Proteomic analysis of jugular venous blood in acute large vessel occlusion stroke with futile recanalization

Futile recanalization (FR) after endovascular treatment (EVT) remains a significant challenge for acute ischemic stroke (AIS) with large vessel occlusion (LVO). The pathogenesis of FR has not been well elucidated. We prospectively enrolled anterior circulation LVO-AIS patients who achieved successful recanalization after EVT. The jugular venous blood ipsilateral to stroke was collected before and immediately after recanalization. Plasma proteomic analysis based on liquid chromatography-mass spectrometry was performed using data-independent acquisition method. Differentially expressed proteins (DEPs) among patients with or without FR in the whole or propensity score matching (PSM) cohorts were screened according to the absolute value of fold change ≥1.5 and P value <0.05. We identified 104 and 34 DEPs between patients with or without FR in the whole cohort and PSM cohort, respectively. Bioinformatic analysis indicated that the identified proteins were primarily related to specific biological processes including immune response, complement activation, oxidative stress, lipid metabolism, protein ubiquitylation as well as autophagy, suggesting that these may be mechanisms in FR pathogenesis. Collectively, we discovered proteins that may be potential research targets for FR. The combination of proteomic and bioinformatic analysis could provide a better understanding of the pathogenesis of FR in a comprehensive manner.

The agreement between jugular bulb and cerebrospinal fluid lactate levels in patients with out-of-hospital cardiac arrest

We investigated the agreement between the jugular bulb (JB) and cerebrospinal fluid (CSF) lactate levels. The study was conducted from July 2021 to June 2023 as a prospective observational cohort study at a single center. The right jugular vein was accessed, and the placement of JB catheter tip was confirmed using lateral cervical spine X-ray. A lumbar catheter was inserted between the 3rd and 4th lumbar spine of the patient. Lactate levels were measured immediately, 24 h, 48 h, and 72 h after ROSC. In patients with a good neurological prognosis, kappa between JB and CSF lactate levels measured immediately, at 24 h, 48 h, and 72 h after ROSC were 0.08, 0.36, 0.14, - 0.05 (p = 0.65, 0.06, 0.48, and 0.75, respectively). However, in patients with a poor neurological prognosis, kappa between JB and CSF lactate levels measured immediately, at 24 h, 48 h, and 72 h after ROSC were 0.38, 0.21, 0.22, 0.12 (p = 0.001, 0.04, 0.04, and 0.27, respectively). This study demonstrated that JB lactate levels exhibited significant agreement with arterial lactate levels, compared to CSF lactate levels. Therefore, this should be considered when using JB lactate to monitor cerebral metabolism.

Impact of insertion into the left internal jugular vein in chemoport-associated infections: a retrospective single-center study of 1690 cases

We analyzed chemoport insertion procedures to evaluate infectious morbidity and factors causing infection. This single-center retrospective study included 1690 cases of chemoport implantation between January 2017 and December 2020. Overall, chemoports were inserted in 1582 patients. The average duration of chemoport use was 481 days (range 1-1794, median 309). Infections occurred in 80 cases (4.7%), with 0.098 per 1000 catheter-days. Among the 80 cases in which chemoports were removed because of suspected infection, bacteria were identified in 48 (60%). Significantly more cases of left internal jugular vein punctures were noted in the infected group (15 [18.8%] vs. 147 [9.1%]; p = 0.004). Pulmonary embolism was significantly different between the infection groups (3 [3.8%] vs. 19 (1.2%), p = 0.048). The hazard ratio was 2.259 (95% confidence interval [CI] 1.288-3.962) for the left internal jugular vein, 3.393 (95% CI 1.069-10.765) for pulmonary embolism, and 0.488 (95% CI 0.244-0.977) for chronic obstructive pulmonary disease. Using the right internal jugular vein rather than the left internal jugular vein when performing chemoport insertion might reduce subsequent infections.

Effect of insertion site on tunnelled haemodialysis catheter outcomes: an observational study of 967 catheters

BACKGROUND

The right internal jugular vein is the preferred approach to tunnelled haemodialysis catheter placement. However, the effect of the insertion site on long-term catheter outcomes remains uncertain.

AIMS

We aimed to analyse a large cohort of tunnelled haemodialysis catheter placements to compare short-term and long-term results according to central venous catheter location.

METHODS

A retrospective cohort study was performed on consecutive tunnelled catheter insertions at two centres over 7 years. The primary outcome was catheter survival, compared according to the central vein site. We used the Kaplan-Meier curve method and Cox proportional hazards modelling to determine the effect of the catheterisation route on primary patency, adjusted for clinical risk factors for catheter failure.

RESULTS

There were 967 tunnelled dialysis catheter placements in 620 patients. The median survival for right internal jugular vein catheters was 569 days. There were no differences in rates of catheter failure between right internal jugular, left internal jugular (adjusted hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.52-1.21), external jugular (HR, 0.79; CI, 0.33-3.13), subclavian (HR, 0.67; CI, 0.58-2.44) and femoral vein (HR, 1.20; CI, 0.36-1.33) catheters following multivariable analysis. There were no major differences in functionality or complications between the groups.

CONCLUSIONS

This study identified no statistically significant relationship between tunnelled haemodialysis catheter insertion site and catheter survival. The contemporary approach to dialysis vascular access should be tailored to specific patient circumstances.

Axillary vein as an alternative venous access site for VV-ECMO cannulation: a case report

BACKGROUND

Ultrasound-guided percutaneous axillary vein cannulation can reduce cannulation failure and mechanical complications, is as safe and effective as internal jugular vein cannulation, and is superior to subclavian vein cannulation using landmark technique. As far, reports of venovenous extracorporeal membrane oxygenation (VV-ECMO) with percutaneous axillary vein cannulation are rare.

CASE PRESENTATION

A 64-year-old man presenting with dyspnea and chest tightness after aspirating sewage was admitted to the emergency department. Computed tomography (CT) showed diffuse exudation of both lungs and arterial blood gas analysis showed an oxygenation index of 86. He was diagnosed with aspiration pneumonia-induced acute respiratory distress syndrome (ARDS) and intubated for deteriorated oxygenation. Despite the combination therapy of protective mechanical ventilation and prone position, the patient's oxygenation deteriorated further, accompanied with multiple organ dysfunction syndrome, which indicated the requirement of support with VV-ECMO. However, vascular ultrasound detected multiple thrombus within bilateral internal jugular veins. As an alternative, right axillary vein was chosen as the access site of return cannula. Subsequently, femoral-axillary VV-ECMO was successfully implemented under the ultrasound guidance, and the patient's oxygenation was significantly improved. Unfortunately, the patient died of hyperkalemia-induced ventricular fibrillation after 36 h of VV-ECMO running. Despite the poor prognosis, the blood flow during ECMO run was stable, and we observed no bleeding complication, vascular injury, or venous return disorder.

