A prospective randomized single-blind trial of patient comfort following vessel closure: extravascular synthetic sealant closure provides less pain than a self-tightening suture vascular compression device.

BACKGROUND AND PURPOSE: The Mynx M5 (AccessClosure, Inc., Mountain View, California, USA), a novel vascular closure device (VCD) utilizing extravascular synthetic sealant, may effectively seal the arteriotomy while reducing the pain associated with arteriotomy closure seen with other VCDs. To date, no studies exist comparing the pain associated with deployment between differing VCDs as a primary end point. METHODS: A blinded, randomized controlled trial was performed comparing the Mynx and a popular VCD that utilizes a self-tightening suture, the Angio-Seal Evolution (St Jude Medical, St Paul, Minnesota, USA). Subjects were all adult patients undergoing diagnostic cerebral angiography via femoral access. Local anesthesia and intraprocedural intravenous pain medication were standardized. Pain was assessed using a horizontal visual analog scale both before and after VCD deployment. RESULTS: 64 patients were enrolled with 32 in each treatment arm. Both pain at closure and pain increase from baseline to closure were significantly higher in the Angio-Seal group (p=0.009 and 0.002, respectively). 88% of patients receiving an Angio-Seal reported closure as the most painful part of the procedure compared with only 34% of patients receiving the Mynx (p<0.001). No adverse events were detected in either treatment arm. CONCLUSIONS: In a blinded, randomized trial comparing the Mynx with the Angio-Seal Evolution, pain with device deployment at arteriotomy closure was significantly lower with the Mynx. The reason for the large pain gradient between groups is likely due to the presence, and absence, of compression elements within the Angio-Seal and Mynx, respectively.

A study of the feasibility of introducing therapeutic touch into the operative environment with patients undergoing cerebral angiography.

The purpose of this pilot study was to determine whether Therapeutic Touch (TT) can be effectively used in the operative setting and whether it could produce positive outcomes in the period from cerebral angiography to discharge. The specific outcomes to be assessed were blood pressure, pulse, and respirations. TT is an intervention that involves the intentional direction of energy for the purpose of healing. The present study was developed within the conceptual framework of Rogers's model of unitary human beings. Data were collected at a center for endovascular surgery. The participants were 40 men and women aged between 18 and 80 years who were referred to the center for cerebral angiograms. The participants were English-speaking, ambulatory patients, with no history of prior cerebral angiograms and no psychiatric diagnosis. The design was a randomized, single-blind experiment. The research data were collected in the normal course of the angiogram procedure and recovery room. The blood pressure, pulse, and respirations were routinely noted before, during, and after the procedure. The study was significant in three aspects: (a) it was the first study to develop a protocol for delivering TT in the preoperative course of neurological patients, (b) the study is conceptualized within Rogers's conceptual model of unitary human beings, and (c) the study explored the impact of TT on selected outcomes in endovascular patients. A protocol for delivering TT in the operative setting was successfully developed and implemented. The efficacy of TT on the blood pressure, respirations, and pulse of the experimental group was not statistically significant. The reasons for this finding are explored, and suggestions are made for future research.

Symptomatic cerebral air embolism during neuro-angiographic procedures: incidence and problem avoidance.

BACKGROUND: While clinically symptomatic cerebral air embolism secondary to neuro-angiographic procedures is rare, the incidence in a large series of procedures is unknown. Understanding this complication's frequency and etiology is critical if systems are to be instituted to reduce its incidence. METHODS: We prospectively reviewed 4,568 consecutive neuro-angiographic procedures performed between June 2000 and July 2005. The occurrence and etiology of a symptomatic air embolus was noted, and an incidence was calculated for all procedures and for diagnostic arteriograms and interventional procedures individually. RESULTS: Four symptomatic cerebral arterial air emboli occurred in 4,568 neuro-angiographic procedures over the five-year period (0.08%). No events occurred in 3,150 diagnostic angiograms while four occurred during 1,418 interventional procedures (0.2%). Two cases occurred during aneurysm coiling embolization (2/548; 0.4%); one case occurred during a carotid stent placement (1/138; 0.7%); one occurred during an internal carotid artery balloon occlusion test (1/73; 1.3%). Three of these complications resulted in permanent neurologic deficits while one resulted in a transient neurologic change that cleared within 60 min of onset. Sources for the emboli included the pressurized arterial flush lines connected to internal carotid artery catheters (three cases) and sudden hypotension with air subsequently entering the internal carotid artery catheter (one case). Two patients were treated with hyperbaric oxygen therapy. CONCLUSION: Symptomatic cerebral air embolism is a rare event during neuro-angiographic procedures. Analysis of the etiologies of this infrequent event may permit us to further reduce its incidence.

Iatrogenic vertebral artery injury.

