Causes, risk factors, and complications of accidental intra-arterial administration of medications in a children's hospital: a case series.

BACKGROUND: Accidental intra-arterial administration of a medication can lead to serious iatrogenic harm. Most studies have discussed single cases of accidental intra-arterial administration of a medication, but only a few have described multiple cases occurring in a single, pediatric hospital setting. METHODS: The subjects were pediatric patients with an accidental intra-arterial administration of a medication. After obtaining approval from the institutional review board, the relevant cases were extracted from incident reports submitted to the patient safety office of the study center between November 2016 and April 2023. RESULTS: A review of 18,204 incident reports yielded 10 cases (patient age: 27 days to 13 years) of accidental intra-arterial administration of a medication. The most common site of the cannulation was the dorsum of the foot followed by the dorsum of the hand. The medications administered were narcotics, sedatives, muscle relaxants, antibiotics, and crystalloids. No serious adverse events occurred after injection. In some cases, the accidental arterial cannulation was not discovered immediately (53 min to 26 days). Seven patients had difficult intravenous access; in two of these, ultrasound-guided peripheral venous cannulation was used. CONCLUSIONS: We experienced 10 cases of accidental intra-arterial administration of a medication. The dorsalis pedis artery and the radial artery around the anatomical tobacco socket were common sites of unintentional arterial cannulation. Difficult intravenous (IV) access may be associated with unintentional arterial cannulation. If IV access is difficult or the free IV drip is sluggish, strict vigilance and repeated confirmation are needed to prevent unintentional arterial cannulation.

Clinical Utility of Ultrasonographic Guidance for Arterial Catheterization in Patients with Obesity: A Randomized Controlled Trial.

OBJECTIVES: To compare the success and complication rates of radial artery catheterization using ultrasound guidance versus the conventional palpation technique in obese patients by anesthesia residents with similar levels of experience in both methods, and to measure the skin-to-artery distance of radial, brachial, and dorsalis pedis arteries using ultrasound with standardized anatomic landmarks. DESIGN: Prospective, randomized controlled trial SETTING: Single tertiary center PARTICIPANTS: Eighty adults with a body mass index (BMI) ≥30 kg/m2 INTERVENTIONS: Ultrasound guidance or conventional palpation method MEASUREMENTS AND MAIN RESULTS: The primary outcome was the first-attempt success rate of arterial catheterization. The skin-to-artery distance of the radial artery was significantly greater in the BMI groups of 40 to 49 kg/m2 and ≥50 kg/m2 compared to the BMI group of 30 to 39 kg/m2 (mean difference, 1.0 mm; 95% confidence interval [CI], 0.4-1.7; p = 0.0029) for BMI 40-49 kg/m2 vs 30-39 kg/m2 and 1.5 mm (95% CI, 0.6-2.4 mm; p = 0.0015) for ≥50 kg/m2 vs 30-39 kg/m2. Similar findings were observed for the brachial artery. BMI was inversely associated with first-attempt success rates (p = 0.0145) and positively with time to successful catheterization (p = 0.0271). The first-attempt success and vascular complication rates of catheterization did not differ significantly between the ultrasound guidance group (65.0% and 52.5%, respectively) and the conventional palpation group (70.0% [p = 0.6331] and 57.5% [p = 0.6531], respectively). CONCLUSION: The results of this study do not support the routine use of ultrasonography during radial arterial catheterizations for obese adults when junior practitioners perform the procedure.

Acoustic Shadowing to Facilitate Ultrasound Guided Arterial Cannulation: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Aim and background: Ultrasound-guided arterial catheterization is a frequently performed procedure. Additional techniques such as acoustic shadowing-assisted ultrasound may be useful in improving success rate. This systematic review aimed to assess the efficacy of acoustic shadowing assisted ultrasound for arterial catheterization. Materials and methods: PubMed, Medline, EMBASE, Cochrane Library, EMCARE, and MedNar were searched in January 2024. Randomized controlled trials comparing the first attempt success rate of arterial catheterization using acoustic shadowing ultrasound vs unassisted ultrasound were included. Data were pooled for risk ratios (RRs) using the random-effects model. Subgroup analysis was conducted based on a single or double acoustic line. Sensitivity analysis was undertaken after excluding pediatric data. The certainty of evidence (COE) was assessed using the GRADE framework. Results: Six randomized controlled trials (n = 777) were included. A meta-analysis found the first attempt success rate is significantly higher in the acoustic ultrasound group (n = 6, RR: 0.47, 95% CI: 0.34-0.66, p ≤ 0.00001). Hematoma formation was significantly less in the acoustic ultrasound group (n = 6, RR: 0.52, 95% CI: 0.34-0.80, p = 0.003). First attempt success was significantly higher in the single acoustic line ultrasound (USG) group compared to the unassisted ultrasound group (n = 3, RR: 0.41, 95% CI: 0.28-0.59, p ≤ 0.00001). Sensitivity analysis after excluding pediatric data was similar to the primary analysis (n = 5, RR: 0.50, 95% CI: 0.33-0.70, p ≤ 0.00001). Certainty of evidence was "Moderate" for the first attempt cannulation. Conclusions: Acoustic shadowing-assisted ultrasound improved first-attempt arterial catheterization success rate and was associated with reduced hematoma formation. How to cite this article: Mishra L, Rath C, Wibrow B, Anstey M, Ho K. Acoustic Shadowing to Facilitate Ultrasound Guided Arterial Cannulation: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2024;28(7):677-685.