CONCLUSIONS

Axillary vein is a feasible alternative access site of return cannula for VV-ECMO if internal jugular vein access were unavailable.

Comparison of plasma l-lactate between jugular and cephalic veins in healthy and systemically ill horses using a point-of-care device

OBJECTIVE

To compare plasma l-lactate (LAC) values between samples collected from jugular and cephalic venipuncture in healthy horses and systemically ill horses.

DESIGN

Prospective, experimental study.

SETTING

Large animal university teaching hospital.

ANIMALS

Thirty healthy adult university-owned horses and 43 client-owned horses presenting to the large animal hospital for elective surgical procedures or for emergent medical evaluation of systemic illness.

INTERVENTIONS

Blood samples were collected from the jugular vein (JV) and cephalic vein (CV) and placed in EDTA blood tubes prior to any medical therapy. LAC values were obtained with a handheld lactate meter at the time of blood collection.

MEASUREMENTS AND MAIN RESULTS

LAC was higher in CV samples than JV samples in healthy horses (P < 0.001); however, all values were within the normal reference range. Similarly, LAC was higher in CV samples than JV samples in systemically ill horses (P < 0.001), but the median JV value was within normal reference range (1.9 mmol/L [17.1 mg/dL]), while the median CV value was outside the normal reference range (2.9 mmol/L [26.1 mg/dL]).

CONCLUSIONS

The CV is an alternative venipuncture site for assessing plasma LAC if the JV is not accessible or to preserve the JV for subsequent catheterization. However, in ill horses, the CV value may be outside the reference range when the corresponding JV value would have been within the reference range.

Operator gender differences in major mechanical complications after central line insertions: a subgroup analysis of a prospective multicentre cohort study

BACKGROUND

A previous study on mechanical complications after central venous catheterisation demonstrated differences in complication rates between male and female operators. The objective of this subgroup analysis was to further investigate these differences. The hypothesis was that differences in distribution of predefined variables between operator genders could be identified.

METHODS

This was a subgroup analysis of a prospective, multicentre, observational cohort study conducted between March 2019 and December 2020 including 8 586 patients ≥ 16 years receiving central venous catheters at four emergency care hospitals. The main outcome measure was major mechanical complications defined as major bleeding, severe cardiac arrhythmia, pneumothorax, arterial catheterisation, and persistent nerve injury. Independent t-test and χ2 test were used to investigate differences in distribution of major mechanical complications and predefined variables between male and female operators. Multivariable logistic regression analysis was used to determine association between operator gender and major mechanical complications.

RESULTS

Female operators had a lower rate of major mechanical complications than male operators (0.4% vs 0.8%, P = .02), were less experienced (P < .001), had more patients with invasive positive pressure ventilation (P < .001), more often chose the internal jugular vein (P < .001) and more frequently used ultrasound guidance (P < .001). Male operators more often chose the subclavian vein (P < .001) and inserted more catheters with bore size ≥ 9 Fr (P < .001). Multivariable logistic regression analysis showed that male operator gender was associated with major mechanical complication (OR 2.67 [95% CI: 1.26-5.64]) after correction for other relevant independent variables.

CONCLUSIONS

The hypothesis was confirmed as differences in distribution of predefined variables between operator genders were found. Despite being less experienced, female operators had a lower rate of major mechanical complications. Furthermore, male operator gender was independently associated with a higher risk of major mechanical complications. Future studies are needed to further investigate differences in risk behaviour between male and female operators.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03782324. Date of registration: 20/12/2018.

Macro- and microscopic changes in veins with short-term central venous catheters: an observational autopsy study

BACKGROUND

Centrally inserted central catheters (CICCs) are indispensable in modern healthcare, but unfortunately, come with complications. Catheter-related thrombosis is a well-known complication reported to occur in 5-30% of patients with CICC. There is a paucity of studies that report the incidence of catheter-related thrombosis after the introduction of real-time ultrasound insertion guidance as clinical practice. This study aimed to demonstrate any pathological macro- or microscopic changes in the vein wall associated with CICCs.

METHODS

The study was approved by the Swedish Ethical Review Authority and was conducted at a large university hospital. The study included 12 patients with a short-term CICC who were subject to autopsies. Vessels with inserted catheters were macroscopically and microscopically examined.

RESULTS

In total, seven female and five male patients with a median age of 70 (interquartile range 63-76) were included. With one exception, all patients received routine thromboprophylaxis throughout the period with CICC. Most inserted CICCs were 9.5 French (54%) and were inserted in the internal jugular vein (92%). The median time with CICC was seven days (interquartile range 1.8-20). At autopsy, thrombi were observed in all cases (100%), macroscopically and microscopically, attached to the distal portion of the CICC and/or the adjacent vessel wall. Inflammatory changes in the vessel walls were seen in all cases, and varying degrees of fibrosis were demonstrated in eight cases (67%).

CONCLUSIONS

This autopsy study demonstrated that catheter-related thrombus formation with adjacent inflammatory and fibrotic vessel wall thickening was very common, despite a limited period of catheter use. The consequences of these findings are important, as thrombi may cause pulmonary embolism and possibly lead to catheter-related infections, and since inflammatory and fibrotic vessel wall thickening may evolve into chronic venous stenosis. Furthermore, the findings are a cause of concern, as CICCs are indispensable in modern healthcare and complications may be masked by the general disease that was the indication for CICC insertion.

Thrombotic triad in microgravity

Thrombotic disease may be an underdiagnosed condition of prolonged exposure to microgravity and yet the underlying factors remain poorly defined. Recently, an internal jugular vein thrombosis was diagnosed in a low-risk female astronaut after an approximately 7-week space mission. Six of the additional 10 crew members demonstrated jugular venous flow risk factors, such as suspicious stagnation or retroversion. Fortunately, all were asymptomatic. Observations in space as well as clinical and in vitro microgravity studies on Earth, where experiments are designed to recapitulate the conditions of space, suggest effects on blood flow stasis, coagulation, and vascular function. In this article, the related literature on thrombotic disease in space is reviewed, with consideration of these elements of Virchow's triad.

Effect of a thin-tipped short bevel needle for peripheral intravenous access on the compressive deformation and displacement of the vein: A preclinical study

BACKGROUND

Peripheral intravenous catheter (PIVC) insertion often fails on the first attempt. Risk factors include small vein size and dehydration, causing vein deformation and displacement due to puncture resistance of the vessel. The authors developed a short, thin-tipped bevel needle and compared its puncture performance with needles of four available PIVCs using an ex vivo model.

METHODS

The PIVC with the thin-tipped short bevel needle was compared to four available PIVCs using an ex vivo model which simulated the cephalic vein of the human forearm. The ex vivo model consisted of a porcine shoulder and porcine internal jugular vein, and was used for evaluation of the rate of vein deformation and vessel displacement during needle insertion.

