Intra-pocket ultrasound-guided axillary vein puncture vs. cephalic vein cutdown for cardiac electronic device implantation: the ACCESS trial.

BACKGROUND AND AIMS: Intra-pocket ultrasound-guided axillary vein puncture (IPUS-AVP) for venous access in implantation of transvenous cardiac implantable electronic devices (CIED) is uncommon due to the lack of clinical evidence supporting this technique. This study investigated the efficacy and early complications of IPUS-AVP compared to the standard method using cephalic vein cutdown (CVC) for CIED implantation. METHODS: ACCESS was an investigator-led, interventional, randomized (1:1 ratio), monocentric, controlled superiority trial. A total of 200 patients undergoing CIED implantation were randomized to IPUS-AVP (n = 101) or CVC (n = 99) as a first assigned route. The primary endpoint was the success rate of insertion of all leads using the first assigned venous access technique. The secondary endpoints were time to venous access, total procedure duration, fluoroscopy time, X-ray exposure, and complications. Complications were monitored during a follow-up period of three months after procedure. RESULTS: IPUS-AVP was significantly superior to CVC for the primary endpoint with 100 (99.0%) vs. 86 (86.9%) procedural successes (P = .001). Cephalic vein cutdown followed by subclavian vein puncture was successful in a total of 95 (96.0%) patients, P = .21 vs. IPUS-AVP. All secondary endpoints were also significantly improved in the IPUS-AVP group with reduction in time to venous access [3.4 vs. 10.6 min, geometric mean ratio (GMR) 0.32 (95% confidence interval, CI, 0.28-0.36), P < .001], total procedure duration [33.8 vs. 46.9 min, GMR 0.72 (95% CI 0.67-0.78), P < .001], fluoroscopy time [2.4 vs. 3.3 min, GMR 0.74 (95% CI 0.63-0.86), P < .001], and X-ray exposure [1083 vs. 1423 mGy.cm², GMR 0.76 (95% CI 0.62-0.93), P = .009]. There was no significant difference in complication rates between groups (P = .68). CONCLUSIONS: IPUS-AVP is superior to CVC in terms of success rate, time to venous access, procedure duration, and radiation exposure. Complication rates were similar between the two groups. Intra-pocket ultrasound-guided axillary vein puncture should be a recommended venous access technique for CIED implantation.

Axillary vein puncture versus cephalic vein cutdown for cardiac implantable electronic device implantation: A meta-analysis.

INTRODUCTION: Cephalic vein cutdown (CVC) and axillary vein puncture (AVP) are both recommended for transvenous implantation of leads for cardiac implantable electronic devices (CIEDs). Nonetheless, it is still debated which of the two techniques has a better safety and efficacy profile. METHODS: We systematically searched Medline, Embase, and Cochrane electronic databases up to September 5, 2022, for studies that evaluated the efficacy and safety of AVP and CVC reporting at least one clinical outcome of interest. The primary endpoints were acute procedural success and overall complications. The effect size was estimated using a random-effect model as risk ratio (RR) and relative 95% confidence interval (CI). RESULTS: Overall, seven studies were included, which enrolled 1771 and 3067 transvenous leads (65.6% [n = 1162] males, average age 73.4 ± 14.3 years). Compared to CVC, AVP showed a significant increase in the primary endpoint (95.7 % vs. 76.1 %; RR: 1.24; 95% CI: 1.09-1.40; p = .001) (Figure 1). Total procedural time (mean difference [MD]: -8.25 min; 95% CI: -10.23 to -6.27; p < .0001; I2  = 0%) and venous access time (MD: -6.24 min; 95% CI: -7.01 to -5.47; p < .0001; I2  = 0%) were significantly shorter with AVP compared to CVC. No differences were found between AVP and CVC for incidence overall complications (RR: 0.56; 95% CI: 0.28-1.10; p = .09), pneumothorax (RR: 0.72; 95% CI: 0.13-4.0; p = .71), lead failure (RR: 0.58; 95% CI: 0.23-1.48; p = .26), pocket hematoma/bleeding (RR: 0.58; 95% CI: 0.15-2.23; p = .43), device infection (RR: 0.95; 95% CI: 0.14-6.60; p = .96) and fluoroscopy time (MD: -0.24 min; 95% CI: -0.75 to 0.28; p = .36). CONCLUSION: Our meta-analysis suggests that AVP may improve procedural success and reduce total procedural time and venous access time compared to CVC.