Aortic valve resuspension using the Florida sleeve technique with replacement of the aortic arch by stent grafting the thoracic aorta with the hybrid prosthesis E-Vita Open Plus in a patient with DeBakey type I acute aortic dissection.

Surgery for acute type A aortic dissection is highly challenging, even in expert hands. The goal in such emergency circumstances is primarily to save the patient's life. To minimize the perioperative risk, surgeons often choose surgery involving only supracoronary ascending aortic and hemiarch replacement. However, to achieve a successful repair, the extremely fragile dissected aortic layers must be reconstructed proximally and distally. Most of the surgical procedures for patients with acute type A aortic dissection are supracoronary ascending aortic replacements. Thereby, the Florida sleeve procedure is an attractive alternative for reimplanting the entire aortic root into a Dacron graft. This approach has overcome most of the technical problems associated with composite valve graft or valve-sparing procedures. The frozen elephant trunk procedure is particularly appealing for treating acute type A aortic dissection because of its ability to treat malperfusion by encouraging true lumen expansion and potentially reducing longer-term adverse remodelling within the descending aorta.

Effectiveness of ultrasound-guided peripheral arterial cannulation in neonates, including very low birth weight infants who are conventionally difficult-to-cannulate: a case series.

The effectiveness of ultrasound-guided peripheral arterial cannulation (UGPAC) in children has been increasingly been reported. However, to the best of our knowledge, there have been no reports of UGPAC in neonates, including very low birth weight infants (VLBWIs). In this study, we aimed to retrospectively review the results of UGPAC in neonates, including VLBWIs, and assess its effectiveness. This case series was conducted in a tertiary neonatal intensive care unit (NICU) in Japan. We included neonates aged below 28 days who underwent UGPAC in our NICU between April 2021 and October 2022. We extracted the following data from medical records and analysed it retrospectively: patient age (days), postconceptional age, patient weight at the time of cannulation, number of punctures using the conventional technique before ultrasound guidance was performed and number of punctures with the ultrasound-guided technique until successful cannulation. A total of 27 UGPACs were performed in 19 neonates, including 14 cannulations in 10 VLBWIs. In infants weighing > 1500 g and VLBWIs, the success rate within the first three punctures was 100% (13/13) and 79% (11/14), respectively. Overall, 41% (11/27) of UGPACs were performed following failed punctures using conventional methods, with a 100% success rate within the first three attempts. In all cases, no apparent adverse events, such as hypothermia, were noted.  Conclusions: Our results suggest that UGPAC had a high success rate in neonates, including VLBWIs. Further studies are required to compare the effectiveness of UGPAC with conventional methods in neonates. What is Known: • The use of ultrasound guidance for arterial cannulation is recommended in children. • Ultrasound-guided peripheral arterial cannulation (UGPAC) in neonates, including very low birth weight infants (VLBWIs), has not been reported. What is New: • UGPAC in neonates, including VLBWIs, was performed with a high success rate; approximately 40% of UGPACs were performed after the failure of the conventional methods. • This study suggested the effectiveness of UGPAC in neonates, including VLBWIs.

Acute superficial and deep necrosis of lower limb following femoral arterial cannulation in a neonate undergoing arterial switch operation for transposition of great arteries.