RESULTS

An ex vivo model was created with a vessel diameter of 2.7-3.7 mm and a depth of 2-5 mm. The thin-tipped short bevel PIVC needle was associated with a significantly lower compressive deformation rate and venous displacement compared to the needles of the other four PIVCs.

CONCLUSION

The thin-tipped short bevel needle induced lower compressive deformation and displacement of the vein than the conventional needles. This needle has the potential to improve the first-attempt success rate of peripheral intravenous catheterization in patients with difficult venous access.

Comparison of supraclavicular brachiocephalic and femoral vein approaches for tunneled dialysis catheter placement in patients with thrombosed internal jugular veins

INTRODUCTION

There is still debate on the best access route in case of bilateral internal jugular vein thrombosis. We aimed to compare the safety, effectiveness, and outcomes of tunneled dialysis catheter placement via supraclavicular brachiocephalic and femoral vein approaches in patients with bilateral internal jugular vein thrombosis.

METHODS

Between January 2018 and December 2021, data of the patients in whom tunneled dialysis catheters were placed via the supraclavicular brachiocephalic vein (n = 42) and femoral vein (n = 57) approaches were extracted. Patient demographics, technical and clinical success rates, complications, and outcomes were noted. The Likert scale was used to assess patient satisfaction.

FINDINGS

Forty two (42.4%) patients were men, and the mean age was 61.9 (range, 12-93) years. The technical and clinical success rate was 100% for both groups. No major complication was encountered. The mean follow-up period was 497.5 (range, 32-1698) catheter days. Thirty-day patency was similar for the brachiocephalic vein and femoral vein group (40 [95.2%] vs. 55 [96.5%], p = 0.754). Also, primary and cumulative patency rates were comparable (p = 0.158; p = 0.660). The infection rate was 2.6 and 4.1 per 1000 catheter days for the brachiocephalic vein and femoral vein group. The infection-free survival was significantly higher in the brachiocephalic vein group (71.9% vs. 35.3% at 12 months, p < 0.001). Patient satisfaction was higher in the brachiocephalic vein group (median satisfaction, 5 vs. 4, p < 0.001).

DISCUSSION

Both supraclavicular brachiocephalic vein and femoral vein approaches have high technical and clinical success with comparable patency rates. However, low infection rate and high patient satisfaction make the supraclavicular brachiocephalic vein approach a reasonable alternative before proceeding to the femoral vein access.

Posture-Induced Changes in Intraocular, Orbital, Cranial, Jugular Vein, and Arterial Pressures in a Porcine Model

Purpose

The purpose of this study was to determine posture-induced changes in arterial blood pressure (ABP), intraocular pressure (IOP), orbital pressure (Porb), intracranial pressure (ICP), and jugular vein pressure (JVP) at various tilt angles in an in vivo pig.

Methods

Anesthetized and ventilated pigs (n = 8) were placed prone on a tiltable operating table. ABP, IOP, Porb, ICP, and JVP were monitored while the table was tilted at various angles between 15 degrees head up tilt (HUT) and 25 degrees head down tilt (HDT) either in stepwise changes (5 degrees per step) or continuously. The mean pressure was calculated from digitized pressure waveforms from each compartment. For stepwise changes in tilt angle the pressures were plotted as a function of tilt angle. For continuous tilt changes, the pressures were plotted as a function of time.

Results

In the case of stepwise changes, ABP remained relatively stable whilst IOP, Porb, ICP, and JVP demonstrated significant differences between most angles (typically P < 0.0001). The difference was greatest for IOP (P < 0.0001) where the average IOP increased from 13.1 ± 1.23 mm Hg at 15 degrees HUT to 46.3 ± 2.03 mm Hg at 25 degrees HDT. The relationship between pressure and tilt angle was almost linear for ICP and JVP, and sigmoidal for IOP and Porb. Interestingly, the effect of changes in tilt angle occurred very rapidly, within a few seconds.

Conclusions

Our results in a pig model demonstrate that changes in posture (tilt angle) induce rapid changes in IOP, Porb, ICP, and JVP, with IOP affected most severely.

Internal jugular vein collapsibility does not predict fluid responsiveness in spontaneously breathing patients after cardiac surgery

PURPOSE

The objective of our study was to evaluate the diagnostic accuracy of internal jugular vein (IJV) collapsibility as a predictor of fluid responsiveness in spontaneously breathing patients after cardiac surgery.

METHODS

In this prospective observational study, spontaneously breathing patients were enrolled on the first postoperative day after coronary artery bypass grafting. Hemodynamic data coupled with simultaneous ultrasound assessment of the IJV were collected at baseline and after passive leg raising test (PLR). Continuous cardiac index (CI), stroke volume (SV), and stroke volume variation (SVV) were assessed with FloTracTM/EV1000™. Fluid responsiveness was defined as an increase in CI ≥ 10% after PLR. We compared the differences in measured variables between fluid responders and non-responders and tested the ability of ultrasonographic IJV indices to predict fluid responsiveness.

RESULTS

Fifty-four patients were included in the study. Seventeen (31.5%) were fluid responders. The responders demonstrated significantly lower inspiratory and expiratory diameters of the IJV at baseline, but IJV collapsibility was comparable (P = 0.7). Using the cut-off point of 20%, IJV collapsibility predicted fluid responsiveness with a sensitivity of 76.5% and specificity of 38.9%, ROC AUC 0.55.

CONCLUSION

In spontaneously breathing patients after surgical coronary revascularisation, collapsibility of the internal jugular vein did not predict fluid responsiveness.

Comparison of Inflammatory Cytokine Levels in Hepatic and Jugular Veins of Patients with Cirrhosis

Background

Systemic inflammation with elevated inflammatory cytokines is a hallmark in patients with cirrhosis and the main driver of decompensation. There is insufficient data on whether inflammatory cytokine levels differ between hepatic and jugular veins, which may have implications for further immunological studies.

Methods

Blood from the hepatic and jugular veins of 40 patients with cirrhosis was collected during hepatic venous pressure gradient (HVPG) measurements. Serum levels of 13 inflammatory cytokines (IL-1β, Int-α2, Int-γ, TNF-α, MCP-1, IL-6, IL-8, IL-10, IL-12p70, IL-17A, IL-18, IL-23, and IL-33) were quantified by cytometric bead array.

Results

Cytokine levels of IFN-α2, IFN-γ, TNF-α, IL-6, IL-8, IL-10, IL-17A, IL-18, IL-23, and IL-33 were significantly elevated in patients with decompensated cirrhosis compared to patients with compensated cirrhosis. When comparing patients with clinically significant portal hypertension (CSPH, HVPG ≥ 10 mmHg) to patients without CSPH, there were significantly enhanced serum levels of IL-6 and IL-18 in the former group. There was no significant difference between cytokine serum levels between blood obtained from the jugular versus hepatic veins. Even in subgroup analyses stratified for an early cirrhosis stage (Child-Pugh (CP) A) or more decompensated stages (CP B/C), cytokine levels were similar.