Perioperative complications after pacemaker implantation: higher complication rates with subclavian vein puncture than with cephalic vein cutdown.

PURPOSE: The cephalic vein cutdown (CVC) and the subclavian puncture (SP) is the most common access for pacemaker implantation. The purpose of this study was to compare the peri-/postoperative complications of these approaches. METHODS: A retrospective analysis of the quality assurance data of the state of North Rhine-Westphalia was performed to evaluate the peri-/postoperative complications of first pacemaker implantation according to the venous access. The primary endpoint was defined as the occurrence of one of the following: asystole, ventricular fibrillation, pneumothorax, hemothorax, pericardial effusion, pocket hematoma, lead dislocation, lead dysfunction, postoperative wound infection or other complication requiring intervention. Descriptive analysis was done via absolute, relative frequencies and Odds Ratio. Fisher's exact test was used for comparison of the both study groups. RESULTS: From 139,176 pacemaker implantations from 2010 to 2014, 15,483 cases were excluded due to other/double access. The median age was 78 years and the access used was CVC for 75,251 cases (60.8%) and SP for 48,442 cases (39.2%). The implanted devices were mainly dual-chamber pacemakers (73.9% in the CVC group and 78.4% in the SP group), followed by single-chamber pacemakers VVI (24.9% and 19.9% in the CVC and SP group respectively). There were significantly fewer peri/postoperative complications in the CVC group compared to the SP group (2.49% vs. 3.64%, p = 0.0001, OR 1.47; 95% CI 1.38-1.57). CONCLUSIONS: CVC as venous access for pacemaker implantation has significantly fewer peri/postoperative complications than SP and appears to be an advantageous technique.

Direct anchoring technique for pacing and defibrillation leads inserted through cephalic vein: insight for a single high-volume center.

BACKGROUND: Direct anchoring of PM and ICD leads over cephalic vein body is officially discouraged by manufactures due to a supposed risk of conductor fracture or insulation failure, however careful tightening of anchoring knots can probably prevent lead damage. Direct anchoring (DA) technique is routinely used in our center for all leads inserted by cephalic vein while standard anchoring sleeves are used to secure subclavian leads only. Aim of the study is to assess short- and long-term safety of cephalic direct anchoring technique. METHODS: All patients undergoing PM and ICD implantation in our center from November 2014 to March 2016 were consecutively enrolled. Primary endpoints were acute lead fracture, lead dislodgement and chronic lead failure. Secondary endpoint was a composite of short-term surgical complications (pocket hematoma, pneumothorax, and pericardial effusion) plus device infections. Subclavian leads secured with sleeve anchoring (SA) were used as control. RESULTS: A total of 550 leads were implanted in 310 consecutive patients. DA involved 323 leads (59%) while SA was used for 227 (41%). Median follow-up was 50 months (IQR 24-62 months). 17 lead malfunctions (3.1%) were observed during follow-up. No difference was observed between groups (10 DA vs. 7 SP, P=ns). Survival analysis found no difference between groups. Secondary endpoints were not statistically different between groups (5 vs. 1, P=0.08). CONCLUSIONS: Direct anchoring technique of PM and ICD leads is a safe technique and does not increase lead malfunction risk.

Different venous approaches for implantation of cardiac electronic devices. A network meta-analysis.

