Pulsatile Femoral Vein Doppler Pattern is a Parameter of Venous Congestion in ICU Patients

OBJECTIVES

The aim of this study was to evaluate if the presence of a pulsatile femoral vein pattern is an indicator of venous congestion in the intensive care unit (ICU).

DESIGN

Retrospective observational study.

SETTING

Three medico-surgical university-affiliated ICUs.

PARTICIPANTS

Adult patients who had an ultrasound evaluation at several time points during their ICU stay: at baseline (within 24 hours of admission to ICU), daily during their ICU stay, and within 24 hours before ICU discharge.

INTERVENTIONS

At each time point, the hemodynamic, respiratory, and cardiac ultrasound parameters were recorded. The common femoral vein was studied with pulsed-wave Doppler at the level of the femoral trigonum, with high frequency (5-13 MHz) linear array vascular probe and venous vascular mode, in supine patients.

MEASUREMENTS AND MAIN RESULTS

One hundred eight patients who underwent 400 ultrasound evaluations (3.7 ± 1 ultrasound evaluations per patient) during their ICU stay were included. Seventy-nine of 108 patients (73%) had a pulsatile femoral vein pattern at least at 1 time point. The multivariable mixed effects logistic regression model demonstrated an association among pulsatile femoral vein pattern, body mass index (OR: 0.91[95% CI 0.85-0.96], p = 0.002), inferior vena cava mean diameter (OR: 2.35 [95% CI 1.18-4.66], p = 0.014), portal vein pulsatility (OR: 2.3 [95% CI 1.2-4.4], p = 0.012), and congestive renal vein flow pattern (OR: 4.02 [95% CI 2.01-8.03], p < 0.001). The results were confirmed by principal component analysis.

CONCLUSION

In the ICU, a pulsatile femoral vein pattern is associated with parameters of venous congestion, independently of the patient's volume status, and ventilatory treatment. These results suggest the femoral vein Doppler pulsatility as a parameter of congestion in ICU patients.

Risk Factors for Venous Thromboembolism and Eventual Amputation in Traumatic Femoral and Iliac Vein Injuries: A Trauma Quality Improvement Program Analysis

BACKGROUND

Iliac and femoral venous injuries represent a challenging dilemma in trauma surgery with mixed results. Venous restoration of outflow (via repair or bypass) has been previously identified as having higher rates of VTE (venous thromboembolism) compared to ligation. We hypothesized that rates of VTE and eventual amputation were similar whether restoration of venous outflow vs ligation was performed at initial operation.

METHODS

Patients in the 2019-2021 National Trauma Data Bank with iliac and femoral vein injuries were abstracted and analyzed. The primary outcomes of interest were in-hospital lower extremity amputation and VTE.

RESULTS

A total of 2642 patients with operatively managed iliac and femoral vein injuries were identified VTE was found in 10.8% of patients. Multivariable logistic regression was performed and identified bowel injury, higher ISS, older age, open repair, and longer time to VTE prophylaxis initiation as independent predictors of VTE. Amputation was required in 4.2% of patients. Multivariable logistic regression identified arterial or nerve injury, femur or tibia fracture, venous ligation, percutaneous intervention, fasciotomy, bowel injury, and higher ISS as independent factors of amputation.

CONCLUSION

Venous restoration was not an independent predictor of VTE. Venous ligation on index operation was the only modifiable independent predictor of amputation identified on regression analysis.

Usefulness of the femoral vein as a graft for portal vein/superior mesenteric vein reconstruction during pancreatectomy

Shibuya and colleagues describe their innovative technique using the femoral vein as a graft for portal vein/superior mesenteric vein reconstruction during pancreatectomy. The femoral vein has an appropriate diameter and is particularly useful when long resection of the superior mesenteric vein is required in surgery for locally advanced pancreatic ductal adenocarcinoma.

A triple tunnel from the mid-calf to the femoral vein in patient with severe dementia

Achieving the ideal exit site is the new philosophy for complicated vascular access patients. Recent publications have described multiple venous access solutions such as tunneling to the scapular region, the chest to the arm, and from the femoral vein to the abdominal and patellar region. In the patients afflicted with delirium, dementia, or confusion even these sites may not be sufficient. The following case study illustrates a triple tunneled femoral catheter on a non-cooperative patient with inoperable endocarditis to be discharged and treated with long term antibiotics.

Effect of femoral PICC line insertion in neonates with digestive tract disease

OBJECTIVE

To investigate the clinical effects of various catheterization pathways to guide vein selection in neonates.

METHODS

In this retrospective study, a total of 40 newborns admitted to the Neonatal Surgery Department of Nanjing Children's Hospital who were hospitalized for gastrointestinal diseases and required intravenous nutrition from March 2020 to December 2020 were included. The patients were divided into a control group (basilic vein and superficial temporal vein) and an observation group (femoral vein of the lower extremity) according to the puncture site of the vein. Blood loss, incidences of phlebitis, incidences of catheter dislocation, frequency of dressing replacement, catheter-related blood infection rate, the satisfaction of family members and bacteriological test results of the catheter tip (1-2 cm) after catheter removal were compared between the two groups.

RESULTS

The incidence of phlebitis and catheter dislocation was lower while the satisfaction rate of family members was higher in the observation group as compared with those in the control group (all P<0.05).

CONCLUSIONS

PICC insertion through the femoral vein can effectively reduce catheter-related complications, shorten the days of hospitalization and improve the comfort of children and the satisfaction of their families.

The long-term outcomes of cardiac implantable electronic devices implanted via the femoral route

Background

Conventional superior access for cardiac implantable electronic devices (CIEDs) is not always possible and femoral CIEDs (F‐CIED) are an alternative option when leadless systems are not suitable. The long‐term outcomes and extraction experiences with F‐CIEDs, in particular complex F‐CIED (ICD/CRT devices), remain poorly understood.

Methods

Patients referred for F‐CIEDs implantation between 2002 and 2019 at two tertiary centers were included. Early complications were defined as ≤30 days following implant and late complications >30 days.

Results

Thirty‐one patients (66% male; age 56 ± 20 years; 35% [11] patients with congenital heart disease) were implanted with F‐CIEDs (10 ICD/CRT and 21 pacemakers). Early complications were observed in 6.5% of patients: two lead displacements. Late complications at 6.8 ± 4.4 years occurred in 29.0% of patients. This was higher with complex F‐CIED compared to simple F‐CIED (60.0% vs. 14.3%, p = .02). Late complications were predominantly generator site related (n = 8, 25.8%) including seven infections/erosions and one generator migration. Eight femoral generators and 14 leads (median duration in situ seven [range 6–11] years) were extracted without complication.

Conclusions

Procedural success with F‐CIEDs is high with clinically acceptable early complication rates. There is a notable risk of late complications, particularly involving the generator site of complex devices following repeat femoral procedures. Extraction of chronic F‐CIED in experienced centers is feasible and safe.

