Routine External Iliac Artery Cannulation in Robotic Cardiac Surgery: Role of the Corona "Vitae" in Distal Limb Perfusion.

OBJECTIVE: Femoral artery cannulation is the most commonly used approach for cardiopulmonary bypass (CPB) in robotic cardiac procedures. However, without adding a distal perfusion cannula, leg ischemia can occur in up to 11.5% of patients. There is a well-described 2 to 4 mm size arterial branch that originates from the medial side of the external iliac artery or inferior epigastric artery, immediately above the inguinal ligament, and connects to the obturator artery. Therefore, it was historically named the corona mortis, which means "crown of death" in Latin. When peripheral cannulation is performed above this branch in the external iliac artery, we consider it a corona "vitae" because of its role as a limb-saving collateral. We report herein our standard technique of peripheral cannulation without the need of a distal perfusion cannula and preventing limb ischemia. METHODS: We included all patients who underwent robotic cardiac surgery with peripheral cannulation over a 16-month period at our institution. We cannulated just above the level of the inguinal ligament through a 2 to 3 cm transverse skin incision. The incidence of limb ischemia and vascular complications was recorded and analyzed. RESULTS: During the study period, 133 patients underwent robotic cardiac procedures with peripheral "external iliac" CPB. The size of the cannula was 21F or larger in 73% and 23F in 54% of the patients. No leg ischemia or femoral artery complications requiring additional intervention occurred. CONCLUSIONS: External iliac cannulation can be successfully performed in robot-assisted cardiac surgery using relatively large cannulas without the need of a distal limb perfusion catheter, with good results. In our view, given the importance of the corona mortis ("crown of death" in Latin) in perfusing the limb during CPB, we propose a new name for this artery in robotic cardiac surgery, namely, the corona vitae ("crown of life" in Latin).

Cannula to Femoral Artery Diameter Ratio Predicts Potential Lower-Limb Ischemia in Minimally Invasive Cardiac Surgery With Femoral Cannulation.

OBJECTIVE: Lower-limb ischemia is a complication of minimally invasive cardiac surgery with femoral cannulation. Herein, we verified our strategy using distal perfusion cannulation (DPC) against this complication. METHODS: We retrospectively assessed 91 cases of aortic valve replacement with femoral cannulation between January 2019 and March 2023. DPC was applied when lower-limb tissue oxygenation index declined by ≥20%. The cannula to femoral artery diameter ratio (C/FA) was calculated by dividing the cannula size (Fr) divided by 3 by the femoral artery inner diameter (mm). Postoperative maximum creatinine kinase (CKmax), lactate dehydrogenase (LDHmax), and lactate levels were analyzed, and univariable logistic regression and receiver operating characteristic curve analyses were employed to determine DPC predictors and the cutoff C/FA for DPC, respectively. Patients without DPC were divided into 2 subgroups based on the cutoff C/FA for further comparisons. RESULTS: DPC was required in 9 patients. Symptomatic ischemia was not observed. All laboratory data were similar in the DPC and non-DPC groups. C/FA was significantly associated with DPC (odds ratio = 1.27, 95% confidence interval: 1.09 to 1.47, P = 0.002), and the cutoff C/FA was 0.70 (sensitivity = 0.89, specificity = 0.80). In the non-DPC group, CKmax (P = 0.027) and LDHmax (P = 0.041) were significantly higher in patients with C/FA ≥0.7 (n = 16) than in those with C/FA <0.7 (n = 66). CONCLUSIONS: Our strategy for preventing symptomatic ischemia is reasonable and could be almost achieved without DPC when C/FA is <0.7. C/FA also predicts asymptomatic potential ischemia, and proactive DPC is preferable when C/FA is ≥0.7.

Axillary vs Femoral Arterial Cannulation in Acute Type A Dissection: International Multicenter Data.