OBJECTIVES: Many of the complications arising from cardiac device implantation are associated to the venous access used for lead placement. Previous analyses reported that cephalic vein cutdown (CVC) is safer but less effective than subclavian vein puncture (SVP). However, comparisons between these techniques and axillary vein puncture (AVP) - guided either by ultrasound or fluoroscopy - are lacking. Thus, we aimed to compare safety and efficacy of these approaches. METHODS: We searched for articles assessing at least two different approaches regarding the incidence of pneumothorax and/or lead failure (LF). When available, bleeding and infectious complications as well as procedural success were analyzed. A frequentist random effects network meta-analysis model was adopted. RESULTS: Thirty-six studies were analyzed. Most articles assessed SVP versus CVC. Compared to SVP, both CVC and AVP were associated with reduced odds of pneumothorax (OR: 0.193, 95%CI: 0.136-0.275 and OR: 0.128, 95%CI: 0.050-0.329; respectively) and LF (OR: 0.63, 95%CI: 0.406-0.976 and OR: 0.425, 95%CI: 0.286-0.632; respectively). No significant differences between AVP and CVC were demonstrated. Limited data suggests no major impact of different approaches on infectious and bleeding complications. Initial CVC approach required significantly more often an alternate/additional venous access for lead placement, compared to both AVP and SVP. No differences between these two were identified. CONCLUSION: Both AVP and CVC seem to decrease incident pneumothorax and LF, compared to SVP. Initial AVP approach seems to decrease the need of alternate venous access, compared to CVC. These results suggest that AVP should be further clinically tested.

Comparison of success rate and time to obtain venous cannulation by cutdown technique at 3 locations using canine cadavers.

OBJECTIVE: To compare the success rates and time taken to cannulate the jugular, cephalic, and lateral saphenous veins using a cutdown technique by personnel with 4 different levels of experience. DESIGN: Prospective ex vivo study. SETTING: Veterinary university teaching hospital. ANIMALS: Eighteen canine cadavers. INTERVENTIONS: Recently euthanized canine patients that were donated to the hospital for research purposes between October 2019 and March 2020 were enrolled. Four groups of personnel participated in the study to give 4 varying levels of experience: 8 final year veterinary students, 2 registered veterinary nurses, 1 emergency and critical care intern and 1 ACVECC diplomate. Each cannula placer had 5 minutes to attempt cannulation by venous cutdown at each site. Time to venous cannulation (VC) was compared for each site and group and complications encountered during each attempt recorded. MEASUREMENTS AND MAIN RESULTS: The overall success rate for cannulation of the jugular, cephalic, and lateral saphenous veins were 81%, 84%, and 87%, respectively. The median times for venous cutdown for all personnel were as follows: jugular vein 119 s (range 51-280 s), cephalic vein 82 s (range 39-291 s), and lateral saphenous vein 110 s (range 41-294 s). There was no difference in time to VC between veins. When comparing personnel at the 3 cannulation sites, the ACVECC diplomate was faster than the registered veterinary nurses and students (P = 0.042 and P = 0.048, respectively). No differences were found between any other groups. Complications encountered often related to cadaver factors such as hematoma from antemortem venipuncture. CONCLUSIONS: All groups were able to perform venous cutdown at each site with good overall success even without prior experience of the technique. VC by cutdown technique of the jugular, cephalic, or lateral saphenous veins may be considered in an emergency setting by personnel of various skill levels.

A Prospective, Comparative Evaluation on Totally Implantable Venous Access Devices by External Jugular Vein versus Cephalic Vein Cutdown.

The request for totally implantable venous access devices (TIVADs) has rapidly grown up through the last decades. TIVADs are implanted by direct vein puncture or by surgical approach with vein cutdown. The authors present a comparative prospective study evaluating external jugular vein (EJV) and cephalic vein cutdown techniques. Two hundred and fifteen patients were consecutively submitted to TIVAD implantation to perform chemotherapy. Patients were divided in two groups, depending on the implantation technique. Group A patients (106) underwent implantation via EJV cutdown and group B (109) patients underwent implantation by cephalic vein cutdown. The following variables were investigated: operating time, need for conversion to other approaches, complications, and intraoperative and postoperative pain. In Group A patients, the success rate of the procedure was 100 per cent, whereas in 11 patients (10.1%) of Group B, a modification of the initial approach was needed. Mean operative time was 23.9 ± 9.2 minutes in Group A and 35.4 ± 11.9 in Group B, and this was statistically significant (P < 0.05). Complication rates at 30 days were similar. Considering intraoperative pain, a difference was found between the two groups because the mean value of pain in Group A was lower than that in Group B (4.13 ± 0.3 vs 5.22 ± 1.24), even if not significant. External jugular vein cutdown approach is quick and safe and allows a very high success rate with very low risk of complications. For these reasons, this approach could be considered as a first choice in TIVAD placement.