Damage control in abdominal vascular trauma

In patients with abdominal trauma who require laparotomy, up to a quarter or a third will have a vascular injury. The venous structures mainly injured are the vena cava (29%) and the iliac veins (20%), and arterial vessels are the iliac arteries (16%) and the aorta (14%). The initial approach is performed following the ATLS principles. This manuscript aims to present the surgical approach to abdominal vascular trauma following damage control principles. The priority in a trauma laparotomy is bleeding control. Hemorrhages of intraperitoneal origin are controlled by applying pressure, clamping, packing, and retroperitoneal with selective pressure. After the temporary bleeding control is achieved, the compromised vascular structure must be identified, according to the location of the hematomas. The management of all lesions should be oriented towards the expeditious conclusion of the laparotomy, focusing efforts on the bleeding control and contamination, with a postponement of the definitive management. Their management of vascular injuries includes ligation, transient bypass, and packing of selected low-pressure vessels and bleeding surfaces. Subsequently, the unconventional closure of the abdominal cavity should be performed, preferably with negative pressure systems, to reoperate once the hemodynamic alterations and coagulopathy have been corrected to carry out the definitive management.

AI-Enabled, Ultrasound-Guided Handheld Robotic Device for Femoral Vascular Access

Hemorrhage is a leading cause of trauma death, particularly in prehospital environments when evacuation is delayed. Obtaining central vascular access to a deep artery or vein is important for administration of emergency drugs and analgesics, and rapid replacement of blood volume, as well as invasive sensing and emerging life-saving interventions. However, central access is normally performed by highly experienced critical care physicians in a hospital setting. We developed a handheld AI-enabled interventional device, AI-GUIDE (Artificial Intelligence Guided Ultrasound Interventional Device), capable of directing users with no ultrasound or interventional expertise to catheterize a deep blood vessel, with an initial focus on the femoral vein. AI-GUIDE integrates with widely available commercial portable ultrasound systems and guides a user in ultrasound probe localization, venous puncture-point localization, and needle insertion. The system performs vascular puncture robotically and incorporates a preloaded guidewire to facilitate the Seldinger technique of catheter insertion. Results from tissue-mimicking phantom and porcine studies under normotensive and hypotensive conditions provide evidence of the technique's robustness, with key performance metrics in a live porcine model including: a mean time to acquire femoral vein insertion point of 53 ± 36 s (5 users with varying experience, in 20 trials), a total time to insert catheter of 80 ± 30 s (1 user, in 6 trials), and a mean number of 1.1 (normotensive, 39 trials) and 1.3 (hypotensive, 55 trials) needle insertion attempts (1 user). These performance metrics in a porcine model are consistent with those for experienced medical providers performing central vascular access on humans in a hospital.

OUTCOME IN PATIENTS AFTER AUTOLOGOUS FEMORAL VEIN RECONSTRUCTION FOR PRIMARY AORTIC INFECTION AND AORTIC GRAFT INFECTION: A CASE SERIES

OBJECTIVES

For surgical treatment of primary aortic infection and aortic graft infection, in situ reconstruction with autologous vein(s) has the lowest rates of re-infection and of graft thrombosis. In this study, we have assessed the outcome after autologous femoral vein reconstruction in patients with aortic (graft) infection and we provide insights into the specific technical surgical considerations of the procedure.

METHODS

In this retrospective single-center study, all patients who underwent autologous femoral vein reconstruction because of primary aortic infection or aortic graft infection between January 2012 and January 2020 were included. The primary outcome parameter was 30-day mortality.

RESULTS

Twenty-nine patients with autologous femoral vein reconstruction for a primary aortic infection (n = 3) or aortic graft infection (n = 26) were included. An aorto-enteral fistula was detected in 13 patients (49%). Venous reconstruction of the aorta was performed with a single femoral vein in 17 patients (59%), and two femoral veins in 12 patients (41%). Thirty-day mortality was 17%. Relapse of infection occurred in two patients (7%) and no amputations were needed. One year after surgery, only three patients (10%) still needed stockings and after two years none of the patients used stockings.

CONCLUSIONS

Central aortic reconstruction with femoral veins is a durable solution for primary aortic and aortoiliac graft infections with a low incidence of reinfections, amputations, and venous hypertension.

Damage control surgery for thoracic outlet vascular injuries: the new resuscitative median sternotomy plus REBOA

Thoracic vascular trauma is associated with high mortality and is the second most common cause of death in patients with trauma following head injuries. Less than 25% of patients with a thoracic vascular injury arrive alive to the hospital and more than 50% die within the first 24 hours. Thoracic trauma with the involvement of the great vessels is a surgical challenge due to the complex and restricted anatomy of these structures and its association with adjacent organ damage. This article aims to delineate the experience obtained in the surgical management of thoracic vascular injuries via the creation of a practical algorithm that includes basic principles of damage control surgery. We have been able to show that the early application of a resuscitative median sternotomy together with a zone 1 resuscitative endovascular balloon occlusion of the aorta (REBOA) in hemodynamically unstable patients with thoracic outlet vascular injuries improves survival by providing rapid stabilization of central aortic pressure and serving as a bridge to hemorrhage control. Damage control surgery principles should also be implemented when indicated, followed by definitive repair once the correction of the lethal diamond has been achieved. To this end, we have developed a six-step management algorithm that illustrates the surgical care of patients with thoracic outlet vascular injuries according to the American Association of the Surgery of Trauma (AAST) classification.

Ultrasound guidance for urgent arterial and venous catheterisation: randomised controlled study

BACKGROUND

Haemodynamically unstable patients often require arterial and venous catheter insertion urgently. We hypothesised that ultrasound-guided arterial and venous catheterisation would reduce mechanical complications.

METHODS

We performed a prospective RCT, where patients requiring both urgent arterial and venous femoral catheterisation were randomised to either ultrasound-guided or landmark-guided catheterisation. Complications and characteristics of catheter insertion (procedure duration, number of punctures, and procedure success) were recorded at the time of insertion (immediate complications). Late complications were investigated by ultrasound examination performed between the third and seventh days after randomisation. Primary outcome was the proportion of patients with at least one mechanical complication (immediate or late), by intention-to-treat analysis. Secondary outcomes included success rate, procedure time, and number of punctures.

RESULTS

We analysed 136 subjects (102 [75%] male; age range: 27-62 yr) by intention to treat. The proportion of subjects with one or more complications was lower in 22/67 (33%) subjects undergoing ultrasound-guided catheterisation compared with landmark-guided catheterisation (40/69 [58%]; odds ratio: 0.35 [95% confidence interval: 0.18-0.71]; P=0.003). Ultrasound-guided catheterisation reduced both immediate (27%, compared with 51% in the landmark approach group; P=0.004) and late (10%, compared with 23% in the landmark approach group; P=0.047) complications. Ultrasound guidance also reduced the proportion of patients who developed deep vein thrombosis (4%, compared with 22% following landmark approach; P=0.012), and achieved a higher procedural success rate (96% vs 78%; P=0.004).

CONCLUSIONS

An ultrasound-guided approach reduced mechanical complications after urgent femoral arterial and venous catheterisation, while increasing procedural success.

CLINICAL TRIAL REGISTRATION

NCT02820909.