BACKGROUND: Cannulation strategy in acute type A dissection (ATAD) varies widely without known gold standards. This study compared ATAD outcomes of axillary vs femoral artery cannulation in a large cohort from the International Registry of Acute Aortic Dissection (IRAD). METHODS: The study retrospectively reviewed 2145 patients from the IRAD Interventional Cohort (1996-2021) who underwent ATAD repair with axillary or femoral cannulation (axillary group: n = 1106 [52%]; femoral group: n = 1039 [48%]). End points included the following: early mortality; neurologic, respiratory, and renal complications; malperfusion; and tamponade. All outcomes are presented as axillary with respect to femoral. RESULTS: The proportion of patients younger than 70 years in both groups was similar (n = 1577 [74%]), as were bicuspid aortic valve, Marfan syndrome, and previous dissection. Patients with femoral cannulation had slightly more aortic insufficiency (408 [55%] vs 429 [60%]; P = .058) and coronary involvement (48 [8%] vs 70 [13%]; P = .022]. Patients with axillary cannulation underwent more total aortic arch (156 [15%] vs 106 [11%]; P = .02) and valve-sparing root replacements (220 [22%] vs 112 [12%]; P < .001). More patients with femoral cannulation underwent commissural resuspension (269 [30.9%] vs 324 [35.3%]; P = .05). Valve replacement rates were not different. The mean duration of cardiopulmonary bypass was longer in the femoral group (190 [149-237] minutes vs 196 [159-247] minutes; P = .037). In-hospital mortality was similar between the axillary (n = 165 [15%]) and femoral (n = 149 [14%]) groups (P = .7). Furthermore, there were no differences in stroke, visceral ischemia, tamponade, respiratory insufficiency, coma, or spinal cord ischemia. CONCLUSIONS: Axillary cannulation is associated with a more stable ATAD presentation, but it is a more extensive intervention compared with femoral cannulation. Both procedures have equivalent early mortality, stroke, tamponade, and malperfusion outcomes after statistical adjustment.

Development and usability of a virtual reality umbilical venous catheter placement simulator.

PURPOSE: Exposure to procedures varies in the neonatal intensive care unit (NICU). A method to teach procedures should be available without patient availability, expert oversight, or simulation laboratories. To fill this need, we developed a virtual reality (VR) simulation for umbilical vein catheter (UVC) placement and sought to establish its face and content validity and usability. METHODS: Engineers, software developers, graphic designers, and neonatologists developed a VR UVC placement simulator following a participatory design approach. The software was deployed on the Meta Quest 2 head-mounted display (HMD). Neonatal nurse practitioners (NNPs) from a level 4 NICU used the simulator and completed an 11-item questionnaire to establish face and content validity. Participants also completed the validated simulation task load index and system usability scale to assess the usability of the simulator. Group 1 tested the VR simulation, which was optimized based on feedback, prior to Group 2's participation. RESULTS: A total of 14 NNPs with 2-37 years of experience participated in testing. Participants scored the content and face validity of the simulator highly, with most giving scores ≥ 4/5. Usability was established with relatively high average system usability scores for both groups (Group 1: 67.14 ± 7.8, Group 2: 71 ± 14.1) and low SIM-TLX scores indicating manageable load while using the simulator. CONCLUSION: After optimization, Group 2 found the UVC simulator to be realistic and effective. Both groups felt the simulator was easy to use and did not cause physical or cognitive strain. All participants felt the UVC simulator provided a safe environment to make mistakes, and the majority would recommend this experience to trainees.

The safe implementation of peripherally inserted central catheters by nurse practitioners for patients with gastroenterological diseases in Japan: a single-center retrospective study.