Long-term clinical outcomes of the single-incision technique for implantation of implantable venous access ports via the axillary vein.

PURPOSE: To evaluate long-term clinical outcomes and complications of the single-incision technique for implantation of totally implantable venous access ports (TIVAPs) via the axillary vein. MATERIALS AND METHODS: A total of 932 TIVAPs were placed in 927 patients between May 2012 and October 2014 using a single-incision technique. Patients included 620 men and 307 women with a mean age of 60.0 years. TIVAPs were placed via the left (n = 475) and right (n = 457) axillary veins after making a single oblique vertical incision and medial side pocket without subcutaneous tunneling. We retrospectively reviewed medical records to evaluate status of the patients and TIVAPs, complications, and reasons for explantation. In patients who still had a TIVAP in place, we calculated the duration of TIVAP use from the cut-off day of November 1, 2015. RESULTS: Clinical follow-up was obtained for a total device service period of 311,069 days with a median indwelling time of 467 days (range: 3-1097 days). A total of 37 (4.0%) complications developed. Early complications (n = 4) were one case each of stenosis of the brachiocephalic vein by tumor growth, thrombosis of axillary vein, intravascular migration, and malfunction depending on patient's position. Late complications (n = 33) were suspected catheter-related blood stream infection (n = 23), local infection of the pocket (n = 4), symptomatic stenosis and thrombosis of central vein (n = 4), malfunction by fibrin sleeve (n = 1), and intravascular migration (n = 1). CONCLUSIONS: A single-incision technique for TIVAP implantation via the axillary vein seems to be safe with a low risk of complication.

Vascular Access in Pediatric Patients in the Emergency Department: Types of Access, Indications, and Complications.

Vascular access is a potentially life-saving procedure that is a mainstay of emergency medicine practice. There are a number of challenges associated with obtaining and maintaining vascular access, and the choice of the route of access and equipment used will depend on patient- and provider-specific factors. In this issue, the indications and complications of peripheral intravenous access, intraosseous access, and central venous access are reviewed. Timely and effective assessment and management of difficult-access patients, pain control techniques that can assist vascular access, and contraindications to each type of vascular access are also discussed.

Actualización en accesos vasculares / No disponible

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Una sorpresa durante la cateterización ecoguiada de la vena yugular interna: arteria carótida común aberrante / A surprise during ultrasound-guided catheterization of the internal yugular vein: aberrant common carotid artery

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Venous access and long-term pacemaker lead failure: comparing contrast-guided axillary vein puncture with subclavian puncture and cephalic cutdown.

AIMS: Existing data on the relationship between venous access and long-term pacemaker lead failure (PLF) are scarce and inconsistent. We aim to study the hypothesis that contrast-guided axillary vein puncture (AP) is better than subclavian puncture (SP) and similar to cephalic vein cutdown (CV) in the incidence of PLF and the success rate of AP is higher than CV. METHODS AND RESULTS: The case records of 409 patients with 681 implantable pacemaker leads were reviewed. Two hundred and fifty-two, 217, and 212 leads were implanted via AP, CV, and SP, respectively. With a mean follow-up of 73.6 ± 33.1 months, 20 (2.9%) PLF occurred. Three (1.2%), 5 (2.3%), and 12 (5.6%) PLF occurred in the AP, CV, and SP groups, respectively. On multivariate Cox regression analysis, the only independent predictor for PLF was the use of SP instead of AP (AP vs. SP; hazard ratio: 0.261; 95% confidence interval: 0.071-0.954, P = 0.042). The success rate of CV (78.2%) was significantly lower than those of AP (97.6%) and SP (96.8%) (P < 0.001). CONCLUSION: Compared with SP, the use of AP but not CV independently predicted a lower risk of PLF. The success rates in achieving venous accesses were similar between AP and SP, but significantly lower for CV. Axillary vein puncture may thus be considered the venous access of choice for pacemaker lead implantation.

Percutaneous versus Cut-Down Technique for Indwelling Port Placement.