Iatrogenic vertebral artery injury (VAI) results from various diagnostic and therapeutic procedures. The objective of this article is to provide an update on the mechanism of injury and management of this potentially devastating complication. A literature search was conducted using PubMed. The iatrogenic VAIs were categorized according to each diagnostic or therapeutic procedure responsible for the injury, i.e., central venous catheterization, cervical spine surgery, chiropractic manipulation, diagnostic cerebral angiography, percutaneous nerve block, and radiation therapy. The incidence, mechanisms of injury, and reparative procedures were discussed for each type of procedure. The type of VAI depends largely on the type of procedure. Laceration was the dominant type of acute injury in central venous catheterization and cervical spine surgery. Arteriovenous fistulae and pseudoaneurysms were the delayed complications. Arterial dissection was the dominant injury type in chiropractic manipulation and diagnostic cerebral angiography. Inadvertent arterial injection caused seizures or stroke in percutaneous nerve block. Radiation therapy was responsible for endothelial injury which in turn resulted in delayed stenosis and occlusion of the vertebral artery (VA). The proximal VA was the most vulnerable portion of the artery. Although iatrogenic VAIs are rare, they may actually be more prevalent than had previously been thought. Diagnosis of iatrogenic VAI may not always be easy because of its rarity and deep location, and a high level of suspicion is necessary for its early detection. A precise knowledge of the surgical anatomy of the VA is essential prior to each procedure to prevent its iatrogenic injury.

Stress reduction through music in patients undergoing cerebral angiography.

We studied the influence of music on stress reaction of patients during cerebral angiography. We randomised 30 patients to a music or a control group. We measured stress hormones, blood pressure, heart rate and psychological parameters. Patients examined without music showed rising levels of cortisol in plasma, indicating high stress levels, while cortisol in patients examined with music remained stable. Systolic blood pressure was significantly lower listening to music. Patients with a high level of fear did appear to benefit particularly from the music.

Neurologic complications of cerebral angiography. A retrospective study of complication rate and patient risk factors.

PURPOSE: To evaluate the neurologic complication rate and individual patient risk factors in cerebral angiographies using the digital subtraction angiography (DSA) technique and non-ionic contrast media in a department with many radiologists in training. MATERIAL AND METHODS: A retrospective study of 483 cerebral angiographic examinations in 454 patients was carried out. The following parameters were registered: sex and age of the patient, indication for the angiography, cerebral CT diagnosis, laboratory data, type of anesthesia, type of angiographic procedure, level of training of the angiographer, number of participating angiographers, type of catheters, number of vessels catheterized, number of exposures, use of compression series, total amount of contrast media, diagnosis of the angiogram, complications and duration of complications. RESULTS: The frequency of all neurologic complications was 2.3%, the frequency of persistent neurologic deficits was 0.4%. Non-neurologic complications were observed in 14.7% of the examinations. Of all the parameters studied, the only factor that significantly increased neurologic risk was a normal angiogram, a finding we are inclined to ascribe to chance. Performance of a compression series showed a trend towards increasing the neurologic risk. CONCLUSION: This study showed a complication rate of persistent neurologic deficits of 0.4% which is in accordance with other recent reports. A compression series should not be performed routinely, but only on special indication. This study confirms the low risk of cerebral angiography when performed in a neuroradiological department using the DSA technique and non-ionic contrast media.

Normal diffusion-weighted imaging in cerebral air embolism complicating angiography.

We report a case of cerebral air embolism resulting from accidental air infection during cerebral angiography. A 60-year-old man was accidentally injected with air via the left subclavian artery. Angiography demonstrated air within the basilar artery. The patient showed signs of posterior circulation ischaemia (confusion, blindness, gaze palsy and hemiparesis). However, MRI, including diffusion-weighted imaging, showed no abnormality 4 h later. The patient was treated with hyperbaric oxygen within 5 h of the embolism. All symptoms and signs resolved completely within a week.

[Morphine and benzodiazepine derivatives in cerebral angiographies]. / Morfinovi i benzodiazepinovi proizvodni pri mozuchni angiografii.

This is a report on thirty-two patients undergoing cerebral angiography, performed under combined local analgesia in conjunction with morphine and benzodiazepine derivatives. Emphasis is laid on the lack of serious life-endangering complications. The risks of general anesthesia are avoided, and the patient's psyche is conserved. Investigations are performed during both planned and emergency angiographies. A pregnant female patient is also examined by the method described. There are no complications worth noting. The method is proposed as a procedure intermediate between general anesthesia and local analgesia.

Amnesia after femorocerebral angiography.

The charts and radiographs of 12 of 1,520 patients who developed amnesia after transfemoral cerebral angiography performed with local anesthesia and minimal sedation were retrospectively reviewed. In three younger patients, exacerbation of organic or idiopathic temporal lobe epilepsy was thought to be the cause of the amnesia, while the amnesia of the nine patients over 40 years old had the characteristics of transient global amnesia. Eight of the patients had had similar episodes before angiography, and three others had other evidence of vertebrobasilar disease. Emboli from atheromatous debris or catheter clot due either to catheter manipulation problems, an inexperienced operator, or the use of a large catheter were considered likely causes in 11 cases, while in three patients contrast emboli or toxicity may have been the etiologic factor.