PURPOSE: As a safe and reliable alternative to central venous catheters (CVCs), peripherally inserted central catheters (PICCs) are commonly used in clinical practice. However, the insertion of PICCs by nurse practitioners (NPs), especially in Japan, has not been reported extensively. Thus, we investigated the safety and efficiency of PICC insertions by NPs. METHODS: The participants were 1322 patients who underwent PICC insertion by NPs at Fujita Health University Hospital (FNPs). The basilic vein in the brachium was the preferred vein for insertion; the brachial vein was the alternative. Patients were monitored from the time of PICC insertion until its removal. Ultrasonography-guided puncture was used for all catheter insertions, and the catheter tip was replaced into the superior vena cava under fluoroscopic imaging with maximal sterile barrier precautions. The outcomes of the PICC insertions by the FNPs were evaluated retrospectively. RESULTS: Overall, 23 FNPs inserted a collective total of 1322 PICCs, which remained in place for a collective total of 23,619 catheter days. The rate of successful PICC insertion was 99% (1310 patients). The median time taken for PICC insertion was 12 min (interquartile range, 10-15 min). Intraoperative complications occurred in two patients (0.2%). The confirmed incidence of central line-associated bloodstream infection was 3.4% (45 patients), and these infections occurred on 1.9 per 1000 catheter days. The median duration of PICC placement was 15 days (range, 10-23 days). CONCLUSION: PICC insertion by NPs is safe and a potential alternative to CVC insertion by surgeons.

Implementation of Tunneled Peripherally Inserted Central Catheters Placement in Cancer Patients: A Randomized Multicenter Study.

This study sought to evaluate the impact of the subcutaneous tunneling technique on peripherally inserted central catheter (PICC) placement. We randomized 694 patients who needed PICC placement to either the tunneled PICCs (experimental group) or the non-tunneled PICCs (control group) from August to December 2021. The cumulative frequency of complications was assessed as the primary outcome. Secondary outcomes comprised of the amount of bleeding, catheter insertion time, self-reported pain score, and one-puncture success rate. After 6 months of follow-up, the tunneled PICCs group showed a significant decrease in the frequency of total complications, especially in infection (3.0% vs. 7.1%, p = .021) and catheter-related thrombosis (3.3% vs. 8.3%, p = .008), although approximately 0.5 ml bleeding and 3.5 min time were increased. This randomized multicenter study supports the efficacy of subcutaneous tunneling technology in reducing PICC-related complications, enhancing patient comfort, and encouraging using subcutaneous tunneling technology for PICC placement.

Transbrachial Artery as Single or Combined Approach for Complex Interventions in Patients with Peripheral Artery Disease.

BACKGROUND: This study aimed to assess the safety and efficacy of the transbrachial approach as a single or combined procedure for complex interventions in peripheral artery disease (PAD). METHODS: Between March 2011 and April 2021, 169 patients with PAD underwent endovascular therapy via the transbrachial approach as a single or dual procedure. Univariate and multivariate analyses were performed to evaluate the predictors of adverse events at the brachial puncture site. All demographic, clinical, and perioperative data were acquired from electronic medical records and retrospectively analyzed. RESULTS: Brachial artery access was used alone and in combination in 87 and 82 patients, respectively. Patients in the combined-approach group underwent more intraoperative stent implantations and had more vascular closure devices (VCD). Multivariate logistic regression analysis revealed that hypertension was an independent factor for higher rates of brachial puncture site adverse events (odds ratio, 4.76; 95% confidence interval, 1.33-16.97; P = 0.016). Brachial artery access-site complications occurred in 26 patients, including 6 (23.1%) major and 20 (76.9%) minor entry-site complications. Entry-site complications were observed in 21 (16.8%) and 5 (11.4%) patients assigned to manual compression and VCD groups, respectively. There were no significant intergroup differences in the incidence of major or minor complications. Interestingly, patients assigned to the VCD group did not experience major entry-site complications. CONCLUSIONS: The transbrachial approach, as a single or combined procedure, is a safe alternative to complex interventions in patients with PAD. Complications of brachial access progressively decrease with improved blood pressure control.

Safety and learning curve of percutaneous axillary artery access for complex endovascular aortic procedures.