Arterial lines are routinely used for hemodynamic monitoring and blood sampling in the operating room and in cardiac surgery intensive care unit. The complications related to arterial line insertion are very low; the knowledge of the relevant artery anatomy, skills and the experience of the operator and selection of a right size cannula plays a vital role in reducing morbidity related to arterial line insertion. We describe extensive superficial and deep necrosis of lower limb following arterial cannula insertion in a preterm neonate undergoing arterial switch procedure and discuss measures to prevent such a complication.

Ascending aortic and proximal hemiarch replacement with antegrade cerebral perfusion for a penetrating aortic ulcer.

We report the surgical repair of a penetrating aortic ulcer in the distal ascending aorta close to the brachiocephalic trunk, by supracoronary ascending aortic and hemiarch replacement via a full sternotomy. The procedure is performed under moderate hypothermia with bilateral antegrade cerebral perfusion.

Accidental Intraarterial Placement of a Venous Cannula: When In Doubt Take It Out!-A Case Report.

An artery may be entered on the dorsum of the hand with the mistaken belief that it is a vein. Intraarterial injection of drugs is one of the dreadful consequences of accidental intraarterial cannulation. In this case of a 3-month-old infant, we emphasize the fact that careful observation can prevent unintentional intraarterial drug injection via an 'assumed intravenous' cannula and prevent the associated morbidity. When there is a suspicion of an intraarterial placement of venous cannula, it is of paramount significance to confirm before the injection of medications. Aberrant arterial anatomy should be kept in mind, particularly in children on the dorsum of the hand, where placement of an intravenous cannula is usually considered safe.

Central aortic versus axillary artery cannulation for aortic arch surgery.

Objective: Central aortic cannulation for aortic arch surgery has become more popular over the last decade; however, evidence comparing it with axillary artery cannulation remains equivocal. This study compares outcomes of patients who underwent axillary artery and central aortic cannulation for cardiopulmonary bypass during arch surgery. Methods: A retrospective review of 764 patients who underwent aortic arch surgery at our institution between 2005 and 2020 was performed. The primary outcome was failure to achieve uneventful recovery, defined as having experienced at least 1 of the following: in-hospital mortality, stroke, transient ischemic attack, bleeding requiring reoperation, prolonged ventilation, renal failure, mediastinitis, surgical site infection, and pacemaker or implantable cardiac defibrillator implantation. Propensity score matching was used to account for baseline differences across groups. A subgroup analysis of patients undergoing surgery for aneurysmal disease was performed. Results: Before matching, the aorta group had more urgent or emergency operations (P = .039), fewer root replacements (P < .001), and more aortic valve replacements (P < .001). After successful matching, there was no difference between the axillary and aorta groups in failure to achieve uneventful recovery, 33% versus 35% (P = .766), in-hospital mortality, 5.3% versus 5.3% (P = 1), or stroke, 8.3% versus 5.3% (P = .264). There were more surgical site infections in the axillary group, 4.8% versus 0.4% (P = .008). Similar results were seen in the aneurysm cohort with no differences in postoperative outcomes between groups. Conclusions: Aortic cannulation has a safety profile similar to that of axillary arterial cannulation in aortic arch surgery.

Arterial Line Placement Using Modified Seldinger Technique: A Novel Approach.

How to cite this article: Srinivasan A, Naidu V, Dhivya P. Arterial Line Placement Using Modified Seldinger Technique: A Novel Approach. Indian J Crit Care Med 2023;27(7):515-516.

Complications and related risk factors of transradial access cannulation for hemodynamic monitoring in general surgery: a prospective observational study.

PURPOSE: To examine the short-term complications of arterial cannulation for intraoperative monitoring and their related risk factors. METHODS: We included adult inpatients (≥ 18 years old) who underwent an initial transradial access (TRA) cannulation and were scheduled for general surgery between April 8 and November 30, 2020. We used 20G arterial puncture needles for puncturing and manual compression for hemostasis. Demographic, clinical, surgical, anesthetic, and laboratory data were extracted from electronic medical records. Vascular, neurologic, and infectious complications of TRA cannulation were recorded and analyzed. Logistic regression analyses were used to identify risk factors related to TRA cannulation for intraoperative monitoring. RESULTS: Among 509 included patients, 174 developed TRA cannulation-related complications. Puncture site bleeding/hematoma and median nerve injury were observed in 158 (31.0%) and 16 (3.1%) patients, respectively. No patient developed cannula-related infections. Logistic regression analysis revealed increased odds of puncture site bleeding/hematoma in women (odds ratio 4.49, 95% CI 2.73-7.36; P < 0.001) and patients who received intraoperative red blood cell (RBC) suspension transfusion ≥ 4U (odds ratio 5.26, 95% CI 1.41-19.57; P = 0.01). No risk factors for nerve injury were identified. CONCLUSION: Bleeding/hematoma were a common complication of TRA cannulation for intraoperative hemodynamic monitoring during general surgery. Median nerve injury may be an under recognized complication. Female sex and extensive intraoperative RBC transfusion are associated with an increased risk of bleeding/hematoma; however, the risk factors for nerve injury remain unclear. TRIAL REGISTRATION: The study protocol was registered at https://www.chictr.org.cn (ChiCTR1900025140).