The superiority of surgical cut-down of the cephalic vein versus percutaneous catheterization of the subclavian vein for the insertion of totally implantable venous access devices (TIVADs) is debated. To compare the safety and efficacy of surgical cut-down versus percutaneous placement of TIVADs. This is a single-institution retrospective cohort study of oncologic patients who had TIVADs implanted by 14 surgeons. Primary outcomes were inability to place TIVAD by the primary approach and postoperative complications within 30 days. Multivariate analysis was performed by logistic regression. Secondary outcomes included operative time. Two hundred and forty-seven (55.9%) percutaneous and 195 (44.1%) cephalic cut-down patients were identified. The 30-day complication rate was 5.2 per cent: 14 patients (5.7%) in the percutaneous and nine (4.6%) in the cut-down group. The technique was not a significant predictor of having a 30-day complication (odds ratio = 0.820; 95% confidence interval 0.342-1.879). Implantation failure was observed in 16 percutaneous patients (6.5%) and 28 cut-down patients (14.4%) (adjusted odds ratio for cephalic vs cut-down = 2.387; 95% confidence interval 1.275-4.606). The median operative time for percutaneous patients was 46 minutes (interquartile range = 35, 59) versus 37.5 minutes (interquartile range = 30, 49) for cut-down patients(P < 0.0001). Both the percutaneous and cut-down technique are safe and effective for TIVAD implantation. Operative times were shorter and the odds of implantation failure higher for cephalic cut-down. As implantation failure is common, surgeons should familiarize themselves with both techniques.

[Control study of total percutaneous access with preclose technique versus open femoral artery exposure for endovascular aneurysm repair].

OBJECTIVE: To compare total percutaneous access using preclose technique with femoral artery cut-down in endovascular aneurysm repair (EVAR) and assess the safety and feasibility of preclose technique. METHODS: In the study, 81 cases undergoing EVAR from Dec. 2011 to Nov. 2014 in Peking University People's Hospital were retrospectively reviewed. Preoperative CT angiography (CTA) showed presence of infrarenal abdominal aortic aneurysm or descending aortic aneurysm in all the cases. The maximum diameter of aneurysm >4.5 cm met the indications for surgical treatment. The conditions of bilateral femoral artery and iliac artery CTA showed were good, and there was no moderate or severe stenosis, nor was there any severe calcification in anterior wall of femoral artery. Not only were the cases fit for percutaneous endovascular aortic aneurysm repair (PEVAR), but also feasible with open endovascular aneurysm repair (OEVAR). According to the intention of the patients about the surgical incision, the cases were divided into group PEVAR and group OEVAR. The data of the general situation, operation time, blood loss, technical success rate, length of hospital stay after procedure and wound complications were analyzed statistically. RESULTS: In the study, 44 cases (78 incisions) were enrolled in group PEVAR and 37 cases (65 incisions) in group OEVAR. There was no significant difference between the two groups in age, gender, body mass index (BMI), accompanying diseases, average number of stents and outer diameter of stent delivery system. Average operation time of group PEVAR was less than that of group OEVAR [(119.1±102.0) min vs. (163.6±61.9) min, P=0.025]. The blood loss in group PEVAR was less than that in group OEVAR [(64.7±97.0) mL vs. (98.6±88.3) mL], but there was no significant difference (P=0.106). There was no difference in the technical success rate (94.9% vs.95.4%, P=1.000). The average length of hospital stay after procedure was significantly shorter in group PEVAR [(7.8±2.8) d vs.(12.3±7.2) d, P<0.001]. There were 2 cases with subcutaneous hematoma of wound in group PEVAR and 7 cases of wound complications that occurred in group OEVAR including 3 cases with lymphatic leakage, 3 cases with lower limb ischemia and 1 case with subcutaneous hematoma. The analysis showed that PEVAR could reduce the wound complications (2.6%vs.10.8%), but there was no significant difference between the two groups (P=0.079). CONCLUSION: Using preclose technique in EVAR is safe and effective. It can shorten the operation time and length of hospital stay after procedure.

Venous cutdown versus the Seldinger technique for placement of totally implantable venous access ports.