BACKGROUND: Percutaneous axillary artery access is increasingly used for large-bore access during interventional vascular and cardiac procedures. The aim of this study was to evaluate the safety and learning curve of percutaneous axillary artery access in patients undergoing complex endovascular aortic repair (fenestrated and branched endovascular aneurysm repair [FBEVAR]) requiring large-bore upper extremity access and to discuss best practices for technique and complication management. METHODS: One-hundred forty-six patients undergoing large-bore percutaneous axillary artery access during FBEVAR in a prospective, nonrandomized, Investigational Device Exemption study between September 2017 and January 2023 were analyzed. Ultrasound guidance and micropuncture were used to access the second portion of the axillary artery and 2 Perclose Proglide or Prostyle devices (Abbott Vascular) were predeployed before the insertion of the large-bore sheath. Completion angiography was performed in all patients to verify hemostatic closure. Axillary artery patency was also assessed on follow-up computed tomography angiography. Patient-related, procedural, and postoperative variables were collected and analyzed. RESULTS: One-hundred forty-five patients underwent successful percutaneous axillary artery access; 1 patient failed axillary access and alternative access was established. The left axillary artery was accessed in 115 patients (79%), and the right axillary artery was accessed in 30 patients (21%). The largest profile sheath was 14 F in 4 patients (2.8%), 12F in 133 patients (91.7%), and 8F in 8 patients (5.5%). Ten patients (6.9%) required covered stent placement (Viabahn, W. L. Gore & Associates) for failure to achieve hemostasis; there were no conversions to open surgical repair. Additional adverse events included transient upper extremity weakness in two patients (1.3%) and transient upper extremity paresthesias in two patients (1.3%). Three patients (2%) suffered postoperative strokes, including one unrelated hemorrhagic stroke and two possibly access-related embolic strokes. On follow-up, axillary artery patency was 100%. There was a trend toward decreased closure failure over time, with seven patients (10%) in the early cohort and three (4%) in the late cohort. There was a significant negative correlation between the cumulative complication rate and the cumulative experience. CONCLUSIONS: Large-bore percutaneous axillary artery access provides safe upper extremity large-bore access during FBEVAR, achieving successful closure in >90% of patients with a low incidence of access-related complications. There was a trend toward better closure rates with increasing experience, suggesting a learning curve effect. Application of best practices including ultrasound guidance and angiography may ensure safe application of the technique of percutaneous large-bore axillary artery access.

Surgical retrieval of transected umbilical vein catheter in an extremely preterm neonate.

Umbilical catheters are used in the care of critically ill neonates for intravenous treatment. It is generally considered a safe procedure, although complications can occur. Of these, catheter breakage and intravenous migration are rare but potentially life-threatening events. Due to the low frequency of which these events occur, obtaining detailed descriptions of removal techniques can pose a challenge. Here, we describe a case of a broken umbilical vein catheter and the surgical retrieval of the retained fragment. We also present a thorough literature search of cases of broken umbilical catheters and the method by which they were removed.

Comparison of ultrasound guidance and palpation technique for femoral artery catheterization in children undergoing cardiac surgery.

OBJECTIVE: The aim of this study was compare the palpation technique and ultrasound-guidance for femoral artery catheterization in pediatric patients undergoing surgery for congenital heart disease. MATERIALS AND METHODS: This prospective and randomized controlled study included American Society of Anesthesiologists III-IV 40 children who underwent congenital heart surgery. The patients were divided into two groups; ultrasound-guided catheterization group and palpation-guided catheterization group. Demographic and clinical characteristics of the patients, access time, success rate, number of attempts, first-attempt success, number of trials, and failed cannulations were recorded. RESULTS: The diameter of the femoral artery was significantly shorter, access time and numbers of trials were significantly lower, and first-attempt success rate was significantly higher in the US group. The complication rate was significantly higher in the P group. The number of failed catheterization was higher in the P group. Total cost required for the procedure was significantly lower in the US group. CONCLUSION: We found that ultrasound-guided arterial catheterization increases the success rate and the number of successful catheterizations, while reducing the overall procedure time, incidence of complications, and cost. Therefore, we believe that the use of ultrasound guidance in arterial catheterization in pediatric cardiac surgery would be a better choice.