Radial artery duplication: Unusual point-of-care-ultrasonography finding during arterial cannulation.

The radial artery is the most common choice for arterial cannulation, coronary interventions, and various interventional radiological procedures. Here, we describe a case of unilateral duplication of the radial artery detected during radial artery cannulation using point-of-care ultrasonography (POCUS). The duplication of the radial artery in the forearm can hinder trans-radial access secondary to variations in the diameter. An actual duplication also carries a high risk of accidental injury to the arterial wall during routine invasive procedures and other forearm procedures such as free flap construction. POCUS is invaluable for detecting arterial anomalies before proceeding with any interventional procedures.

Acute Upper Limb Ischemia and Amputation Post Antecubital Fossa Cannulation: A Report of Two Postpartum Patients.

Upper extremity arterial thrombosis is less common than that in the lower extremity. Upper extremity arterial thrombosis, when present, is more likely to occur on the ulnar side of the circulation. Severe ischemia resulting from radial artery thrombosis is rare, but iatrogenic cannulation is the most common etiology when it occurs. The risk factors underlying this dreadful presentation are numerous and still under investigation. Pregnancy and the immediate postpartum period are physiological hypercoagulable states. Here we present unusual cases of acute limb ischemia post iatrogenic cannulation in two patients within six weeks postpartum. At four weeks postpartum, a 26-year-old para-1 live-1 female presented to the emergency department with swelling in her right upper limb for four weeks and its blackish discoloration for one week. A 24-year-old primigravida female who had a termination of a blighted ovum 12 days ago presented to the emergency department with gangrenous changes in her right hand and forearm. Both patients reported recent antecubital fossa cannulation within six weeks postpartum, triggering gangrenous hand changes. Both patients had to undergo amputation of the digits and hand ultimately. Thus we postulate the need for extra care and education of healthcare workers in the cannulation of pregnant and post-pregnancy patients to prevent limb-threatening complications.

Comparison between the long-axis in-plane and short-axis out-of-plane approaches for ultrasound-guided arterial cannulation: a meta-analysis and systematic review.

BACKGROUND: The two most common methods for ultrasound-guided arterial cannulation are the long-axis in-plane (LA-IP) and short-axis out-of-plane (SA-OOP) approaches. However, it is uncertain which method is more advantageous. We conducted a meta-analysis of reported randomized clinical trials (RCTs) comparing the two techniques in terms of success rate, cannulation time, and complications. METHODS: We systematically searched PubMed, Embase, and the Cochrane Library database for RCTs comparing the LA-IP and SA-OOP techniques for ultrasound-guided arterial cannulation published from inception through April 31, 2022. The Cochrane Collaboration's Risk of Bias Tool was used to evaluate the methodological quality of each RCT. Review Manager 5.4 and Stata/SE 17.0 were used to analyze the two primary outcome measures (first-attempt success rate and total success rate) and two secondary outcome measures (cannulation time and complications). RESULTS: A total of 13 RCTs with 1,377 patients were included. There were no significant differences in first-attempt success rate (risk ratio [RR], 0.93; 95% confidence interval [CI], 0.78-1.12; P = 0.45; I2 = 84%) and overall success rate (RR, 0.99; 95% CI, 0.95-1.02; P = 0.48; I2 = 57%). When compared with the LA-IP technique, the SA-OOP technique was associated with an increased incidence of posterior wall puncture (RR, 3.01; 95% CI, 1.27-7.14; P = 0.01; I2 = 79%) and hematoma (RR, 2.15; 95% CI, 1.05-4.37; P = 0.04; I2 = 63%). There was no significant difference in the incidence of vasospasm between techniques (RR, 1.26; 95% CI, 0.37-4.23; P = 0.07; I2 = 53%). CONCLUSIONS: The present results suggest that the SA-OOP technique is associated with a higher incidence of posterior wall puncture and hematoma than the LA-IP technique, whereas success rates are similar for the two ultrasound-guided arterial cannulation techniques. These findings should be experimentally evaluated in a more rigorous manner due to high inter-RCT heterogeneity.

