Ultrasound guidance for femoral venous access in patients undergoing pulmonary vein isolation: a quasi-randomized study

INTRODUCTION

Routine ultrasound (US)-guidance for femoral venous access to decrease vascular complications of atrial fibrillation (AF) ablation procedures has been advocated. However, the benefit has not been unequivocally demonstrated by randomized-trial data.

METHODS AND RESULTS

Consecutive patients undergoing pulmonary vein isolation (PVI) on uninterrupted anticoagulant treatment were included. A quasi-random allocation to either US-guided or conventional puncture group was based on which of the two procedure rooms the patient was scheduled in, with only one of the rooms equipped with an US machine including a vascular transducer. The same 4 novice operators in rotation, with no relevant previous experience in US-guided vascular access performed venous punctures in both rooms. Major and minor vascular complications and the rate of prolonged hospitalization were compared. Major vascular complication was defined as groin hematoma, arteriovenous fistula, or pseudoaneurysm. Hematoma was considered as a major vascular complication if it met type 2 or higher Bleeding Academic Research Consortium criteria (requiring nonsurgical, medical intervention by a health care professional; leading to hospitalization or increased level of care, or prompting evacuation). Of the 457 patients 199 were allocated to the US-guided puncture group, while the conventional, palpation-based approach was performed in 258 cases. Compared to the conventional technique, US-guidance reduced the rate of any vascular complication (11.63% vs. 2.01%, p<0.0001), including both major (4.26% vs. 1.01%, p=0.038) and minor (7.36% vs 1.01%, p=0.001) vascular complications. In addition, the rate of prolonged hospitalization was lower in the US-guided puncture group (5.04% vs. 1.01%, p=0.032).

CONCLUSION

The use of US for femoral vein puncture in patients undergoing PVI decreased the rate of both major and minor vascular complications. This quasi-randomized comparison strongly supports adapting routine use of US for AF ablation procedures. This article is protected by copyright. All rights reserved.

Subaortic left brachiocephalic vein and real-time ultrasound-guided puncture

We describe a subaortic left brachiocephalic vein, a congenital anomaly that can be suspected during the rapid central vein assessment before central venous catheterization. Since the vein descends vertically/obliquely rapidly from its origin, we suggest that the puncture should be made at a greater angle (50°-60°) than what is usually used to puncture this vein (20°-30°). Failure to identify this anomaly may cause a failed puncture or complications from the puncture of adjacent blood vessels.

A comparative study of ultrasound-guided puncture biopsy combined with histopathology and Xpert MTB/RIF in the diagnosis of lymph node tuberculosis

Background

Cervical tuberculous lymphadenitis (CTBL) is a disease often ignored in clinical work, and pathology and Xpert MTB/RIF (Xpert) are the commonly used methods for tuberculosis diagnosis. This study aimed to compare ultrasound-guided puncture biopsy combined with histopathology and Xpert in the diagnosis of lymph node tuberculosis.

Methods

A total of 217 patients highly suspected for CTBL were retrospectively enrolled. All patients underwent ultrasound-guided puncture sampling. All samples were subjected to pathological examination and Xpert test. The sensitivity and specificity of the two methods were compared for all samples. The kappa value was calculated to assess the consistency of the pathological examination and Xpert test using comprehensive diagnosis as the gold standard. Receiver operating characteristic curves of the pathological examination, Xpert test, and their combination were generated, and the areas under the curve (AUCs) were calculated to compare the diagnostic value of the three methods.

Results

The sensitivity and specificity of the pathological diagnosis of CTBL were 70.1 and 100%, respectively. The sensitivity and specificity of Xpert for CTBL diagnosis were 82.5 and 97.5%, respectively. The results of the pathological examination and Xpert test showed poor consistency in the diagnosis of CTBL, with a kappa value of 0.388. The AUC of the pathological diagnosis of CTBL was 0.850 (95% CI: 0.796-0.895), whereas that of Xpert was 0.900 (95% CI: 0.852-0.936), and the difference was statistically significant (P = 0.0483). The AUC of pathological examination combined with Xpert for the diagnosis of CTBL was 0.956 (95% CI: 0.920-0.979), and the difference between pathological examination combined with Xpert for the diagnosis of CTBL was statistically significant compared with pathological examination and Xpert alone, respectively (both P < 0.001).

Conclusion

The diagnostic efficiency of Xpert test is higher than that of pathological examination, but its sensitivity is still not ideal for clinical diagnosis. According to this study, the consistency of Xpert test and pathological diagnosis is poor, and the combination of Xpert test and pathological diagnosis can significantly increase the diagnostic efficiency.

Case Report: Primary Mediastinal Large B-Cell Lymphoma Invasion of Extranodal Thyroid Tissue Mimicking Tuberculosis and Confounded by Similar Ultrasonic Appearance

Background

Primary mediastinal large B-cell lymphoma (PMBCL) is a rare type of diffuse large B-cell lymphoma, which has significant features that overlap with those of Hodgkin’s lymphoma. Ultrasound is a commonly used modality to characterize superficial lymph no5des, and ultrasonic findings are often used to distinguish lymphoma from lymph node tuberculosis in daily clinical practice. Although a common malignancy, lymphoma rarely involves extranodal tissues.

Case Presentation

Here we report the case of a 42-year-old Chinese male patient with PMBCL who was misdiagnosed with tuberculosis because of extranodal invasion. He visited our hospital for a neck mass that he had been noting for 1 week. Ultrasound revealed multiple enlarged lymph nodes on both sides of the neck. The lesions appeared to involve the surrounding soft tissue and thyroid gland, resembling a tuberculous sinus tract formation. Cervical spine computed tomography showed no obvious abnormalities in the cervical cone or bone damage. Contrast-enhanced ultrasound indicated that one of the enlarged lymph nodes in the right neck was rich in blood supply and exhibited centripetal enhancement, with uniform high enhancement at the peak. The patient underwent two ultrasound-guided punctures; the first puncture was performed for an enlarged lymph node in the right neck at Hangzhou Red Cross Hospital. Hodgkin’s lymphoma was suspected based on pathological and immunohistochemical findings, whereas a rare type of diffuse large B-cell lymphoma was suspected at Zhejiang Cancer Hospital.

Conclusions

Lymphoma is often misdiagnosed, causing delayed treatment initiation and affecting patient outcomes as the disease progresses. The present case demonstrates that the ultrasonic appearance of lymphoma may sometimes be confused with that of tuberculosis. Although ultrasound-guided needle biopsy has a high diagnostic accuracy, it may also cause diagnostic deviation because of insufficient sampling volume. Moreover, owing to the enlargement of multiple lymph nodes due to lymphoma or lymph node tuberculosis, puncturing different lymph nodes may provide different results.