OBJETIVO: El objetivo de este estudio fue comparar la técnica de palpación y ecoguiado para el cateterismo de la arteria femoral en pacientes pediátricos operados de cardiopatías congénitas. MATERIALES Y MÉTODOS: Este estudio prospectivo, aleatorizado y controlado incluyó a 40 niños ASA III-IV que se sometieron a cirugía cardíaca congénita. Los pacientes se dividieron en 2 grupos; Grupo de cateterismo guiado por ecografía y grupo de cateterismo guiado por palpación. RESULTADOS: El diámetro de la arteria femoral fue significativamente más corto, el tiempo de acceso y el número de intentos fueron significativamente menores y la tasa de éxito del primer intento fue significativamente mayor en grupo estadounidense. La tasa de complicaciones fue significativamente mayor en el grupo P. El número de cateterismos fallidos fue mayor en el grupo P. El costo total requerido para el procedimiento fue significativamente menor en el grupo de EE. CONCLUSIONES: Encontramos que el cateterismo arterial guiado por ultrasonido aumenta la tasa de éxito y el número de cateterismos exitosos, al tiempo que reduce el tiempo total del procedimiento, la incidencia de complicaciones y el costo. Por tanto, creemos que el uso de guía ecográfica en cateterismo arterial en cirugía cardiaca pediátrica sería una mejor opción.

Clinical characteristics of peripherally inserted central catheter-related complications in cancer patients undergoing chemotherapy: a prospective and observational study.

PURPOSE: The incidence of peripherally inserted central catheter (PICC)-related complications is higher in cancer patients than in noncancer patients. However, the pattern of specific complication occurrence over time remains unclear. The purpose of this study was to investigate the clinical characteristics of PICC-related complications in cancer patients undergoing chemotherapy. METHODS: This prospective, observational study was conducted at a university-affiliated hospital in Western China. Cancer patients undergoing PICC insertion for anticancer treatment were recruited and followed up until the first week after catheter removal. Any complications, including occurrence time and outcomes, were recorded. The trajectory of specific PICC-related complications over time were identify based on the Kaplan‒Meier curve analysis. RESULTS: Of the 233 patients analyzed, nearly half (n = 112/233, 48.1%) developed 150 PICC-related complication events. The most common were symptomatic catheter-related thrombosis (CRT) (n = 37/233, 15.9%), medical adhesive-related skin injury (MARSI) (n = 27/233, 11.6%), and catheter dislodgement (n = 17/233, 7.3%), accounting for 54.0% (n = 81/150, 54.0%) of total complications events. According to Kaplan‒Meier curve analysis, symptomatic CRT, pain, phlebitis, and insertion site bleeding were classified as the "early onset" group mainly occurring within the first month post-insertion. Catheter fracture and catheter-related bloodstream infection were classified as the "late onset" group occurring after the second month post-insertion. MARSI, catheter dislodgement, occlusion, and insertion site infection were classified as the "persistent onset" group persistently occurring during the whole catheter-dwelling period. Among the 112 patients with PICC-related complications, 50 (44.6%) patients had their catheters removed due to complications, and 62 (55.4%) patients successfully retained their catheters until treatment completion through conventional interventions. The major reasons for unplanned catheter removal were catheter dislodgement (n = 12/233, 5.2%), symptomatic CRT (n = 10/233, 4.3%), and MARSI (n = 7/233, 3.0%), accounting for 58.0% (n = 29/50, 58.0%) of the total unplanned catheter removal cases. Catheter dwelling times between patients with complications under successful interventions (130.5 ± 32.1 days) and patients with no complications (138.2 ± 46.4 days) were not significantly different (t = 1.306, p = 0.194; log-rank test = 2.610, p = 0.106). CONCLUSIONS: PICC-related complications were pretty common in cancer patients undergoing chemotherapy. The time distribution of PICC-related complications varied, and medical staff should develop time-specific protocols for prevention. Because more than half of the patients with PICC-related complications could be managed with conventional interventions, PICCs remain a priority for cancer patients undergoing short-term chemotherapy. The study was registered in 02/08/2019 at Chinese Clinical Trial Registry (registration number: ChiCTR1900024890).