A Randomized Trial to Compare Ultrasound-Guided Dorsalis Pedis Versus Posterior Tibial Artery Cannulation in Neurosurgical Patients.

Introduction Dorsalis pedis or posterior tibial artery is selected as an alternative to radial artery cannulation when there is no access or unsuccessful cannulation of a radial artery. This study aimed to compare the two major arteries of the foot (dorsalis pedis and posterior tibial) in terms of their ultrasound (USG)-guided cannulation characteristics in patients posted for elective neurosurgical procedures. Methods All consenting patients, 18-65 years of age, scheduled for elective neurosurgical procedures under general anesthesia requiring arterial cannulations were enrolled. The first-pass success rate, assessment time, cannulation time, total procedural time, and the number of cannulation attempts for both procedures were estimated. Results A total of 90 patients were included in the study. The assessment time, cannulation time, and total time for arterial cannulation were significantly greater in the dorsalis pedis artery group than in the posterior tibial artery group (p < 0.001). Successful arterial cannulation in the first attempt was 73.3% in the dorsalis pedis, whereas it was 80% in the posterior tibial group but comparable (p = 0.455). The successful cannulation outcome was slightly more in the posterior tibial artery group but comparable (p = 1.00). Conclusion First-pass successful cannulation rates in the posterior tibial and the dorsalis pedis artery are comparable. However, the assessment time, cannulation time, and total procedural time are higher and statistically significant for dorsalis pedis artery cannulation compared to the posterior tibial artery group.

Comparison of ultrasound guided dorsal radial artery cannulation and conventional radial artery cannulation at the volar aspect of wrist: A pilot randomized controlled trial.

BACKGROUND: Distal radial artery cannulation at the "anatomical snuffbox" carries several theoretical advantages over conventional radial arterial cannulation at the wrist. However, these two techniques have not been evaluated in perioperative settings. METHODS: In this randomized controlled trial, n = 200 patients requiring arterial cannulation for perioperative monitoring were recruited. Patients were randomized to either ultrasound guided distal radial artery cannulation group (group D) or ultrasound guided conventional radial artery cannulation group (group W). Primary outcome of this study was first attempt cannulation success rate. RESULTS: First attempt cannulation success rate was significantly lower in distal radial artery cannulation (57% in group D and 77% in group W; p = 0.003). Use of alternative cannulation site was significantly higher in group D when compared to group W (p = 0.015) and number of attempts for successful cannulation was significantly higher in group D when compared to group W (p = 0.015). None of the patients in any group developed thrombosis and related complications and intraoperative catheter dislodgement. Time to puncture the artery (p < 0.0001), total cannulation time (p < 0.0001), and actual catheter insertion time (p < 0.0001) were significantly higher in group D in comparison to group W. CONCLUSION: Distal radial artery cannulation was associated with lower first attempt cannulation success rate and requires longer time to perform. As distal radial artery is a new technique, further studies are required in different clinical settings.

Femoral artery cannulation increases the risk of postoperative stroke in patients with acute DeBakey I aortic dissection.

BACKGROUND: The selection of different arterial cannulation site influences the incidence of postoperative stroke in patients with DeBakey I acute aortic dissection. The study aimed to explore the optimal arterial cannulation for these patients. METHODS: From January 2009 to 2019, a total of 1514 patients with DeBakey I acute aortic dissection underwent frozen elephant trunk and total arch replacement at a tertiary center. They were divided into 2 groups: the axillary artery only cannulation group (n = 1075) and the femoral artery cannulation group (n = 439). After balancing the differences of baseline condition by propensity score matching, the prognosis was compared. RESULTS: The incidence of stroke and acute brain infarction in the femoral artery cannulation group was higher than in the axillary artery only cannulation group (stroke, 11.7% vs 7.0%, P = .03; acute brain infarction, 6.0% vs 2.7%, P < .01). The femoral artery cannulation group was further divided into 2 groups: femoral artery only cannulation group (n = 106) and axillary combined with femoral artery cannulation group (n = 333). The comparison was performed between the axillary combined with femoral artery cannulation group and the axillary artery only cannulation group. After propensity score matching, the incidence of stroke and acute brain infarction in the axillary combined with femoral artery cannulation group was higher than in the axillary artery only cannulation group (stroke, 13.5% vs 7.2%, P < .01; acute brain infarction, 6.9% vs 2.5%, P < .01). CONCLUSIONS: Axillary artery only cannulation is recommended as the optimal arterial cannulation strategy for most patients with DeBakey I acute aortic dissection. For those patients who are not suitable for axillary artery only cannulation, axillary combined with femoral artery cannulation is not recommended.