BACKGROUND: Totally implantable venous access ports (TIVAPs) provide patients with a safe and permanent venous access, for instance in the administration of chemotherapy for oncology patients. There are several methods for TIVAP placement, and the optimal evidence-based method is unclear. OBJECTIVES: To compare the efficacy and safety of three commonly used techniques for implanting TIVAPs: the venous cutdown technique, the Seldinger technique, and the modified Seldinger technique. This review includes studies that use Doppler or real-time two-dimensional ultrasonography for locating the vein in the Seldinger technique. SEARCH METHODS: The Cochrane Vascular Trials Search Co-ordinator searched the Cochrane Vascular Specialised Register (last searched August 2015) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 7), as well as clinical trials registers. SELECTION CRITERIA: We included randomised or quasi-randomised controlled clinical trials that randomly allocated people requiring TIVAP to the venous cutdown, Seldinger, or modified Seldinger technique. Two review authors independently assessed studies for inclusion eligibility, with a third review author checking excluded studies. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data. We assessed all studies for risk of bias. We assessed heterogeneity using Chi(2) statistic and variance (I(2)statistic) methods. Dichotomous outcomes, summarised as odds ratio (OR) with 95% confidence interval (CI), were: primary implantation success, complications (in particular infection), pneumothorax, and catheter complications. We conducted separate analyses to assess the two access veins, subclavian and internal jugular (IJ) vein, in the Seldinger technique versus the venous cutdown technique. We used both intention-to-treat (ITT) and on-treatment analyses and pooled data using a fixed-effect model. MAIN RESULTS: We included nine studies with a total of 1253 participants in the review. Five studies compared Seldinger technique (subclavian vein access) with venous cutdown technique (cephalic vein access). Two studies compared Seldinger (IJ vein) versus venous cutdown (cephalic vein). One study compared the modified Seldinger technique (cephalic vein) with the venous cutdown (cephalic vein), and one study compared the Seldinger (subclavian vein) versus the Seldinger (IJ vein) technique.Seldinger technique (subclavian or IJ vein access) versus venous cutdown (cephalic vein): We included seven trials with 1006 participants for analysis. Both ITT (OR 0.40; 95% CI 0.25 to 0.65) and on-treatment analysis (OR 0.59; 95% CI 0.36 to 0.98) showed that the Seldinger technique for implantation of TIVAP had a higher success rate compared with the venous cutdown technique. We found no difference between overall peri- and postoperative complication rates: ITT (OR 1.16; 95% CI 0.76 to 1.75) and on-treatment analysis (OR 0.93; 95% CI 0.62 to 1.40). In the Seldinger group, the majority of the trials reported use of the subclavian vein for venous access, with only a limited number of trials utilising the IJ vein for access. When individual complication rates of infection, pneumothorax, and catheter complications were analysed, the Seldinger technique (subclavian vein access) was associated with a higher rate of catheter complications compared to the venous cutdown technique: ITT (OR 6.77; 95% CI 2.31 to 19.79) and on-treatment analysis (OR 6.62; 95% CI 2.24 to 19.58). There was no difference in incidence of infections, pneumothorax, and other complications between the groups.Modified Seldinger technique (cephalic vein) versus venous cutdown (cephalic vein): We identified one trial with 164 participants. ITT analysis showed no difference in primary implantation success rate between the modified Seldinger technique (69/82, 84%) and the venous cutdown technique (66/82, 80%), P = 0.686. We observed no differences in the peri- or postoperative complication rates.Seldinger (subclavian vein access) versus Seldinger (IJ vein access): We identified one trial with 83 participants. The primary success rate was 84% (37/44) for Seldinger (subclavian vein) versus 74% (29/39) for the Seldinger (IJ vein). There was a higher overall complication rate in the subclavian group (48%) compared to the jugular group (23%), P = 0.02. However, when specific complications were compared individually, we found no differences between the groups.The overall quality of the trials included in this review was moderate. The methods used for randomisation were inadequate in four of the nine included studies, but sensitivity analysis excluding these trials did not alter the outcome. The nature of the interventions, either venous cutdown or Seldinger techniques, meant that it was not feasible to blind the participant or personnel, therefore we judged this to be at low risk of bias. The majority of participants in the included trials were oncology patients at tertiary centres, and the outcomes were applicable to the typical clinical scenario. For all outcomes, when comparing venous cutdown and Seldinger technique, serious imprecision was evident by wide confidence intervals in the included trials. The quality of the overall evidence was therefore downgraded from high to moderate. Due to the limited number of included studies we were unable to assess publication bias. AUTHORS' CONCLUSIONS: Moderate-quality evidence showed that the Seldinger technique has a higher primary implantation success rate compared with the venous cutdown technique. The majority of trials using the Seldinger technique used the subclavian vein for venous access, and only a few trials reported the use of the internal jugular vein for venous access. Moderate-quality evidence showed no difference in the overall complication rate between the Seldinger and venous cutdown techniques. However, when the Seldinger technique with subclavian vein access was compared with the venous cutdown group, there was a higher reported incidence of catheter complications. The rates of pneumothorax and infection did not differ between the Seldinger and venous cutdown group. We identified only one trial for each of the comparisons modified Seldinger technique (cephalic vein) versus venous cutdown (cephalic vein) and Seldinger (subclavian vein access) versus Seldinger (IJ vein access), thus a definitive conclusion cannot be drawn for these comparisons and further research is recommended.