High Deep Femoral Artery Bifurcation Can Disturb Safe Femoral Venous Access: CT Assessment in Patients Who Underwent Femoral Venous Access Under Doppler Ultrasound Guidance

PURPOSE

To retrospectively evaluate the variations of deep femoral artery (DFA) bifurcation on computed tomography (CT) and technical success in femoral venous access.

MATERIALS AND METHODS

CT images of 353 patients who underwent adrenal venous sampling were evaluated. Height with relation to the inferior border of the femoral head and direction of DFA bifurcations were classified as follows: type L, low bifurcation; type H1, high lateral bifurcation; type H2, high posterior to posterolateral bifurcation; type H3, high posteromedial bifurcation; and type H4, high medial bifurcation crossing in front of the femoral vein. Technical success and complications during femoral venous access were also evaluated.

RESULTS

The frequencies of types L, H1, H2, H3, and H4 were 82.7%, 9.1%, 6.9%, 0.4%, and 0.9%, respectively. In 92.2% of type H1 and 69.4% of type H2, the superior femoral artery displaced medially by the high DFA partially overlapped the femoral vein. Upon the inclusions of H3 and H4, in 14.4% of cases, the high DFAs could obstruct the access route to the femoral vein. Using Doppler ultrasound guidance, no significant differences were observed in the rates of success for puncture in the first attempt (84.5% vs. 75.4%, p = 0.122) and accidental arterial puncture (1.0% vs. 0%, p = 1.00) between low and high DFA bifurcations, respectively.

CONCLUSIONS

High DFA bifurcation is observed in 17.3% of patients and could obstruct the access route to the femoral vein. This can be evaluated using Doppler ultrasound guidance to avoid accidental arterial puncture during femoral venous access.

Exercise-Induced Modulation of Angiotensin II Responses in Femoral Veins From 2-Kidney-1-Clip Hypertensive Rats

The present study investigated the angiotensin II (Ang II) responses in rat femoral veins taken from 2-kidney-1clip (2K1C) hypertensive rats at 4 weeks after clipping, as well as the effects of exercise on these responses. In this manner, femoral veins taken from 2K1C rats kept at rest or exposed to acute exercise or to exercise training were challenged with Ang II or endothelin-1 (ET-1) in organ bath. Simultaneously, the presence of cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) were determined in these preparations by western blotting. In these experiments, femoral veins exhibited subdued Ang II responses. However, after nitric oxide (NO) synthesis blockade, the responses were higher in the femoral veins taken from animals kept at rest [0.137(0.049–0.245); n = 10] than those obtained in trained animals kept at rest [0.008(0.001–0.041); n = 10] or studied after a single bout of exercise [0.001(0.001–0.054); n = 11]. In preparations in which, in addition to NO synthesis, both the local production of prostanoids and the action of ET-1 on type A (ET_A) or B (ET_B) receptors were inhibited, the differences induced by exercise were no longer observed. In addition, neither ET-1 responses nor the presence of COX-1 and COX-2 in these preparations were modified by the employed exercise protocols. In conclusion, NO maintains Ang II responses reduced in femoral veins of 2K1C animals at rest. However, vasodilator prostanoids as well as other relaxing mechanisms, activated by ET_B stimulation, are mobilized by exercise to cooperate with NO in order to maintain controlled Ang II responses in femoral veins.

Location of Femoral Vessels Around the Acetabulum in Crowe Type 4 Dysplastic Hips

BACKGROUND

There are anatomical differences in the femur and acetabulum on the dysplastic hips. Yet, although there are detailed researches on bony structure differences, studies regarding anatomical differences for the vascular structure are insufficient. The study aimed to determine the relationship between the femoral artery and vein with acetabulum in computed tomography evaluation of Crowe type 4 hips and to compare with normal hip femoral vein and artery anatomic position.

METHODS

Forty patients with one side hip Crowe type 4 deformity and opposite side normal hip were found suitable for the study. Pelvis CT was previously applied to all patients for the planning of total hip arthroplasty surgery. Normal hip acetabulum and the true acetabulum of the dysplastic hip were marked with the Ranawat's triangle and were then divided into quarters with four axial slices of the acetabulum; as dome, proximal one-fourth, center, and distal three-fourths. The shortest distance from the femoral vessels to the pelvis was measured at these 4 axial slices at the dysplastic side and compared with the healthy side.

RESULTS

The distance of the vein to the acetabulum is closer to the dysplastic side. At distal three-fourths of Ranawat's triangle axial images, both femoral artery and femoral vein are closer to acetabulum at the dysplastic side.

CONCLUSION

The analysis of preoperative images in cases of Crowe type 4 hip shows that the femoral vessels are closer to the anterior wall of the dysplastic true acetabulum at the level of the center of the hip (vein, mean: 2.7 mm closer) and below the center of the hip (vein, mean: 3 mm; and artery, mean: 3.3 mm closer) when compared with the normal acetabulum. Anatomic relationships knowledge can be used intraoperatively to avoid iatrogenic vascular injury during Crowe type 4 dysplastic hip arthroplasty surgery.

A retrospective analysis of the clinical effectiveness of subcutaneously tunneled femoral vein cannulations at the bedside: A low risk central venous access approach in the neonatal intensive care unit

OBJECTIVE

The purpose of this retrospective analysis was to evaluate the clinical efficacy and safety of ultrasound (US)-guided, subcutaneously tunneled, femoral inserted central catheters (ST-FICCs) in the neonatal intensive care unit (NICU).

METHODS

Following clinical success with ST-FICCs in adults, we expanded this practice to the neonatal population. In an 18-month retrospective cohort analysis (2018-2020) of 82 neonates, we evaluated the clinical outcome for procedural success, completion of therapy, and incidence of early and late complications for insertion of US-guided ST-FICCs in the NICU.

RESULTS

Placement of ST-FICCs were successful in 100% of neonates (n = 82/82) with 94% to the right (n = 77/82) and 6% to the left common femoral veins (n = 5/82). Gestational age ranged 23-39 weeks with median age of 29 weeks. Birthweight ranged from 450 g to >2000 g. Weight at insertion ranged 570 to 3345 g and day of life 1 to 137, with median at day 5. Ultrasound guided femoral vein puncture was recorded on 74 patients, first attempt 63/74 (85%), second attempt 8/74 (11%) and third attempt 3/74 (4%). Catheter french used: 1.9Fr (n = 80/82), 2.6Fr (n = 1/82), and 3-Fr (n = 1/82). Catheter lengths were 8 to 20 cm, average 12cm. Catheter termination confirmed with posterior/anterior and lateral abdominal radiographs with inferior vena cava (IVC) (n = 33/82), IVC/right atrial junction (n = 31/82), or right atrium (n = 18/82). Atrial placements were retracted; no cases of malposition to the lumbar/renal/hepatic veins (n = 0/82). 1528 catheter days ranging 5 to 72 days (average 18). No insertion-related or post-insertion complications. All patients completed prescribed therapy with one catheter.

CONCLUSION

Bedside placement of an ST-FICC is a safe route for central venous access in the NICU, preserving upper extremity vasculature, eliminates risks associated with sedation, fluoroscopy, tunneled and non-tunneled supra-diaphragmatic central venous insertion.