Complex high-risk percutaneous coronary intervention types, trends, and outcomes according to vascular access site.

BACKGROUND: Radial access is associated with improved outcomes following percutaneous coronary intervention (PCI); however, its role in complex, high-risk percutaneous coronary intervention (CHiP) remains poorly studied. METHODS: We studied retrospectively all registered patients's records from the British Cardiovascular Intervention Society dataset and compared the baseline characteristics, trends and outcomes of CHiP procedures performed electively between January 2006 and December 2017 according to the access site. RESULTS: Out of 137,785 CHiP procedures, 61,825 (44.9%) were undertaken via transradial access (TRA). TRA use increased over time (14.6% in 2006 to 67% in 2017). The TRA patients were older, with a greater prevalence of previous stroke, hypertension, peripheral vascular disease, and smokers. TRA was used more frequently in most CHiP procedures (elderly (51.6%), chronic renal failure (52.6%), poor left ventricular (LV) function (47.6%), left main PCI (48.0%), treatment for severe vascular calcification (50.3%); although transfemoral access (TFA) was used more commonly in those with prior history of coronary artery bypass graft surgery, and PCI to a chronic total occlusion and LV support patients. Following adjustment for differences in clinical and procedural characteristics, TFA was independently associated with higher odds for mortality [adjusted odds ratio (aOR): 1.3 (1.1-1.7)], major bleeding [aOR: 2.9 (2.3-3.4)], and MACCE (following propensity score matching) [aOR: 1.2 (1.1-1.4)]. The same was found with multiple accesses: mortality [aOR: 2.1 (1.5-2.8)], major bleeding [aOR: 5.5 (4.3-6.9)], and MACCE [aOR: 1.4 (1.2-1.7)]. CONCLUSION: TRA has become the predominant access site for CHiP procedures and is associated with significantly lower mortality, major bleeding and MACCE odds than TFA.

Transradial Access for Transarterial Radioembolization (TARE) in Patients with Hepatocellular Carcinoma: Comparison with Transfemoral Access.

PURPOSE: To compare safety, efficacy, radiation exposure and patients comfort in patients of transradial access (TRA) in patients undergoing TARE compared with transfemoral access (TFA) including patient radiation exposure and patient comfort. METHODS: A total of 222 patients undergoing technetium-99 m macro-aggregated albumin and TARE were retrospectively reviewed from 2017 to 2022. We analyzed procedure-related pain, quality of life, recovery time, procedure time, fluoroscopy time (FT), air kerma product and air kerma (AK) to compare the two access for intervention for HCC. RESULTS: A total of 222 [(TFA (n = 147) and TRA (n = 75)] patients who underwent TARE for hepatocellular carcinoma (HCC) were included. No significant difference was found regarding FT and DAP in comparison of TRA and TFA. (p = 0.385, p = 0.842). While the mean AK was 892.7 mGy in TFA patients, it was 545.2 mGy in TRA patients and there was statistically significant difference (p = 0.017). Patients who underwent TRA had significantly shorter hospital stays, and recovery times compared to those who underwent TFA (p = 0.001, p = 0.001). In terms of both mental health and physical function, TRA versus TFA has been observed to produce more favorable outcomes (p = 0.044, p = 0.032). CONCLUSION: TRA access for TARE procedures significantly enhances patient comfort and satisfaction. The total radiation dose exposed to the patients who underwent TRA access was found to be significantly lower than the patients who underwent TFA access.

[Application of Midline Catheter Placed Under Ultrasound Guidance in Intravenous Therapy for Oral and Maxillofacial Tumor].