Conclusion

Cytokine levels increase with decompensation and increasing portal hypertension in patients with cirrhosis. There is no relevant difference in cytokine levels between hepatic and jugular blood in patients with cirrhosis.

Cannulation via the external jugular vein--An alternative to conventional peripherally inserted central catheterisation for paediatric patients

PURPOSE

This study aimed to describe a peripherally inserted central catheterisation (PICC) for paediatric patients with inaccessible access and a high risk of general anaesthesia (GA).

METHODS

This was a retrospective observational study involving all paediatric inpatients who performed the PICC via an EJV approach without GA between September 2014 and September 2021 in a provincial key clinical speciality.

RESULTS

A total of 290 EJV line placement attempts were performed, and 29 were excluded due to missing placement results, resulting in a sample size of 261. The anatomical localisation, punctures, and catheterisation success rates for this practice were 100%, 100%, and 90.04%, respectively. The placement success rate in children younger than one year was 93.75% (45/48). The median line duration of use was 19 days, with a median length of catheter insertion of 13 cm. The most common complications were catheter malposition (n = 20) and dislodgement (n = 7).

CONCLUSION

The PICC via an EJV approach without GA is a feasible and safe practice with acceptable success and complication rates, and low costs. It might be an attractive alternative for obtaining central vascular access for paediatric patients.

Respiratory variation in the internal jugular vein does not predict fluid responsiveness in the prone position during adolescent idiopathic scoliosis surgery: a prospective cohort study

BACKGROUND

Respiratory variation in the internal jugular vein (IJVV) has not shown promising results in predicting volume responsiveness in ventilated patients with low tidal volume (Vt) in prone position. We aimed to determine whether the baseline respiratory variation in the IJVV value measured by ultrasound might predict fluid responsiveness in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF) with low Vt.

METHODS

According to the fluid responsiveness results, the included patients were divided into two groups: those who responded to volume expansion, denoted the responder group, and those who did not respond, denoted the non-responder group. The primary outcome was determination of the value of baseline IJVV in predicting fluid responsiveness (≥15% increases in stroke volume index (SVI) after 7 ml·kg-1 colloid administration) in patients with AIS undergoing PSF during low Vt ventilation. Secondary outcomes were estimation of the diagnostic performance of pulse pressure variation (PPV), stroke volume variation (SVV), and the combination of IJVV and PPV in predicting fluid responsiveness in this surgical setting. The ability of each parameter to predict fluid responsiveness was assessed using a receiver operating characteristic curve.

RESULTS

Fifty-six patients were included, 36 (64.29%) of whom were deemed fluid responsive. No significant difference in baseline IJVV was found between responders and non-responders (25.89% vs. 23.66%, p = 0.73), and no correlation was detected between baseline IJVV and the increase in SVI after volume expansion (r = 0.14, p = 0.40). A baseline IJVV greater than 32.00%, SVV greater than 14.30%, PPV greater than 11.00%, and a combination of IJVV and PPV greater than 64.00% had utility in identifying fluid responsiveness, with a sensitivity of 33.33%, 77.78%, 55.56%, and 55.56%, respectively, and a specificity of 80.00%, 50.00%, 65.00%, and 65.00%, respectively. The area under the receiver operating characteristic curve for the baseline values of IJVV, SVV, PPV, and the combination of IJVV and PPV was 0.52 (95% CI, 0.38-0.65, p=0.83), 0.54 (95% CI, 0.40-0.67, p=0.67), 0.58 (95% CI, 0.45-0.71, p=0.31), and 0.57 (95% CI, 0.43-0.71, p=0.37), respectively.

CONCLUSIONS

Ultrasonic-derived IJVV lacked accuracy in predicting fluid responsiveness in patients with AIS undergoing PSF during low Vt ventilation. In addition, the baseline values of PPV, SVV, and the combination of IJVV and PPV did not predict fluid responsiveness in this surgical setting.

TRAIL REGISTRATION

This trial was registered at www.chictr.org (ChiCTR2200064947) on 24/10/2022. All data were collected through chart review.

Hemodialysis Catheter Breakage in an Infant

A 3-month-old male infant was admitted to our unit due to acute decompensation of chronic kidney disease of unknown etiology. Further investigation led to the diagnosis of primary hyperoxaluria type 1. As the patient did not recover, hemodialysis was initiated with a non-tunneled femoral catheter. A tunneled Hickman catheter was placed in the internal jugular vein. The patient experienced moderate intradialytic exit-site bleeding and catheter malfunction, which initially responded to pressure and postural changes. During the third session, the patient suffered cardiopulmonary arrest. After stabilization, a chest hematoma was identified. Fluoroscopy revealed a catheter breakage. Despite initial stabilization, the patient developed septic shock due to Pseudomonas aeruginosa and died several days later. Hemodialysis is sometimes necessary in children under 24 months with chronic kidney disease. Vascular access is a major challenge in these patients due to lack of appropriate catheter sizes and high complication rates. Hemodialysis catheter fracture is an uncommon complication, and diagnosis can be difficult when the breakage involves the subcutaneous segment. Persistent intradialytic bleeding and mechanical malfunction should raise suspicion of this complication and should elicit catheter revision under fluoroscopy. Without prompt diagnosis, catheter breakage may have fatal consequences, as in our case.

A Rare Cause of Red Tympanic Membrane: Jugular Bulb Diverticulum

SIGNIFICANCE STATEMENT

Pulsatile tinnitus with erythematous tympanic membrane mass suggests vascular pathologies such as dural arteriovenous fistula, glomus tympanicum, or aberrant carotid artery. Jugular bulb aneurysmatic diverticulum is rare but should be suspected in a case with the presence of aneurysm in other organs. An imaging study is mandatory to confirm the diagnosis. Patient must avoid digging ear as it can cause profuse bleeding. Treatment option can be open surgery or endovascular treatment.

Percutaneous transvenous coil embolization (PTCE) for treatment of single extrahepatic portosystemic shunt in dogs

BACKGROUND

There is limited information regarding percutaneous transvenous coil embolization (PTCE) for single extrahepatic portosystemic shunt (PSS). This study aimed to describe the procedure and outcome of PTCE in dogs with a single extrahepatic PSS. Forty-two privately owned dogs were included in this study. All dogs were diagnosed with extrahepatic PSS by computed tomography (CT). Preoperative CT images were used to evaluate the diameter of the PSS for coil placement. A multipurpose balloon catheter was percutaneously inserted into the PSS via the jugular vein, and transvenous retrograde portography (TRP) and measurement of blood pressure in the PSS (pPSS) were performed during balloon inflation; one or more embolization coils were implanted via the catheter.