A retrospective analysis of the clinical effectiveness of subcutaneously tunneled femoral vein cannulations at the bedside: A low risk central venous access approach in the neonatal intensive care unit

OBJECTIVE

The purpose of this retrospective analysis was to evaluate the clinical efficacy and safety of ultrasound (US)-guided, subcutaneously tunneled, femoral inserted central catheters (ST-FICCs) in the neonatal intensive care unit (NICU).

METHODS

Following clinical success with ST-FICCs in adults, we expanded this practice to the neonatal population. In an 18-month retrospective cohort analysis (2018-2020) of 82 neonates, we evaluated the clinical outcome for procedural success, completion of therapy, and incidence of early and late complications for insertion of US-guided ST-FICCs in the NICU.

RESULTS

Placement of ST-FICCs were successful in 100% of neonates (n = 82/82) with 94% to the right (n = 77/82) and 6% to the left common femoral veins (n = 5/82). Gestational age ranged 23-39 weeks with median age of 29 weeks. Birthweight ranged from 450 g to >2000 g. Weight at insertion ranged 570 to 3345 g and day of life 1 to 137, with median at day 5. Ultrasound guided femoral vein puncture was recorded on 74 patients, first attempt 63/74 (85%), second attempt 8/74 (11%) and third attempt 3/74 (4%). Catheter french used: 1.9Fr (n = 80/82), 2.6Fr (n = 1/82), and 3-Fr (n = 1/82). Catheter lengths were 8 to 20 cm, average 12cm. Catheter termination confirmed with posterior/anterior and lateral abdominal radiographs with inferior vena cava (IVC) (n = 33/82), IVC/right atrial junction (n = 31/82), or right atrium (n = 18/82). Atrial placements were retracted; no cases of malposition to the lumbar/renal/hepatic veins (n = 0/82). 1528 catheter days ranging 5 to 72 days (average 18). No insertion-related or post-insertion complications. All patients completed prescribed therapy with one catheter.

CONCLUSION

Bedside placement of an ST-FICC is a safe route for central venous access in the NICU, preserving upper extremity vasculature, eliminates risks associated with sedation, fluoroscopy, tunneled and non-tunneled supra-diaphragmatic central venous insertion.

Primary leiomyosarcoma is a rare cause of femoral triangle mass: A case report

OBJECTIVES

Primary leiomyosarcoma in the femoral vein is an extremely rare vascular disorder and is often misdiagnosed. In order to improve the knowledge and treatment of this disease, a case of leiomyosarcoma in the femoral vein was reported.

METHODS

We report the case of a 58-year-old woman with a leiomyosarcoma of the femoral vein and treated successfully by surgical resection. After surgery, no recurrence had been noted follow-up.Subsequently, we reviewed information derived from 31 previously published cases from 1954 to 2019.

RESULTS

A total of 31 patients diagnosed with femoral vein leiomyosarcoma were presented in previous studies; in all of these patients, 14 (45.2%, 14/31) patients were men. Of these, the median age was 51.6 years old (ranging from 3 to 84).

CONCLUSIONS

Complete resection with adjuvant chemotherapeutic was the main strategy to treat the disease. Prognosis remains poor if metastasis was present, especially pulmonary metastasis.

In Well-Selected Patients With a Femoral Deep Vein Thrombosis Central Venous Imaging May Identify Additional Iliocaval Disease

OBJECTIVE

Patients who present acutely with a femoral deep vein thrombosis (DVT) diagnosed by ultrasound are often treated with anticoagulation and instructed to follow-up electively. This study sought to assess whether obtaining axial imaging of the central venous system results in the identification of additional iliocaval pathology warranting treatment.

METHODS

This study was a retrospective review of a prospectively maintained registry from November 2014 through April 2017 with follow-up through March 2020. Consecutive patients with a diagnosis of femoral DVT diagnosed by ultrasound were evaluated; those who underwent axial imaging of the iliocaval system (Group A) were compared to those who did not undergo imaging of the central veins (Group B). The primary outcome was the performance of any percutaneous central venous intervention. Secondary outcomes included the extent of DVT identified on duplex and after axial imaging, follow-up duplex patency and persistence of severe symptoms.

RESULTS

Eighty patients presented with an ultrasound diagnosis of a femoral vein DVT. Mean follow-up was 551 ± 502 days. Group A comprised 24 patients (30%) and Group B comprised 56 patients (70%). Baseline demographics did not differ significantly between the 2 groups. After duplex imaging, Group A exhibited an increased prevalence of DVT in the common femoral vein. After central imaging, Group A exhibited an increased prevalence of DVT in the iliocaval veins. The number of patients who underwent invasive treatment differed significantly between the 2 groups, Group A 16/24 (67%) vs. Group B 9/56 (16%), P < 0.0001. The number of patients that demonstrated duplex patency and had persistent symptoms on follow-up did not differ significantly.

CONCLUSIONS

Patients with an ultrasound diagnosis of femoral DVT may have additional iliocaval pathology warranting intervention. Well-selected imaging of the central veins may reveal a more complete picture, potentially altering management.

Risk factors for venous bleeding complication at the femoral puncture site after catheter ablation of atrial fibrillation

BACKGROUND

Venous bleeding complication is often observed after catheter ablation of atrial fibrillation (AF), but the risk factors remain unclear.

METHODS

We retrospectively evaluated 570 consecutive patients who underwent catheter ablation of AF from April 2012 to March 2017. After the procedure, the sheaths were removed, and hemostasis was obtained by manual compression followed by application of rolled gauze with elastic bandage and continuous pressure to the puncture site. We evaluated the risk factors for venous bleeding complications defined as hemorrhage from the puncture site that needed recompression after removal of the elastic bandage and rolled gauze.

RESULTS

After excluding 11 patients because of missing data, 559 patients (395 [70.7%] men, mean age: 65.6 ± 8.7 years) were included for analysis. Venous bleeding complication was observed in 213 patients (38.1%). In the multivariate logistic regression analysis, low body mass index (BMI; odds ratio [OR] 0.95, 95% CI 0.90-1.00, P = .04), short compression time (OR 0.77, 95% CI 0.68-0.88, P < .001), and antiplatelet therapy (OR 1.86, 95% CI 1.09-3.16, P = .02) were independent risk factors for venous bleeding complication.

CONCLUSIONS

Low BMI, short compression time, and antiplatelet therapy were independent risk factors for venous bleeding complication after catheter ablation of AF. Longer compression time may be needed for patients with low BMI and/or those receiving antiplatelet therapy.