Objective: To examine the application effect of ultrasound-guided placement of midline catheter and to select the appropriate placement method of intravenous catheter for patients with oral and maxillofacial tumors. Methods: We retrospectively analyzed the general data and venous catheter-related information of 143 oral and maxillofacial tumor patients who received treatment between June 2019 and December 2021. There were two patient groups, a control group of patients with inserted peripheral venous catheters (PVC) and an observation group of patients with midline catheters placed under ultrasound guidance. We made a comparative analysis of the incidence of catheter-related complications, including bleeding at the insertion site, phlebitis, catheter blockage, extravasation, etc., in the two groups. When the baseline data from the two groups were not balanced, we used propensity score matching (PSM) to match the general data before comparing the complication incidence between the two groups. Results: There were 71 patients who underwent 215 times of PVC placement in the control group and 72 patients who underwent 72 times of midline catheter placement in the observation group. There was no significant difference between the patients in the two groups in terms of age, sex, diagnosis, or the use of anticoagulant medication ( P>0.05) . The observation group had longer average length-of-stay than the control group did ( P<0.01). The cost of catheter placement in the observation group was 1080 yuan per set, with the average daily cost being about (56.27±20.23) yuan. Patients in the control group had PVC placement for an average of (3.03±0.93) times. The cost for PVC placement was 96 yuan per time and the average daily cost was about (19.94±7.50) yuan. There was significant difference in the average daily cost between the observation group and the control group ( P<0.01). PSM was performed for the two groups. Before PSM, the incidence of catheter-related complications in the observation group (8.3%, 6/72) was lower than that of the control group (30.2%, 65/215) and the difference was statistically significant ( P<0.01). After PSM, 72 times of catheter placement from each group were included in comparative analysis. The incidence of catheter-related complications in the observation group (8.3%, 6/72) was lower than that of the control group (54.2%, 39/72) and the difference was statistically significant ( P<0.01). Conclusion: Patients have low incidence of catheter-related complications when they have midline catheter placed under ultrasound guidance, which helps reduce the pain of repeated venous insertion that patients incur and the workload of clinical nurses. The use of midline catheters is appropriate for and should be popularized among patients with oral and maxillofacial malignant tumors, especially patients who have poor peripheral venous conditions and those who are undergoing repair and reconstruction surgeries.

Ultrasound-guided closure of the femoral artery during venoarterial decannulation using a large-bore closure device.

BACKGROUND: Peripheral femoro-femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) is viable for fast hemodynamic assistance during cardiogenic shock. Ultrasound-guided closure with a large-bore device (MANTA®) is a feasible option potentially replacing surgical arteriotomy closure in peripheral VA-ECMO decannulation. METHODS: This retrospective study included patients weaning from percutaneously inserted femoro-femoral VA-ECMO at the Helsinki University Hospital, Finland in 2012-2020. The primary endpoints were access-site complications, a composite of hematomas/seromas/surgical site infections (SSIs), and the safety endpoint of vascular complications (VCs). RESULTS: A total of 100 consecutive percutaneously implanted and weaned VA-ECMO patients were stratified into two groups by decannulation strategy: percutaneous ultrasound-guided MANTA device (n = 21, 21.0%) or surgical approach (n = 79, 79.0%). The mean age of the cohort was 51 ± 13 years and females represented 25.0%. The technical success rate of the percutaneous ultrasound-guided MANTA technique was 95.2%. In multivariate analysis, surgical closure was associated with a higher incidence of combined access site hematomas/seromas/SSIs compared to percutaneous ultrasound-guided deployment of MANTA device (44.3% versus 9.5%, odds ratio (OR): 7.162, 95% confidence interval (CI): 1.544-33.222; p = 0.012). Similarly, access-site complications necessitating interventions were more frequent in the surgical closure group compared to US-MANTA (ultrasound-guided MANTA) group (26.6% versus 0.0%, p = 0.005). VCs were infrequent in both groups without any significant intergroup difference (p > 0.99). CONCLUSIONS: Percutaneous ultrasound-guided MANTA closure of the femoral artery after VA-ECMO decannulation was associated with high technical success rate and low incidence of VCs. Compared to surgical closure, access-site complications were significantly less frequent, along with access-site complications necessitating interventions.