RESULTS

In most cases, preoperative median fasting and postprandial serum total bile acid (TBA) concentrations were high (fasting, 86.5 μmol/L [ 3.7-250.0 μmol/L]; postprandial, 165.5 μmol/L [ 1.5-565.0 μmol/L]). CT revealed that 30 dogs had left gastrophrenic shunt; eight had left gastroazygos shunt; and one each had left gastrocaval, splenocaval, splenophrenic, and left colocaval shunt. TRP revealed that intrahepatic portal vascularity was clearly detectable in all dogs. The median values of pPSS before and during the balloon occlusion were 4.8 mmHg [2.0-13.0 mmHg] and 8.6 mmHg [5.0-18.0 mmHg], respectively. The median number and diameter of coils used were 2 coils [1 - 5 coils] and 8.0 mm [4.0 - 12.0 mm], respectively. The median times of irradiation and PTCE were 9 min [4-26 min] and 40 min [23-75 min], respectively. The median fasting and postprandial TBAs significantly decreased to 8.2 μmol/L [0.3-45.1 μmol/L, n = 38, p = 0.0028] and 19.8 μmol/L [0.3-106.7 μmol/L, n = 38, p = 0.0018], respectively, approximately 1 month after PTCE. The clinical success rate of PTCE without requirement for a second surgery was 95.2% (40/42 dogs). During revision surgery, one dog underwent surgical ligation and, in another dog, an ameroid constrictor was placed.

CONCLUSIONS

PTCE was clinically effective in treating single extrahepatic PSS in dogs. Preoperative CT and TRP prior to PTCE might be clinically valuable for choosing the size of embolization coils, deciding the appropriate location of coil implantation, and estimating the number of coils to be implanted. PTCE is a promising alternative to conventional surgical procedures for single extrahepatic PSS in dogs.

Pentagalloyl glucose-stabilized decellularized bovine jugular vein valved conduits as pulmonary conduit replacement

Congenital heart diseases (CHD) are one of the most frequently diagnosed congenital disorders, affecting approximately 40,000 live births annually in the United States. Out of the new patients diagnosed with CHD yearly, an estimated 2,500 patients require a substitute, non-native conduit artery to replace structures congenitally absent or hypoplastic. Devices used for conduit replacement encounter limitations exhibiting varying degrees of stiffness, calcification, susceptibility to infection, thrombosis, and a lack of implant growth capacity. Here, we report the functionality of pentagalloyl glucose (PGG) stabilized decellularized valved bovine jugular vein conduit (PGG-DBJVC). The PGG-DBJVC tissues demonstrated mechanical properties comparable to native and glutaraldehyde fixed tissues, while exhibiting resistance to both collagenase and elastase enzymatic degradation. Subcutaneous implantation of tissues established their biocompatibility and resistance to calcification, while implantation in sheep in the pulmonary position demonstrated adequate implant functionality, and repopulation of host cells, without excessive inflammation. In conclusion, this PGG-DBJVC device could be a favorable replacement option for pediatric patients, reducing the need for reoperations required with current devices. STATEMENT OF SIGNIFICANCE: Congenital Heart Disease (CHD) is a common congenital disorder affecting many newborns in the United States each year. The use of substitute conduit arteries is necessary for some patients with CHD who have missing or underdeveloped structures. Current conduit replacement devices have limitations, including stiffness, susceptibility to infection and thrombosis, and lack of implant growth capacity. Pentagalloyl glucose-stabilized bovine jugular vein valved tissue (PGG-DBJVC) offers a promising solution as it is resistant to calcification, and biocompatible. When implanted in rats and as pulmonary conduit replacement in sheep, the PGG-DBJVC demonstrated cellular infiltration without excessive inflammation, which could lead to remodeling and integration with host tissue and eliminate the need for replacement as the child grows.

Septic thrombophlebitis of portal and splenic vein secondary to Fusobacterium nucleatum: A case report of an abdominal variant of lemierre syndrome

RATIONALE

Septic thrombophlebitis of the internal jugular vein also known as Lemierre syndrome occurs secondary to an oropharyngeal infection often leading to septic embolisms to distant sites. Anaerobic gram-negative bacillus, Fusobacterium nucleatum and Fusobacterium necrophorum are commonly isolated organisms. Fusobacterium species has also been reported to complicate an intra-abdominal infection leading to septic thrombophlebitis of portal vein also known as pylephlebitis or abdominal variant of lemierre syndrome.

PATIENT CONCERNS

The patient was a middle-aged female patient with chief complaints of abdominal discomfort, intermittent fever and vomiting for one month.

DIAGNOSES

The final diagnosis was septic thrombophlebitis of portal and splenic vein secondary to Fusobacterium nucleatum.

INTERVENTIONS

Patient was managed with broad spectrum intravenous antibiotics with coverage against gram-negative bacilli, anaerobes, and aerobic streptococcus species with therapeutic anticoagulation.

OUTCOMES

Patient gradually improved and was discharged on oral apixaban. She was instructed to follow up with gastrointestinal specialist upon discharge in anticipation of the need for liver transplant in future.

LESSONS

Due to its high mortality and associated long term disease morbidity, clinicians should always strive towards early diagnosis and treatment of the condition with involvement of multidisciplinary teams.

Assessing the feasibility of using the antecubital vein to perform right heart catheterization in children and adults with congenital heart disease: a retrospective, observational single-center study

BACKGROUND

Right heart catheterization (RHC) usually is performed via the femoral vein or the internal jugular vein. However, the antecubital fossa vein is a valid venous access, and it has become increasingly popular to perform right heart catheterization utilizing this access.

METHODS

A retrospective, observational study was conducted to describe use of the antecubital fossa vein for right heart catheterization in adults and children with congenital heart disease (CHD). Patients who had undergone RHC via antecubital fossa vein at the authors' hospital between September 2019 and December 2022 were included. The outcomes studied were procedural failure and procedure-related adverse events.

RESULTS

Fifty-two patients with CHD underwent right cardiac catheterization via an upper arm vein. The upper arm vein was unable to perform the RHC in only 2 patients (3.8%). Only 1 patient developed a minor adverse event. No irreversible and/or life-threating adverse events were detected.

CONCLUSIONS

The upper arm veins are safe and effective to perform a RHC in children and adults with CHD. This approach demonstrates a high percentage of technical success, and few mild complications.

