Managing central venous access during a health care crisis.

OBJECTIVE: During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic. METHODS: We conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19. RESULTS: Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group). CONCLUSIONS: Implementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises.

Echocardiographic assessment with right ventricular function improvement following ultrasound-accelerated catheter-directed thrombolytic therapy in submassive pulmonary embolism.

Introduction The objective of this study was to evaluate the efficacy of ultrasound-accelerated catheter-directed thrombolytic therapy in patients with submassive pulmonary embolism. Methods Clinical records of 46 patients with submassive pulmonary embolism who underwent ultrasound-accelerated catheter-directed pulmonary thrombolysis using tissue plasminogen activator, from 2007 to 2017, were analyzed. All patients experienced clinical symptoms with computed tomography evidence of pulmonary thrombus burden. Right ventricular dysfunction was present in all patients by echocardiographic finding of right ventricle-to-left ventricle ratio > 0.9. Treatment outcome, procedural complications, right ventricular pressures, and thrombus clearance were evaluated. Follow-up evaluation included echocardiographic assessment of right ventricle-to-left ventricle ratio at one month, six months, and one year. Results Technical success was achieved in all patients ( n = 46, 100%). Our patients received an average of 18.4 ± 4.7 mg of tissue plasminogen activator using ultrasound-accelerated thrombolytic catheter with an average infusion time of 16.5± 5.4 h. Clinical success was achieved in all patients (100%). Significant reduction of mean pulmonary artery pressure occurred following the treatment, which decreased from 36 ± 8 to 21 ± 5 mmHg ( p < 0.001). There were no major bleeding complications. All-cause mortality at 30 days was 0%. No patient developed recurrent pulmonary embolism during follow-up. During the follow-up period, 43 patients (93%) showed improvement of right ventricular dysfunction based on echocardiographic assessment. The right ventricle-to-left ventricle ratio decreased from 1.32 ± 0.18 to 0.91 ± 0.13 at the time of hospital discharge ( p < 0.01). The right ventricular function remained improved at 6 months and 12 months of follow-up, as right ventricle-to-left ventricle ratio were 0.92 ± 0.14 ( p < 0.01) and 0.91 ± 0.15 ( p < 0.01), respectively. Conclusion Ultrasound-accelerated catheter-directed thrombolysis is a safe and efficacious treatment for submassive pulmonary embolism. It reduces pulmonary hypertension and improves right ventricular function in patients with submassive pulmonary embolism.

Cost-effectiveness of revascularization for limb preservation in patients with marginal functional status.

BACKGROUND: Revascularization and limb salvage attempts are often offered to patients with foot wounds and chronic limb ischemia who are thought to be good-risk candidates, but some skepticism remains about the utility of these efforts for elderly patients with marginal functional status. We sought to determine whether limb preservation efforts in this population could be justified from a patient-centered, cost-effectiveness perspective. METHODS: A probabilistic Markov model was used to simulate the clinical outcomes, health utilities, and costs over a 10-year period with various management strategies. Clinical parameter estimates were obtained from previous clinical trials and large observational series. Cost estimates were obtained from cost literature and also a single-center study that reviewed total costs accumulated (including secondary amputations, wound care, outpatient nursing care, and nursing home costs). Cost (in 2011 U.S. dollars) per year of ambulation (with limb preservation or with a prosthesis after amputation) was the primary measure of cost-effectiveness. RESULTS: The total 10-year costs of revascularization--either endovascular or surgical--were lower than the costs of either local wound care alone or primary amputation. Revascularization strategies also produced more health benefits as measured in terms of years of ambulatory ability, years of limb salvage, or quality-adjusted life-years. In none of the scenarios modeled in deterministic sensitivity analyses did primary amputation prove to be cost-effective. CONCLUSIONS: Revascularization and limb preservation attempts appear less costly and provide more health benefits than wound care alone or primary amputation, even among patients with marginal functional status at baseline.

Establishment of a transcatheter aortic valve program and heart valve team at a Veterans Affairs facility.

BACKGROUND: The US Food and Drug Administration recently approved a transcatheter aortic valve for patients for whom open heart surgery is prohibitively risky. METHODS: A multidisciplinary heart valve team partnered with administration to launch a transcatheter aortic valve replacement (TAVR) program. Clinical registries were used to show robust valve caseloads and outcomes at our Veterans Affairs (VA) facility and to project future volumes. A TAVR business plan was approved by the VA leadership as part of a multiphase project to upgrade and expand our surgical facilities. RESULTS: The heart valve team completed a training program that included simulations and visits to established TAVR centers. Patients were evaluated and screened through a streamlined process, and the program was initiated successfully. CONCLUSIONS: Establishing a TAVR program at a VA facility requires a multidisciplinary team with experience in heart valve and endovascular therapies and a supportive administration willing to invest in a sophisticated infrastructure.

Percutaneous treatment of varicocele with microcoil embolization: comparison of treatment outcome with laparoscopic varicocelectomy.

Successful treatment of a testicular varicocele, which can result in scrotal pain and swelling as well as male subfertility, can be accomplished via operative ligation of the varicocele or interventional treatment with coil embolization of the testicular vein. This study compared the treatment outcome of percutaneous embolization treatment versus laparoscopic varicocelectomy in patients with symptomatic varicoceles. Patients with varicoceles undergoing either laparoscopic varicocelectomy or percutaneous coil embolization of the testicular vein during a recent 5-year period were analyzed. Treatment outcome and hospital costs of these two minimally invasive treatment modalities were compared. Forty-one patients underwent percutaneous coil embolization of the testicular vein, which were compared with a cohort of 43 patients who underwent laparoscopic varicocelectomy. Technical success in interventional and laparoscopic treatment was 95% and 100%, respectively. The mean operative time or procedural time was 63 +/- 13 minutes and 52 +/- 25 minutes for interventional and laparoscopic cohorts (not significant), respectively. Embolization treatment resulted in two recurrent varicoceles (4.8%) compared to one patient following laparoscopic repair (2.3%, not significant). Embolization treatment was associated with a lower complication rate than laparoscopic repair (9.7% vs 16.3%, p = .03). Regarding cost analysis, no significant difference in hospital cost was noted between the interventional or laparoscopic treatment strategies. Both laparoscopic varicocelectomy and coil embolization are effective treatment modalities for varicoceles. With lower treatment complication rates in the interventional treatment group, coil embolization of the testicular vein offers treatment advantage compared with laparoscopic repair in patients with varicoceles.