The Treatment Results of a Standard Algorithm for Choosing the Best Entry Vessel for Intravenous Port Implantation.

Vascular cutdown and echo guide puncture methods have its own limitations under certain conditions. There was no available algorithm for choosing entry vessel. A standard algorithm was introduced to help choose the entry vessel location according to our clinical experience and review of the literature. The goal of this study is to analyze the treatment results of the standard algorithm used to choose the entry vessel for intravenous port implantation.During the period between March 2012 and March 2013, 507 patients who received intravenous port implantation due to advanced chemotherapy were included into this study. Choice of entry vessel was according to standard algorithm. All clinical characteristic factors were collected and complication rate and incidence were further analyzed.Compared with our clinical experience in 2006, procedure-related complication rate declined from 1.09% to 0.4%, whereas the late complication rate decreased from 19.97% to 3.55%. No more pneumothorax, hematoma, catheter kinking, fractures, and pocket erosion were identified after using the standard algorithm. In alive oncology patients, 98% implanted port could serve a functional vascular access to fit therapeutic needs.This standard algorithm for choosing the best entry vessel is a simple guideline that is easy to follow. The algorithm has excellent efficiency and can minimize complication rates and incidence.

Low incidence of complications after cephalic vein cutdown for pacemaker lead implantation in children weighing less than 10 kilograms: A single-center experience with long-term follow-up.

BACKGROUND: Only a few studies on the cephalic vein cutdown technique for pacemaker lead implantation in children weighing ≤10 kg have been reported even though the procedure is widely accepted in adults. OBJECTIVE: The purpose of this study was to prove that cephalic vein cutdown for pacemaker lead implantation is a reliable technique with a low incidence of complications in children weighing ≤10 kg. METHODS: The study included 44 children weighing ≤10 kg with an endocardial pacemaker. Cephalic, subclavian, and axillary vein diameters were measured by ultrasound before implantation. The measured diameters were used to select either an endocardial or epicardial surgical technique. Regular 6-month follow-up visits included pacemaker interrogation and clinical and ultrasound examinations. RESULTS: Two dual-chamber and 42 single-chamber pacemakers were implanted. Mean weight at implantation was 6.24 kg (range 2.25-10.40 kg), and mean age was 11.4 months (range 1 day-47 months). In 40 children (90.1%), the ventricular leads were implanted using the cephalic vein cutdown technique, and implantation was accomplished via the prepared right external jugular vein in 4 of the children (9.9%). The atrial leads were implanted using axillary vein puncture and external jugular vein preparations. Mean follow-up was 8.9 years (range 0-20.9 years). Only 1 pacemaker-related complication was detected (a lead fracture near the connector that was successfully resolved using a lead repair kit). CONCLUSION: The cephalic vein cutdown technique is feasible and reliable in children weighing ≤10 kg, which justifies the application of additional surgical effort in the treatment of these small patients.

Difficult indirect carotid-cavernous fistulas--alternative techniques to gaining access for treatment.