The jugular venous-to-arterial P C O 2 ${P_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ difference during rebreathing and end-tidal forcing: Relationship with cerebral perfusion

We examined two assumptions of the modified rebreathing technique for the assessment of the ventilatory central chemoreflex (CCR) and cerebrovascular CO2 reactivity (CVR), hypothesizing: (1) that rebreathing abolishes the gradient between the partial pressures of arterial and brain tissue CO2 [measured via the surrogate jugular venousP C O 2 ${P_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ and arterialP C O 2 ${P_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ difference (Pjv-a CO2 )] and (2) rebreathing eliminates the capacity of CVR to influence the Pjv-a CO2 difference, and thus affect CCR sensitivity. We also evaluated these variables during two separate dynamic end-tidal forcing (ETF) protocols (termed: ETF-1 and ETF-2), another method of assessing CCR sensitivity and CVR. Healthy participants were included in the rebreathing (n = 9), ETF-1 (n = 11) and ETF-2 (n = 10) protocols and underwent radial artery and internal jugular vein (advanced to jugular bulb) catheterization to collect blood samples. Transcranial Doppler ultrasound was used to measure middle cerebral artery blood velocity (MCAv). The Pjv-a CO2 difference was not abolished during rebreathing (6.2 ± 2.6 mmHg; P < 0.001), ETF-1 (9.3 ± 1.5 mmHg; P < 0.001) or ETF-2 (8.6 ± 1.4 mmHg; P < 0.001). The Pjv-a CO2 difference did not change during the rebreathing protocol (-0.1 ± 1.2 mmHg; P = 0.83), but was reduced during the ETF-1 (-3.9 ± 1.1 mmHg; P < 0.001) and ETF-2 (-3.4 ± 1.2 mmHg; P = 0.001) protocols. Overall, increases in MCAv were associated with reductions in the Pjv-a CO2 difference during ETF (-0.095 ± 0.089 mmHg cm-1  s-1 ; P = 0.001) but not during rebreathing (-0.028 ± 0.045 mmHg · cm-1  · s-1 ; P = 0.067). These findings suggest that, although the Pjv-a CO2 is not abolished during any chemoreflex assessment technique, hyperoxic hypercapnic rebreathing is probably more appropriate to assess CCR sensitivity independent of cerebrovascular reactivity to CO2 . KEY POINTS: Modified rebreathing is a technique used to assess the ventilatory central chemoreflex and is based on the premise that the rebreathing method eliminates the difference between arterial and brain tissueP C O 2 ${P_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ . Therefore, rebreathing is assumed to isolate the ventilatory response to central chemoreflex stimulation from the influence of cerebral blood flow. We assessed these assumptions by measuring arterial and jugular venous bulbP C O 2 ${P_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ and middle cerebral artery blood velocity during modified rebreathing and compared these data against data from another test of the ventilatory central chemoreflex using hypercapnic dynamic end-tidal forcing. The difference between arterial and jugular venous bulbP C O 2 ${P_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ remained present during both rebreathing and end-tidal forcing tests, whereas middle cerebral artery blood velocity was associated with theP C O 2 ${P_{{\mathrm{C}}{{\mathrm{O}}_{\mathrm{2}}}}}$ difference during end-tidal forcing but not rebreathing. These findings offer substantiating evidence that clarifies and refines the assumptions of modified rebreathing tests, enhancing interpretation of future findings.

Microsurgical Creation of Giant Bifurcation Aneurysms in Rabbits for the Evaluation of Endovascular Devices

Giant aneurysms are dangerous lesions requiring endovascular treatment, with high rates of aneurysm recanalization and re-rupture. Reliable in vivo models are rare but are required for testing new endovascular devices. We demonstrate the technical aspects of the creation of giant bifurcation aneurysms in New Zealand white rabbits (2.5-5.5 kg). A 25-30 mm long venous pouch is taken from the external jugular vein, and a bifurcation between both carotid arteries is created microsurgically. The pouch is sutured in the bifurcation to mimic a giant aneurysm. This protocol summarizes our previously published standard technique for venous pouch true arterial bifurcation aneurysms and highlights its essential modification steps for giant aneurysms. Using this modified technique, we were able to create an animal model for giant aneurysms with high comparability to humans regarding the hemodynamics and coagulation systems. Furthermore, low morbidity and high aneurysm patency rates were achieved. The proposed giant aneurysm model offers an excellent possibility for testing new endovascular devices.

Budd-Chiari syndrome: An unusual complication of an internal jugular tunneled dialysis catheter

Budd-Chiari syndrome due to the tip of an internal jugular tunneled dialysis catheter malposition in inferior vena cava or hepatic vein is a rare complication. We aimed to present our experience and compare it with the previous reports to highlight the clinical features and the optimal management. A 57-year-old female with history of ANCAp vasculitis, treated by hemodialysis in the last 2 years on a right internal jugular vein tunneled catheter was admitted for pain in the right upper quadrant. A subacute Budd-Chiari syndrome due to catheter malposition was diagnosed. The catheter was removed, and a new tunneled hemodialysis line was inserted in the right internal jugular vein with the tip at the junction of right atrium with superior vena cava. Anticoagulation with apixaban 2.5 mg twice daily was started after catheter replacement and the patient was discharged. At 1 month follow-up the patient had no symptoms, and the ultrasound revealed the absence of the thrombus in the inferior vena cava. Imagining monitoring for malposition after insertion or in a clinical context suggestive for Budd-Chiari syndrome is essential for early diagnosis and treatment. In our case, anticoagulation with apixaban and prompt catheter replacement resulted in Budd-Chiari syndrome resolution.

New strategy of using double-network hydrogel extravascular stent for preventing venous graft restenosis after coronary artery bypass grafting

OBJECTIVE

Effective therapies for the prevention of vein graft failure, which frequently occurs in coronary artery bypass grafting (CABG) due to intimal hyperplasia (IH), are still lacking. Here, we investigated the effects of the perivenous application of double-network hydrogel on vein grafts in carotid artery bypass grafting in a rabbit model.

METHODS

Healthy New Zealand white rabbits were randomized into the following groups: no graft, graft, or graft + Double-network hydrogel external stent (DNHES). The rabbits' carotid artery was bypassed via the jugular vein. Double-network hydrogel external stent was wrapped around the jugular graft after the anastomoses were completed. Blood flow parameters and tissue histology of the vein grafts were evaluated.

RESULTS

Compared with the untreated vein grafts at 12 weeks after the surgery, the DNHES significantly improved graft flow, attenuated intimal and medial thickening, reduced the anti-proliferating cell nuclear antigen proliferation index of the vein grafts, decreased the mRNA and protein expression of Mitogen-Activated Protein Kinase (MAPK) and Transforming Growth Factor-β (TGF-β), and increased the mRNA and protein expression of endothelial Nitric Oxide Synthase (eNOS).

CONCLUSION

The perivenous application of DNHES exerts beneficial effects on vein grafts, reduces the inflammatory response in carotid artery bypass grafting in a rabbit model, and appears to be a safe and promising strategy to prevent vein graft failure.