Angiography in pediatric patients: Measurement and estimation of femoral vessel diameter

The diameter of femoral vessels was angiographically explored in pediatric patients with congenital heart disease (CHD) and compared with anthropometric and demographic indexes.A total of 153 pediatric patients younger than 3 years old were recruited. The sex, age, weight, and height of patients were recorded daily, and the body surface area (BSA) was calculated with the Mosteller formula.The values of mean left-right diameters were 3.13 (0.32) mm for the femoral artery (FA) and 5.14 (0.68) mm for the femoral vein (FV). The FA diameter (FA-Dm) and FV diameter (FV-Dm) were clearly related (R = 0.84, P < .001), and the FA-Dm/FV-Dm ratio ranged from 0.61 to 0.622. The diameters of femoral vessels were significantly correlated with age, height, weight and BSA (R = 0.63 to 0.73, P < .001). The FA-Dm and FV-Dm were most closely associated with the height of patients (FA-Dm: R = 0.73, P < .001; FV-Dm: R = 0.69, P < .001).The FV-Dm and FA-Dm were consistent with the weight, height, age and BSA in the surveyed pediatric patients. The FA-Dm and FV-Dm were closely associated with the height of pediatric patients. Furthermore, the FA-Dm/FV-Dm ratio was stable in these patients. Such estimations could help clinicians select the appropriate diameter of cannulation needles and catheters for interventional therapy pediatric patients with CHD.

Cannulation of the superficial femoral vein at mid-thigh when catheterization of the superior vena cava system is contraindicated

PURPOSE

Patients needing medium- to long-term infusion therapy with limited catheterization via the superior vena cava system is a challenging condition. The conventional catheterization via the femoral vein in the groin has a high complication rate, discomfort, and short indwelling time. Since changing the insertion site can avoid the disadvantage of conventional catheterization via the femoral vein in the groin, the present study aimed to investigate the effects of femoral inserted central catheters insertion via the superficial femoral vein at the mid-thigh to resolve the issue of limited superior vena cava system catheterization.

METHODS

Based on the symptoms and signs, enhanced computed tomography findings, and insertion history, in 121 patients, limited catheterization via the superior vena cava system was identified. Subsequently, the femoral inserted central catheters were inserted via the superficial femoral vein at the mid-thigh under the guidance of ultrasound, and the tip of femoral inserted central catheters was in the inferior vena cava.

RESULTS

A total of 121 patients underwent femoral inserted central catheters insertion via a superficial femoral vein at the mid-thigh from August 2017 to December 2018. The success rate of insertion was 100%, and the indwelling time was 3-472 days. The complications of femoral inserted central catheters in the thigh were similar to that of peripherally inserted central catheters in the arm. The incidence of primary malposition was 1.65%, the incidence of catheter-related thrombosis was 0.83%, and the central line associated bloodstream infection rate was 0.83%. Subsequently, 116 lines (95.87%) were removed at the end of the treatment, one line (0.83%) was accidentally removed by the patient, and four lines (3.31%) were unplanned removed due to complications.

CONCLUSION

The technique of femoral inserted central catheters insertion via the superficial femoral vein at the mid-thigh has a high success rate, low complication rate, and less impact on activities, and is easy to maintain. This phenomenon resolves the patient's needs of medium- to long-term infusion therapy with limited catheterization of superior vena cava system.

Death due to severe blood loss following an accidental lesion to the femoral vessels

Deaths from sharp force injuries are a significant cause of violent death. While homicides and suicides caused by sharp force wounds are common, accidental injuries are less often described in forensic literature, so their actual incidence or prevalence is not known. This paper presents an accidental death due to massive blood loss which resulted from lesions to the left femoral vessels by glass fragments. The body was found in a pool of blood surrounded by hundreds of glass fragments. Autopsy revealed a near-total transection of the superficial femoral artery, and two wounds of the superficial femoral vein. In case of accidental sharp force injuries, a thorough medico-legal process, including death scene investigation, autopsy examination and toxicological analyses, is always necessary to determine the manner of death.

Accidental guidewire migration following emergency femoral central venous catheterization

Central venous catheter placement especially the femoral venous catheter is a common practice in critically ill patients. Awareness of potential complications of the guidewire such as guidewire migration is of utmost importance. Though potentially retrievable by a vascular surgeon or interventional radiologist if it occurs, close supervision by a senior person during passage by a junior or inexperienced person, the use of ultrasound before and after placement of catheter, and use of a checklist may help to identify and prevent its occurrence. We present a very rare complication of central venous cannulation of a guidewire migration in our institution. A 12-year-old girl presented to the Paediatric Emergency Unit (PEU) with status epilepticus and aspiration pneumonia and subsequently transferred to the Paediatric Intensive Care Unit (PICU) for ventilatory support. She had accidental guidewire migration to the left internal jugular vein following a right transfemoral central venous catheterization. She underwent successful guidewire retrieval via a right groin incision.

Research protocol for mechanical complications after central venous catheterisation: a prospective controlled multicentre observational study to determine incidence and risk factors of mechanical complications within 24 hours after cannulation

INTRODUCTION

Central venous catheterisation is a common procedure in intensive care therapy and the use of central venous catheters is essential for treatment of many medical disorders. Although rare, central venous catheterisation is associated with mechanical complications that can be life-threatening if untreated. Real-time ultrasound guidance reduces the incidence of mechanical complications when compared with the anatomic landmark method. The purpose of this study is to determine the incidence of and potential risk factors associated with early mechanical complications of central venous catheterisation in an era where real-time ultrasound guidance has become clinical practice.

METHODS AND ANALYSIS

This is a prospective, controlled, multicentre, observational study. All participating hospitals follow the same clinical guidelines for central venous catheterisation. Each central venous catheter insertion will be recorded in the common electronic chart system according to a recently revised template. An automated script-based search will identify all recorded central venous catheter insertion templates during the study period and relevant variables will be extracted. Outcome measures and independent variables are pre-defined in this study protocol. Multivariable and univariable logistic regression analysis will be used to determine associations and risk factors of mechanical complications.

ETHICS AND DISSEMINATION

The Regional Ethical Review Board in Lund, Sweden has approved this study. The results will be submitted for publication in peer-reviewed medical journals and presented at national and international scientific meetings.

TRIAL REGISTRATION NUMBER

NCT03782324.

Internal Jugular Vein as Alternative Access for Implantation of a Wireless Pulmonary Artery Pressure Sensor

BACKGROUND

A wireless pulmonary artery pressure sensor (CardioMEMS) is approved for implantation via the femoral vein. The internal jugular vein (IJ) is an attractive alternative access route commonly used in pulmonary artery catheterization.

METHODS AND RESULTS

Retrospective chart review was performed for all sensor implants from 10 providers at 4 centers from September 2016 to June 2018. To compare procedural outcomes and discharge efficiency between groups, multivariate analyses incorporating potential confounders were performed. Seventy-three (28%) patients had femoral access, and 189 (72%) had IJ access; demographics were similar between the groups. Complications, including one case of hematoma and 4 cases of mild hemoptysis, and 30-day mortality (2%-3%) did not differ between groups. Provider preference for IJ access substantially increased over time, with IJ accounting for 90% of cases in 2018. After risk-adjustment, IJ cases had 20% (5%-33%) shorter fluoroscopy time (P=0.01) and 24% (7%-38%) lower contrast volume (P=0.008). Compared with outpatient femoral cases, outpatient IJ cases had 62% (52%-69%) faster needle-to-door time and were 34 times (6-235) more likely to have same-day discharge (P<0.001 for both).