AIMS: Carotid-cavernous fistulas (CCFs) are abnormal communications between the carotid arterial system and the cavernous sinus that occur mainly in elderly. Occasionally, treatment of indirect CCFs with conventional endovascular approach through large veins or the inferior petrosal sinus may not be possible. In these cases, a direct surgical cut down on to the superior ophthalmic vein (SOV) is necessary. We describe three such cases of embolization of CCFs through SOV, and their results. METHODS: A retrospective case notes review of treated patients over the past 10 years in one tertiary center constituted our methodology. RESULTS: The fistulas in two cases were successfully coiled with complete obviation of symptoms and signs. The third case was complicated due to difficulty in canulating a deeply seated vein and so had to be abandoned and catheterized through contralateral superior petrosal sinus and treated with liquid embolic material Onyx(®) successfully. CONCLUSION: In cases where conventional access to the cavernous sinus may not be possible due to local variations of anatomy, multidisciplinary surgical approaches via the SOV provide an alternative route to successfully and safely close a CCF. However, unexpected anatomical variations could also be encountered within the SOV for which the surgeon should be prepared.

Cephalic vein cutdown for totally implantable central venous port in children: a retrospective analysis of prospectively collected data.

BACKGROUND: The jugular vein cutdown for a totally implantable central venous port (TICVP) has 2 disadvantages: 2 separate incisions are needed and the risk for multiple vein occlusions. We sought to evaluate the feasibility of a cephalic vein (CV) cutdown in children. METHODS: We prospectively followed patients who underwent a venous cutdown for implantation of a TICVP between Jan. 1, 2002, and Dec. 31, 2006. For patients younger than 8 months, an external jugular vein cutdown was initially tried without attempting a CV cutdown. For patients older than 8 months, a CV cutdown was tried initially. We recorded information on age, weight, outcome of the CV cutdown and complications. RESULTS: During the study period, 143 patients underwent a venous cutdown for implantation of a TICVP: 25 younger and 118 older than 8 months. The CV cutdown was successful in 73 of 118 trials. The 25th percentile and median body weight for 73 successful cases were 15.4 kg and 28.3 kg, respectively. There was a significant difference in the success rate using the criterion of 15 kg as the cutoff. The overall complication rate was 8.2%. CONCLUSION: The CV cutdown was an acceptable procedure for TICVP in children. It could be preferentially considered for patients weighing more than 15 kg who require TICVP.

CONTEXTE: La dissection de la jugulaire pour la mise en place d'un dispositif d'accès veineux central totalement implantable comporte 2 inconvénients : 2 incisions distinctes sont nécessaires et il y a un risque de multiples occlusions veineuses. Nous avons voulu évaluer la faisabilité d'une dissection de la veine céphalique chez les enfants. MÉTHODES: Nous avons suivi de manière prospective des patients soumis à une dissection veineuse pour implantation d'un dispositif d'accès veineux central entre le 1er janvier 2002 et le 31 décembre 2006. Pour les patients de moins de 8 mois, une dissection de la jugulaire externe a d'abord été tentée, sans tentative de dissection de la veine céphalique. Pour les patients de plus de 8 mois, une dissection de la veine céphalique a d'abord été tentée. Nous avons noté l'âge, le poids, l'issue de la dissection de la veine céphalique et les complications. RÉSULTATS: Au cours de la période de l'étude, 143 patients ont subi une dissection veineuse pour pose d'un dispositif d'accès veineux central totalement implantable : 25 avaient moins de 8 mois et 118 avaient plus de 8 mois. La dissection de la veine céphalique a réussi lors de 73 tentatives sur 118. Le poids du 25e percentile et le poids médian pour les 73 cas réussis étaient de 15,4 kg et de 28,3 kg, respectivement. On a observé une différence significative du taux de réussite associé au critère du poids seuil de 15 kg. Le taux global de complications a été de 8,2 %. CONCLUSION: La dissection de la veine céphalique a été une intervention acceptable pour la pose de dispositifs d'accès veineux centraux totalement implantables chez les enfants. Elle pourrait être envisagée chez les patients de plus de 15 kg qui ont besoin d'un dispositif d'accès veineux central implantable.