Central vein stenosis: a rare cause of orbital congestion in a haemodialysis patient

We report a rare, potentially sight-threatening ocular complication due to central venous stenosis related to a previous site of haemodialysis catheter. A dialysis-dependent woman in her 60s presented with left eye redness for 1 month followed by a remarkably prominent vessel on the left upper eyelid for 2 weeks. Examinations found left eyelid oedema with prominent venous dilatation on the upper eyelid as well as left eye mild proptosis, conjunctiva injection with corkscrew vessels, raised intraocular pressure, and dilated and tortuous retina vessels. Central thoracic venogram showed total occlusion on the left brachiocephalic vein with retrograde reflux to the jugular vein. An endovascular percutaneous transluminal balloon angioplasty was performed for the left brachiocephalic vein stenosis, which resolved the orbital, facial and neck venous congestion. The patient remained asymptomatic after 1 year.

The Course and Variation of the Facial Vein in the Face-Known and Unknown Facts: An Anatomical Study

Background and Objectives: The facial vein is the main collector of venous blood from the face. It plays an important role in physiological as well as pathological context. However, to date, only limited data on the course and tributaries of the facial vein are present in contemporary literature. The aim of this study was to provide detail on the course and the tributaries of the facial vein. Materials and Methods: In 96 sides of 53 body donors, latex was injected into the facial vein. Dissection was carried out and the facial vein and its tributaries (angular vein, ophthalmic vein, nasal veins, labial veins, palpebral veins, buccal and masseteric veins) were assessed. Results: The facial vein presented a textbook-like course in all cases and crossed the margin of the mandible anterior to the masseter in 6.8% of cases, while being located deep to the zygomaticus major muscle in all cases and deep to the zygomaticus minor in 94.6% of cases. Conclusions: This work offers detailed information on the course of the facial vein in relation to neighboring structures, which shows a relatively consistent pattern, as well as on its tributaries, which show a high variability.

Long-term safety and efficacy of stenting on correcting internal jugular vein and cerebral venous sinus stenosis

OBJECTIVES

To compare the long-term safety and efficacy of stenting in correcting cerebral venous sinus stenosis (CVSS) and internal jugular venous stenosis (IJVS).

METHODS

Patients confirmed with CVSS or IJVS by imaging were enrolled in this real-world study from 2014 through 2021. Clinical characteristics and long-term outcomes of these two diseases entities post-stenting were followed up and compared.

RESULTS

Three hundred and nineteen patients were enrolled in this study, with a mean age of 48.83 years and a BMI of 25.08 on average. In which, 144 patients underwent stenting, the stenotic segments were corrected and the venous blood flow was restored immediately post-stenting. At 6.15 ± 1.67 days follow-up, significant improvement was observed in headache, tinnitus, insomnia, ICP, and mean pressure gradient in both groups (all p < 0.05). At 30.53 ± 4.41 months follow-up post-stenting, the headache, tinnitus, visual loss, papilledema, and insomnia were attenuated remarkably or even completely disappeared. The Frisen papilledema grade scores declined from 2 (0-4) to 1 (0-3) in IJVS group and from 4 (1-5) to 1 (0-4) in CVSS group compared to the baseline. One hundred and twenty-seven out of the 144 patients (95.5%) maintained sufficient blood flow verified by followed up computed tomographic venography or contrast-enhanced magnetic resonance angiography. Adverse events related to stenting included three cases of intraluminal restenosis and three cases of in-stent thrombosis, no intracranial hemorrhage, venous thromboembolisms, stent-adjacent stenosis, and stent displacement occurred.

INTERPRETATION

Using stents to correct IH and related neurological issues has shown to be a safe and effective approach for both IJVS and CVSS.

First report of an Aveir retrievable leadless pacemaker in a pediatric patient, via internal jugular vein access

BACKGROUND

The Aveir device allows retrievability and mapping prior to fixation over alternative leadless pacemakers.

CASE SUMMARY

We describe the first case of Aveir leadless pacemaker implantation into a 44.5 kg, pediatric patient with symptomatic sinus dysfunction. Access by the right internal jugular vein (RIJ) with 1st attempt implantation into the septal location.

DISCUSSION

Placement of the Aveir leadless pacemaker is feasible in a 44.5 kg pediatric patient via a RIJ approach.

An Automatic Method for Sublingual Image Segmentation and Color Analysis

Automatic segmentation of sublingual images and color quantification of sublingual vein are of great significance to disease diagnosis in traditional Chinese medicine. With the development of computer vision, automatic sublingual image processing provides a noninvasive way to observe patients' tongue and is convenient for both doctors and patients. However, current sublingual image segmentation methods are not accurate enough. Besides, the differences in subjective judgments by different doctors bring more difficulties in color analysis of sublingual veins. In this paper, we propose a method of sublingual image segmentation based on a modified UNet++ network to improve the segmentation accuracy, a color classification approach based on triplet network, and a color quantization method of sublingual vein based on linear discriminant analysis to provide intuitive one-dimensional results. Our methods achieve 88.2% mean intersection over union (mIoU) and 94.1% pixel accuracy on tongue dorsum segmentation, and achieves 69.8% mIoU and 82.7% pixel accuracy on sublingual vein segmentation. Compared with the state-of-art methods, the segmentation mIoUs are improved by 5.8% and 5.3% respectively. Our sublingual vein color classification method has the highest overall accuracy of 81.2% and the highest recall for the minority class of 77.5%, and the accuracy of color quantization is 90.5%.Clinical Relevance- The methods provide accurate and quantified information of the sublingual image, which can assist doctors in diagnosis.

Acute hemodialysis catheter follows the path of least resistance

The placement of large bore double-lumen catheters for hemodialysis (HD) is one of the most frequent procedures performed in HD patients. However, these procedures are associated with complications, the most common being catheter malposition. In this context, catheter deviation to the left superior intercostal vein (LISV) is a very uncommon malposition, which must be differentiated from intrathoracic extravascular catheter lodgment. We report a case of an adult male patient on hemodialysis who presented with a thrombosed arteriovenous fistula and requiring urgent HD. His past medical history included hemophilia, allergy to contrast media, and multiple previous central vein catheterizations. A non-tunneled HD catheter was placed without any difficulty in the left internal jugular vein. However, the arterial lumen failed to pull any blood with free flow in the venous lumen. A chest X-ray revealed a surprising finding. The malpositioned catheter was removed successfully without any complications.