CONCLUSIONS

IJ access for CardioMEMS implant is a safe alternative associated with superior procedural and discharge outcomes. Implanters at 4 high-volume centers adopted IJ access as the preferred implant approach.

Applied Uses of Extracorporeal Membrane Oxygenation Therapy

Extracorporeal membrane oxygenation (ECMO) therapy has been around since the 1970s and has completely changed how critical care physicians view supportive therapy for certain patients. ECMO therapy is a supportive therapy provided by a mechanical extracorporeal circuit that is able to directly oxygenate and remove carbon dioxide from the blood. By performing this, ECMO can provide cardiac, respiratory, or combined cardiopulmonary supportive therapy in cases of failure. ECMO therapy also places less emphasis on invasive mechanical ventilation, which prevents barotrauma and gives rest to the lungs. Therefore, they are used for several different conditions. This review article focuses on the definition, principles, types, and practical applications of ECMO therapy.

The angle range of leg abduction with external hip rotation which can minimize femoral artery and vein overlap in pediatric patients

BACKGROUND

Since the femoral artery frequently overlaps the femoral vein, femoral central venous catheterization carries the risk of arterial puncture in pediatric patients.

AIMS

We evaluated the angle range of leg abduction with external hip rotation to minimize the overlap between the femoral artery and vein in pediatric patients undergoing general anesthesia.

METHODS

Eighty-two pediatric patients who underwent elective surgery with general anesthesia were enrolled in this study. Using ultrasonography, patients were divided into groups N (patients with non-overlap) and O (patients with continuing overlap) based on the presence of non-overlap range between the femoral artery and vein. The range minimizing the overlap was defined as the range without overlap in group N and as the range presenting the overlap that was less-than-half of the radius of the femoral vein in group O. By increasing the angle of leg abduction with external hip rotation, the starting and ending angles minimizing the overlap were found using ultrasonographic images.

RESULTS

The angle range of leg abduction with external hip rotation minimizing the overlap between the femoral artery and vein was defined as the range from the maximum 99% confidence interval of starting angles to the minimum 99% confidence interval of ending angles, which was between 45° and 65° in group N and between 48° and 58° in group O, respectively.

CONCLUSION

Positioning patients in a range of 48° and 58° leg abduction with external hip rotation can minimize the overlap between the femoral artery and vein. However, the clinical usefulness of this positioning for femoral venous catheterization remains to be seen.

Endovascular Treatment for a Perforated Superficial Femoral Vein Graft for an Infected Abdominal Aortic Aneurysm

The patient had an infected abdominal aortic aneurysm. Aneurysmectomy and in situ reconstruction of the abdominal aorta using the bilateral superficial femoral veins with omentopexy were performed. On postoperative day 18, hematemesis and melena occurred. Computed tomography showed extravasation from the right graft limb, and gastrointestinal endoscopy showed a duodenal fistula. Covered stent implantation was performed for the limb. Bleeding from the contralateral graft limb occurred the next day, and the patient underwent covered stent graft implantation for that limb followed by partial duodenectomy and duodenojejunostomy. Intraoperative findings demonstrated a pinhole leakage from the branch ligation site on both vein grafts.

Human Femoral Vein Diameter and Topography of Valves and Tributaries: A Post Mortem Analysis

The femoral vein (FV) is a clinically important vessel. Failure of its valves can lead to chronic venous insufficiency (CVI) with severe manifestations such as painful ulcers. Although they are crucial for identifying suitable implant sites for therapeutic valves, studies on the topography of FV tributaries and valves are rare. Moreover, the femoral vein diameter (FVD) must be known to assess the morphometric requirements for valve implants. To reassess the anatomical requirements for valve implants, 155 FVs from 82 human corpses were examined. FVDs and tributary and valve topographies were assessed using a laboratory straightedge. The FVD increased from 6 mm in the distal femoropopliteal vein to 11 mm in the iliofemoral vein proximal to the saphenofemoral junction (SFJ). Diameters were significantly bigger in males than females. Height correlated positively with FVD. Distal to the SFJ, within a distance of 38 cm, one to eight valves were present. Up to two valves were present within 10 cm proximal to the SFJ. Individual tributary and valve topography must be considered to ensure appropriate design and successful implantation of a venous valve for CVI therapy in the FV. A suitable implant site would be proximal to the SFJ via an infrainguinal transfemoral access. Clin. Anat. 31:1065-1076, 2018. © 2018 Wiley Periodicals, Inc.

Biomechanical properties of veins cultured in vitro under elevated internal pressure

BACKGROUND

The venous response to elevated blood pressure (BP) is of major importance because it is closely related to the etiology of venous diseases and the competency of vein grafts. In vitro culture experiments may provide useful information on the function of vein grafts because it is easier to separate mechanical and hemodynamic effects from other systemic influences compared to in vivo experiments.

OBJECTIVE

To study the effects of BP elevation on wall dimensions and mechanical properties of in vitro cultured veins.

METHODS

Rabbit femoral veins were cultured in vitro under internal pressures of 1 to 50 mmHg for 1 week, and their wall dimensions, biomechanical properties, and histology were determined.

RESULTS

No significant differences were observed in internal vein diameter and wall thickness among vessels cultured at 10-50 mmHg compared to non-cultured control vessels. For an internal pressure of 10 mmHg applied to vessels during culture (equivalent to in vivo working BP), wall circumferential stress was maintained within control levels. There were no significant effects of pressure on basal tone and contractility of vascular smooth muscle and vascular compliance.

CONCLUSIONS

The in vitro results were essentially similar to those obtained from previous in vivo animal experiments, indicating that in vitro tissue culture techniques are applicable to studies of venous remodeling.

Open Repair of Mycotic Abdominal Aortic Aneurysms With Biological Grafts: An International Multicenter Study

BACKGROUND

The treatment of mycotic abdominal aortic aneurysm requires surgery and antimicrobial therapy. Since prosthetic reconstructions carry a considerable risk of reinfection, biological grafts are noteworthy alternatives. The current study evaluated the durability, infection resistance, and midterm outcome of biological grafts in treatment of mycotic abdominal aortic aneurysm.

METHODS AND RESULTS

All patients treated with biological graft in 6 countries between 2006 and 2016 were included. Primary outcome measures were 30- and 90-day survival, treatment-related mortality, and reinfection rate. Secondary outcome measures were overall mortality and graft patency. Fifty-six patients (46 males) with median age of 69 years (range 35-85) were included. Sixteen patients were immunocompromised (29%), 24 (43%) had concomitant infection, and 12 (21%) presented with rupture. Bacterial culture was isolated from 43 (77%). In-situ aortic reconstruction was performed using autologous femoral veins in 30 patients (54%), xenopericardial tube-grafts in 12 (21%), cryopreserved arterial/venous allografts in 9 (16%), and fresh arterial allografts in 5 (9%) patients. During a median follow-up of 26 months (range 3 weeks-172 months) there were no reinfections and only 3 patients (5%) required assistance with graft patency. Thirty-day survival was 95% (n=53) and 90-day survival was 91% (n=51). Treatment-related mortality was 9% (n=5). Kaplan-Meier estimation of survival at 1 year was 83% (95% confidence interval, 73%-94%) and at 5 years was 71% (52%-89%).