Comparison of Ultrasound-Guided Versus Palpatory Method of Posterior Tibial Artery Cannulation: A Prospective Randomized Controlled Study.

INTRODUCTION: Superficial arteries, such as radial and dorsalis pedis arteries, are commonly cannulated for invasive blood pressure monitoring. Failure to cannulate these arteries necessitates alternate arteries, such as the posterior tibial artery (PTA). The deep-seated anatomy of PTA makes arterial cannulation precarious by the palpatory technique. Ultrasound guidance during PTA cannulation may overcome this problem. With this background, we evaluated the ultrasound-guided (USG) versus palpatory method for PTA cannulation with respect to the first attempt's success and number of attempts. METHODS: A total of 240 American Society of Anesthesiology (ASA) physical status I-IV adult patients undergoing major surgeries requiring arterial cannulation were randomly allocated (1:1) to group A (USG-guided cannulation, n = 120) and Group B (cannulation by palpatory technique, n =120). PTA was cannulated by either of the techniques according to randomization. Data were analyzed and compared in both groups for first-attempt success, number of attempts, assessment time, cannulation time, and complications. RESULT: The successful cannulation in the first attempt in Group A was 25.8% (n = 31), and in Group B, it was 12.5% (n = 15) (p = 0.009). In Group A, 78.3% of patients (n = 94) had successful cannulation, and in group B, 65% of patients (n =78) had successful cannulation (p = 0.022). Both groups had similar assessment time (p = 0.348) and cannulation time (p = 0.864). CONCLUSION: USG-guided PTA cannulation offers a greater chance of success without any added increase in procedure time.

Arterial cannulation with ultrasound: clinical trial protocol for a randomised controlled trial comparing handheld ultrasound versus palpation technique for radial artery cannulation.

Background: Early intraoperative hypotension is associated with acute kidney and myocardial injury in patients undergoing noncardiac surgery. Precise arterial blood pressure measurement before and during the induction of general anaesthesia may avert early intraoperative hypotension. However, rapid arterial cannulation in anxious, conscious patients can be challenging. We describe the protocol for a randomised controlled trial designed to test the hypothesis that readily available, handheld ultrasound-guided arterial cannulation is the optimal method in conscious patients undergoing noncardiac surgery. Methods: Participants >45 yr undergoing noncardiac surgery expected to last >120 min and requiring an overnight hospital stay will be eligible. We will randomly allocate participants to undergo cannulation of the radial artery in the non-dominant arm before the induction of general or regional anaesthesia using either handheld ultrasound-guided dynamic needle position technique or palpation. The primary outcome is first-pass successful arterial cannulation, analysed by intention-to-treat. Secondary outcomes include adequacy/characteristics of the arterial waveform and complications within 24 h of cannulation. We will require 118 patients to demonstrate a doubling of successful first-pass arterial cannulation, from ∼30% using the palpation approach (α=0.05; 1-ß=0.1). Results: This study has been approved by the NHS Health Research Authority and Health Care Research Wales (21/WA/0403) and commenced recruitment in May 2022. Conclusions: This study will establish whether handheld ultrasound-guided arterial cannulation before the induction of anaesthesia should be the standard of care in patients at risk of developing perioperative organ injury after noncardiac surgery. Clinical trial registration: NCT05249036.

Peripheral cannulation and endoaortic balloon occlusion for management of porcelain aorta during cardiac surgery.

Porcelain aorta with extensive calcification of the ascending aorta complicates cardiac surgery and increases perioperative risk. Aortic cannulation and cross-clamping in these patients increase the risk of serious complications including perioperative embolic stroke. Although different techniques have been proposed, surgery in these patients remains a challenge. We present the clinical implications of the porcelain aorta and surgical strategies involving axillary arterial cannulation and endoaortic balloon to allow for the institution of cardiopulmonary bypass and cardioplegic arrest during surgery. The surgery included a redo sternotomy with bioprosthetic mitral valve replacement, tricuspid valve repair with an annuloplasty, and closure of the left atrial appendage. In appropriately selected patients, endoaortic balloon occlusion was a valuable tool to facilitate the safe conduct of an operation. Careful preoperative evaluation and planning by a multidisciplinary team are essential in these cases.