Modified Tail Vein and Penile Vein Puncture for Blood Sampling in the Rat Model

Blood samples are required in most experimental animal designs to assess various hematological parameters. This paper presents two procedures for blood collection in rats: the lateral tail vein puncture and the dorsal penile vein puncture, which offer significant advantages over other previously described techniques. This study shows that these two procedures allow for fast sampling (under 10 min) and yield sufficient blood volumes for most assays (202 μL ± 67.7 μL). The dorsal penile vein puncture must be done under anesthesia, whereas the lateral tail vein puncture can be done on a conscious, restrained animal. Alternating these two techniques, therefore, enables blood draw in any situation. While it is always recommended for an operator to be assisted during a procedure to ensure animal welfare, these techniques require only a single operator, unlike most blood sampling methods that require two. Moreover, whereas these previously described methods (e.g., jugular stick, subclavian vein blood draw) require extensive prior training to avoid harm to or death of the animal, tail vein and dorsal penile vein puncture are rarely fatal. For all these reasons, and according to the context (e.g., for studies including male rats, during the perioperative or immediate postoperative period, for animals with thin tail veins), both techniques can be used alternately to enable repeated blood draws.

[Fatal injury to the neck while working with an angle grinder]

A fatal accident using an angle grinder is presented. During the forensic medical examination of the corpse, a soft tissue wound of the neck was found, localized in the region of its anterior and right lateral surfaces, with damage to the common carotid artery, internal jugular vein, sternocleidomastoid and sternothyroid muscles, thyroid lobe, incomplete transection of the trachea and esophagus caused by the rotating disc of an angle grinder. This observation supplements the existing ideas about injuries caused by power tools, as well as the possibility of reconstructing an event based on a comprehensive assessment of data from the scene.

Evaluation of the Effect of Interscalene Brachial Plexus Block on Intracranial Pressure Using Optic Nerve Sheath Diameter and Internal Jugular vein Collapsibility Index

OBJECTIVE

To determine the effect of single-shot interscalene brachial plexus (ISBP) block on intracranial pressure (ICP) by evaluating the extravascular volume effect of the medicine on the internal jugular vein (IJV).

STUDY DESIGN

Interventional study.

PLACE AND DURATION OF STUDY

Department of Anaesthesiology and Reanimation, Sivas Cumhuriyet University, Sivas, Turkey, from January to June 2022.

METHODOLOGY

Thirty-four patients were included in this prospective clinical study. All patients had single-shot ISBP block with 25 ml of local anaesthetic. Optic nerve sheath diameter (ONSD), maximum (Dmax) and minimum (Dmin) diameters of IJV and IJV collapsibility index (IJV-CI) were recorded before the block (basal), 20 minutes, and 60 minutes after the block.

RESULTS

Twenty-nine patients had higher ONSD values at 60th minute compared to their basal values. There were negative correlations between the changes of ONSD and IJVCI (r=0.616, p<0.001) and ONSD and Dmax (r=0.581, p<0.001) in time period between basal and 20th minute. There were negative correlations between the changes of ONSD and IJVCI (r=0.518, p=0.002), ONSD and Dmax (r=0.664, p<0.001) in time period between basal and 60th minute.

CONCLUSION

Single-shot ISBP block with 25 ml of local anaesthetic may be a factor that increases ICP. Repeated intraoperative ONSD measurements are recommended in patients operated with ISBP block.

KEY WORDS

Interscalene Brachial Plexus Block, Intracranial pressure, Optic nerve sheath diameter, Internal jugular vein collapsibility index.

Push-pull monorail technique to overcome a difficult course through the left internal jugular vein

BACKGROUND

We assessed the outcomes of a push-pull monorail technique to overcome a difficult anatomical course through the left internal jugular vein in implantable port insertions.

METHODS

From December 2018 to May 2021, a total of 5326 patients were referred for implantable port insertion in our interventional unit, among which 472 cases were requested for insertion on the left side. Our monorail technique was applied only when the catheter tip entered the azygos vein instead of the superior vena cava (n = 8). The technique consists of a puncture at the distal tip of the port catheter with a 21-gauge micropuncture needle, advancing a 0.018-inch hair-wire to the guide, providing support for the pre-assembled port, and advancing the microsheath over the hair-wire to prevent extrusion of the catheter.

RESULTS

The push-pull monorail technique was performed in eight patients, and all cases were technically successful, exhibiting a technical success rate of 100%. There were no immediate or delayed complications.

CONCLUSIONS

The push-pull monorail technique is helpful in overcoming the difficult anatomical course through the left internal jugular vein during implantable port insertion.

[Pulmonary Vascular Remodeling Characteristics of Pulmonary Arterial Hypertension Mouse Model Induced by Left Pneumonectomy and Jugular Vein Injection of Monocrotaline Pyrrole]

Objective

To compare and investigate the differences and characteristics of pulmonary vascular remodeling in three mouse models of pulmonary arterial hypertension (PAH) constructed by left pneumonectomy, jugular vein injection of monocrotaline pyrrole, and left pneumonectomy combined with jugular vein injection of monocrotaline pyrrole, to explore for a PAH animal model that approximates the clinical pathogenesis of PAH, and to create a model that will provide sound basis for thorough investigation into the pathogenesis of severe PAH.

Methods

59 male C57/BL mice (10-12 weeks, 24-30 g) were randomized into four groups, a control group ( n=9), a group that had left pneumonectomy (PE, n=15), a group that had jugular vein injection of monocrotaline pyrrole (MCTP, n=15), and the last group that had left pneumonectomy combined with jugular injection of monocrotaline pyrrole (P+M, n=20). To evaluate the effect of modeling and the characteristics of pulmonary vascular remodeling, hemodynamic and morphological parameters, including right ventricular systolic pressure (RVSP), right ventricle/(left ventricle plus septum) (RV/LV+S), percent of wall thickness in the pulmonary artery (WT%), muscularization of non-muscular arteries, neointima formation, and vascular obstruction score (VOS), were measured in each group.

Results

1) Compared with those of the control group, the RVSP, RV/LV+S, WT%, and the degree of small pulmonary arteries muscularization in the P+M group were significantly increased ( P<0.01). The MCTP group had just slightly higher findings for these indicators ( P<0.05), while no significant change in these indicators was observed in the PE group ( P>0.05). 2) Neointima formation in the acinus pulmonary arteries, which caused obvious stenosis of the lumen, was observed in the P+M group, the VOS being 1.25±0.80 points ( P<0.001). In contrast, neointima formation was not observed in the MCTP group or the PE groups, the VOS being 0 point ( P>0.05).

Conclusion

Left pneumonectomy combined with jugular intravenous injection of MCTP could induce severe PAH formation in mouse. The model provides a good simulation of neointima formation, the characteristic pathological change of clinical severe PAH.

A common complaint… a rare disease!

A 2-year-old previously well child presented to the emergency department with temperatures and lethargy. He was pale and looked unwell. He received a fluid bolus and was commenced on intravenous ceftriaxone. Pus was discharging from his left ear with postauricular swelling and erythema. Given clinical concerns, urgent neuroimaging was arranged.