CONCLUSIONS

Mycotic abdominal aortic aneurysm repair with biological grafts is a durable option for patients fit for surgery presenting an excellent infection resistance and good overall survival.

Femoro-jugular cannulation in veno-venous extracorporeal membrane oxygenation PRO/CON

Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is the most efficient technique for respiratory support. It is based on a patient adequate circulation and cardiac function and it is indicated for isolated lung failure after optimization of the ventilatory support and the medical treatment. We describe PRO and CONs of the Femoro-jugular (F>J) approach, as an ideal setting for patients which require high flow (>5 L/min), such as those with extreme hypoxemia and/or septic shock. This technique can be accomplished very quickly at the bedside also in an unstable patient.

Intravascular epithelioid hemangioendothelioma of the femoral vein diagnosed by contrast-enhanced ultrasonography: A care-compliant case report

RATIONALE

Intravascular epithelioid hemangioendothelioma (EHE) is a rare endothelial tumor with an intermediate grade of malignancy. We present a case of one woman affected by EHE of the femoral vein. Contrast-enhanced ultrasonography played a role in diagnosing EHE and helped differentiate it from thrombosis. To our knowledge, this is the first reported contrast-enhanced ultrasonography of intravascular EHE in the imaging literature.

PATIENT CONCERNS

A 46-year-old woman presented to our hospital due to pain and swelling in her right lower limb since 5 years prior to her presentation.

DIAGNOSES

The patient was misdiagnosed as having thrombosis by ultrasound. Contrast-enhanced ultrasonography showed solid lesions with visible blood supply, suggesting angiogenic tumors.

INTERVENTIONS

The patient was treated by complete surgical removal of the mass and postoperative radiotherapy. Pathological examination confirmed the diagnosis of EHE.

OUTCOMES

During follow-up, there were no signs of local or distant relapse.

LESSONS

Intravenous EHE may be misdiagnosed as thrombosis by ultrasound and contrast-enhanced ultrasonography can help make the differential diagnosis.

Transvenous Intravascular Ultrasound-Guided Endovascular Treatment for Chronic Total Occlusion of the Infrainguinal Arteries

PURPOSE

To investigate the 1-year outcomes of transvenous intravascular ultrasound (IVUS)-guided endovascular therapy (EVT) for chronic total occlusion (CTO) of the lower extremity arteries.

METHODS

Transvenous IVUS-guided EVT was performed in 44 patients (50 limbs) with CTO of the femoropopliteal arteries or tibioperoneal trunk. Treatment involved crossing a guidewire through the CTO under the guidance of both fluoroscopic and IVUS imaging, along with insertion of the IVUS catheter into a vein parallel to the target artery. Primary success rate, complications, and target lesion revascularization (TLR) at 12-month follow-up were investigated.

RESULTS

Successful recanalization, defined as grade 3 flow (Thrombolysis in Myocardial Infarction score) and no flow-limiting dissection, was observed in 48 (96%) limbs. Two limbs with failed recanalization had a very long CTO lesion from the superficial femoral artery to below the knee. A bidirectional approach was selected in 11 (22%) limbs. Complications at the access site occurred in only 2 patients. The rate of freedom from TLR at 12 months was 77.9% (95% confidence interval 61.4 to 87.9).

CONCLUSION

Transvenous IVUS-guided EVT is safe and can provide optimal short-term results for EVT of CTO in the infrainguinal arteries. IVUS-guided EVT may be one of the most effective treatment strategies for CTO of the femoropopliteal arteries or tibioperoneal trunk.

Biventricular ICD Placement Percutaneously Via the Iliac Vein: Case Reports and a Review

Cardiac resynchronization therapy (CRT) has been demonstrated to improve symptoms of heart failure. As a result, it has become the standard of care in selected patients, and is commonly completed with three leads placed via an upper-extremity vein. However, in rare situations, such as in the case of superior vena cava occlusion, venous access is not possible via the upper extremity. It is in such instances that alternative means must be sought. Here, two patients who received a CRT defibrillator via an iliac vein approach with a mid-abdominal generator are introduced, and a review of the techniques used is presented. Technical aspects to this approach are discussed, including iliac venous access, defibrillation electrode positioning, coronary sinus access, and lead tunneling to an abdominal generator for patient comfort. This approach should be considered when vascular access is compromised, at least until combined leadless CRT pacing and subcutaneous implantable cardioverter-defibrillator devices become available and feasible for use.

Iliac Artery Reconstruction With the Superficial Femoral Vein After Major Oncologic Resection

The large size of some retroperitoneal tumors and the complex anatomy of the retroperitoneal structures often require en bloc resection of contiguous organs and, sometimes, resection of critical vascular structures. Vascular reconstructive techniques allow reconstruction of major vascular structures, and autologous vein grafting is the preferred option. Although great saphenous vein can be used in select cases, other options must be explored in cases of caliber mismatch between saphenous vein and native vessel. In addition, the use of synthetic grafts should be avoided in potentially infected vascular beds. The use of the superficial femoral vein in such settings is well documented especially in relation to treatment of infected aortic grafts and has the added advantage of appropriate size match for reconstruction of the major abdominal and pelvic vascular structures. Here, we present a case of a 56-year-old woman with a local recurrence of urothelial cancer in the pelvis after radical cystectomy and radiotherapy. Computed tomography (CT) angiography showed the right iliac artery directly involved by the tumor, and vessel resection was necessary to achieve oncologic surgical margins. The tumor was excised en bloc, and vascular reconstruction using the reversed contralateral superficial femoral vein in an end-to-end fashion was performed. The postoperative course was uneventful. Patient was maintained on low-molecular-weight heparin for 1 month and then on low-dose (100 mg acetylsalicylic acid) antiplatelet therapy and compression stockings. Six months later, the patient is asymptomatic, without leg swelling, and the CT scan shows patency of the vascular repair and no tumor recurrence.

A simple method of placing a coronary sinus catheter through the femoral vein in miniature swine

The aim of the present study was to evaluate the feasibility of placing a coronary sinus (CS) catheter through the femoral veins of miniature swine. A total of 16 male domestic pigs (3-4 months old, 25±2 kg) were used. Firstly, the anatomic structure of the CS ostium of swine heart was observed at different angles under X-ray. The guide wire and Cobara catheter were subsequently advanced into the right atrium through the femoral vein. Subsequently, the guide wire was retracted behind the fix curve of the Cobara catheter and the catheter bent spontaneously in the absence of supporting guide wire following retraction. The catheter was then gently rotated clockwise to direct the catheter tip to the left allowing the catheter to easily be placed in the CS ostium. This method was associated with a short procedure time: The time on separation of the blood vessels was 15.5±5.8 min and the time of radiation exposure was 112±20 sec. The success rate of placing the catheter to CS ostium was 100%. Only one pig experienced a hematoma after the sheath was pulled out. All swine recovered without serious complications, such as perforation of coronary vein and pericardial tamponade. Therefore, this method of placing CS catheter is simple, safe and reliable, which may offer help for related research.