Spontaneous migration of peripherally inserted central catheter into the azygos vein during postoperative gastrointestinal dysmotility: A case report.

RATIONALE: The spontaneous migration of the peripherally inserted central catheter (PICC) is the displacement of the PICC tip from a satisfactory documented position in the superior vena cava (SVC) into its adjacent veins after several days or months of PICC insertion, and most frequently occurs in the ipsilateral internal jugular vein. However, it is rarely reported to detect migration of PICC tip into the azygos vein in patients who suffered from gastrointestinal dysmotility after abdominal surgery. We report 2 cases of spontaneous malposition of PICC into the azygos vein here and discuss the predisposing factors and processing procedures of this condition. PATIENT CONCERNS: Two female patients with pancreatic disease were inserted PICCs on the left limbs before the abdominal surgery. After the surgery, 1 patient suffered from gastroparesis, and the other suffered from constipation. The nurses found that blood could not be aspirated from the PICCs while normal saline could be injected through the PICCs smoothly. DIAGNOSES: We identified the position of the PICC tip step-by-step, using ultrasound, intracavitary electrocardiogram, and chest X-ray, and confirmed that the tip of the PICC migrated into the azygos vein. INTERVENTIONS: The patients were placed in the semi-reclining position from the supine position, and blood could be easily aspirated from the PICC after flushing with the push-pause flush technique. Intracavitary electrocardiogram displayed the elevated P, indicating that the PICC tip reentered the SVC and was at the lower 1/3 of SVC. OUTCOMES: The PICCs of the 2 patients functioned well afterward and were removed after the parenteral nutrition support was completed. LESSONS: It is critical to assess the function of the PICC before every time of infusion. For patients who undergo abdominal surgery with PICC on the left side, when they had gastrointestinal dysmotility combined with PICC dysfunction, the possibility of spontaneous migration of PICC tip into the azygos vein should be considered.

Ultrasound-Guided Radial Arterial Catheterization in Patients With Regurgitant and Stenotic Left-Sided Cardiac Valvular Lesions.

Background. The pulse characteristics of arterial circulation might affect radial artery catheterization's success rate. Therefore, we hypothesized that the success rate of radial artery catheterization would be lower in the left-sided severe stenotic valvular lesion group than severe regurgitant valvular lesion group. Methods. This prospective study was conducted among patients with left-sided cardiac valvular lesions undergoing cardiac and non-cardiac surgery. The patients with left-sided severe valvular stenosis and left-sided severe valvular regurgitation were included in the study. Radial artery cannulation was performed using an ultrasound-guided out-of-plane short-axis approach. The outcome measures were success rate, number of attempts, and cannulation time. Result. One hundred fifty-two patients were recruited for the study, and all were eligible for final analysis. The first attempt success rate was non-significantly higher in the stenotic valvular lesion group than the regurgitant group (69.7% vs 56.6%; P = .09). Furthermore, the number of attempts (median; 95% CI) was significantly higher in the regurgitant group (1; 1.2-1.43 vs 1; 1.38-1.67; P = .04). However, it may not be of clinical relevance. Moreover, the cannulation time and the number of redirections of the cannula were comparable. Heart rate was significantly higher in the regurgitant group (91.8 ± 13.9 vs 82.26 ± 15.92 beats/min; P = .00), while the incidence of atrial fibrillation was significantly higher in the stenotic lesion (P = .00). No failure was reported, and the incidence of periarterial hematoma was comparable. Conclusion. The success rate of ultrasound-guided radial arterial catheterization is comparable in left-sided stenotic valvular and regurgitant lesion groups.