 total elements (3 × 3) having total dimensions of 1.5 mm × 1.5 mm was designed to operate at 17 MHz. A proof-of-concept 2D array transducer was fabricated and characterized acoustically. The developed array was then used to image a wire target, a peripheral stent, and an ex vivo porcine iliac artery. Images were formed using the described synthetic aperture beamforming strategy. Acoustic characterization showed a mean resonance frequency of 17.6 MHz and a -6 dB bandwidth of 35%. Lateral and axial resolution were 0.271 mm and 0.122 mm, respectively, and an increase in SNR of 4.8 dB was observed for the 2D array relative to the single element case. The first 2D array imaging system utilizing both mechanical and electronic steering for guidewire-based imaging was developed and demonstrated. A 2D array imaging system operating on the tip of the mechanically-steered guidewire provides improved frame rate and increases field of view relative to a single element transducer. Finally, 2D array and single element imaging were compared for introduced motion errors, with the 2D array providing a 46.1% increase in SNR, and 58.5% and 17.3% improvement in lateral and axial resolution, respectively, relative to single element guidewire imaging.

An unsupervised learning-based guidewire shape registration for vascular intervention surgery robot.

In a vascular interventional surgery robot(VISR), a high transparency master-slave system can aid physicians in the more precise manipulation of guidewires for navigation and operation within blood vessels. However, deformations arising from the movement of the guidewire can affect the accuracy of the registration, thus reducing the transparency of the master-slave system. In this study, the degree of the guidewire's deformation is analyzed based on the Kirchhoff model. An unsupervised learning-based guidewire shape registration method(UL-GSR) is proposed to estimate geometric transformations by learning displacement field functions. It can effectively achieve precise registration of flexible bodies. This method not only demonstrates high registration accuracy but also performs robustly under different complexity degrees of guidewire shapes. The experiments have demonstrated that the UL-GSR method significantly improves the accuracy of shape point set registration between the master and slave sides, thus enhancing the transparency and operational reliability of the VISR system.

Escaping a Nightmare: Successfully Retrieving a Fractured Guidewire During Percutaneous Coronary Intervention.

A guidewire fracture seldom occurs as a complication of percutaneous coronary intervention (PCI). Guidewire fragments retained in the coronary tree can result in thrombosis, embolic phenomena, dissection, perforation, and vessel occlusion. This study represents a rare incidence of fractured guide wire, which occurred during PCI in a 44-year-old male due to the acute angle and heavy calcification which was safely and successfully retrieved using a 4×40 mm Solitaire device (Irvine, CA: Medtronic) (neurovascular remodeling device).