Morphometric analysis of rat femoral vessels under a video magnification system

The right femoral vessels of 80 rats were identified and dissected. External lengths and diameters of femoral arteries and femoral veins were measured using either a microscope or a video magnification system. Findings were correlated to animals’ weights. Mean length was 14.33 mm for both femoral arteries and femoral veins, mean diameter of arteries was 0.65 mm and diameter of veins was 0.81 mm. In our sample, rats’ body weights were only correlated with the diameter of their femoral veins.

Measuring the Pharmacokinetic Properties of Drugs with a Novel Surgical Rat Model

Purpose/aim of the study: The pharmacokinetic (PK) parameters in animal models can help optimize novel candidate drugs prior to human trials. However, due to the complexity of pharmacokinetic experiments, their use is limited in academia. We present a novel surgical rat model for investigation of pharmacokinetic parameters and its use in an anti-obesity drug development program.

MATERIALS AND METHODS

The model uses anesthetized male Wistar rats, a jugular, a femoral catheter, and an insulin pump for peptide infusion. The following pharmacokinetic parameters were measured: metabolic clearance rate (MCR), half-life, and volume of distribution (Vd). Glucagon-like peptide 1 (GLP-1), glucagon (GCG), and exendin-4 (Ex-4) were used to validate the model. The pharmacokinetic parameters of anti-obesity drug candidates X1, X2, and X3 were measured.

RESULTS

GLP-1 had a significantly higher MCR (83.9 ± 14.1 mL/min/kg) compared to GCG (40.7 ± 14.3 mL/min/kg) and Ex-4 (10.1 ± 2.5 mL/min/kg) (p < .01 and p < .001 respectively). Ex-4 had a statistically significant longer half-life (35.1 ± 7.4 min) compared to both GCG (3.2 ± 1.7 min) and GLP-1 (1.2 ± 0.4 min) (p < .01 for both GCG and GLP-1). Ex-4 had a statistically significant higher volume of distribution (429.7 ± 164.9 mL/kg) compared to both GCG (146.8 ± 49.6 mL/kg) and GLP-1 (149.7 ± 53.5 mL/kg) (p < .01 for both GCG and GLP-1). Peptide X3 had a statistically significant longer half-life (21.3 ± 3.5 min) compared to both X1 (3.9 ± 0.4 min) and X2 (16.1 ± 2.8 min) (p < .001 for both X1 and X2).

CONCLUSIONS

We present an affordable and easily accessible platform for the measurement of PK parameters of peptides. This novel surgical rat model produces consistent and reproducible results while minimizing animal use.

Cystic adventitial disease of the common femoral vein: A case report

Adventitial cystic disease (ACD) of the common femoral vein is a rare vascular disorder. It becomes more difficult to recognize preoperatively especially when the femoral vein is affected. We report the case of a 62-year-old female patient who presented with a one-month history of painless swelling in her right lower extremity. She had no specific past medical history and no history of trauma, and had a full coagulopathy profile that was negative for any hypercoagulable syndrome. On examination, her lower right leg was significantly swollen with a palpable mass in her right inguinal region. A computerized tomography (CT) with contrast was performed to provide more information and revealed an eccentric compression over the medial wall of the right common femoral vein. During surgical exploration, adventitial cystic mucinous disease was enucleated and the patient underwent femoral exploration, excision of the cysts and reconstruction of iliac femoral vein graft using an artificial blood vessel. The pathological examination confirmed the diagnosis. The patient continued to do well, and she had an unremarkable venous duplex evaluation at her 6-month follow-up. The presentation, investigation, treatment, and pathology of this condition are discussed with a literature review.

Late Stent Graft Infection after the Emergency Endovascular Repair of a Secondary Iliac Artery-Enteric Fistula Treated with Graft Removal and In Situ Aortic Reconstruction Using Femoral Veins

An arterioenteric fistula is a devastating and life-threatening condition that requires urgent treatment. Less-invasive endovascular treatment has emerged as an alternative to conventional open repair, but postoperative graft infection remains a major concern. We herein report a case of late stent graft infection after emergency endovascular repair of a secondary iliac artery-enteric fistula. The patient was a 63-year-old male who presented with a fever, who had undergone successful endovascular stent grafting for a secondary common iliac artery-enteric fistula 29 months prior. The diagnosis of a stent graft infection was confirmed via computed tomography. He underwent graft removal and in situ reconstruction with femoral vein grafts. At 6-month follow-up, the patient is in a good general condition without any symptoms.

Infected iliac artery aneurysm with aortocaval fistula

Case

We report a case of an infected iliac artery aneurysm complicated by an aortocaval fistula.

Outcome

A 74-year-old-man was admitted with fever, chills, general fatigue, and appetite loss. The patient was diagnosed with an infected iliac artery aneurysm, which was controlled with antibiotics preoperatively. During hospitalization, deep vein thrombosis developed with a pulmonary embolism resulting from an aortocaval fistula. The patient was successfully operated on with in situ autologous vein graft reconstruction.

Conclusion

An infected iliac artery aneurysm with aortocaval shunt has rarely been reported. We successfully treated the patient with a combination of appropriate i.v. antibiotics and surgical resection.

Femoral Placement of Totally Implantable Venous Access Ports in Patients with Bilateral Breast Cancer

Purpose: Aim of this study was to determine the rate of complications following femoral placement of totally implantable venous access ports (f-TIVAP) in women with bilateral breast cancer, with a special focus on long-term function, deep vein thrombosis (DVT), and port infection. Methods: 73 patients with bilateral breast cancer treated between October 2000 and January 2013 with placement of an f-TIVAP using a transfemoral approach were retrospectively reviewed. All patients were followed up, and all complications of f-TIVAP were recorded. Results: The median age was 62.5 years (range: 35-86 years). Four patients received f-TIVAP under local anesthesia, and 69 underwent placement under general anesthesia. Mean follow-up was 33.7 months (SD 25.9; range: 0.2-93.5 months). Complications over the entire period of observation included infections in 21 %, DVT in 19 % and catheter occlusion in 12 %. Patients receiving chemotherapy who developed leukopenia were more likely to experience DVT at the access site (p = 0.037). There was a trend towards a higher infection rate when the device was used more often (p = 0.084). Conclusion: Although the rates of complications in the longer term, especially device infections and DVTs, appeared to be relatively high, TIVAP implantation using femoral vein access is recommended in patients with bilateral breast cancer not suitable for cephalic vein cut-down.

Unilateral Double Great Saphenous Vein: A Clinically Significant Case Report

Great saphenous vein (GSV) is the longest vein in the body originating from the dorsum of the foot at medial malleolus to the level of groin skin crease. It is one among the clinically significant superficial veins of the lower limb. Double or duplication of GSV is considered to be one of its rarest variant forms, which might be often mistaken with the accessory saphenous vein. The overall incidence of duplicated GSV is reported to be 1%. We report herein, a unilateral duplication of GSV with its morphological and clinical perspectives. The major clinical complication that is often encountered from its duplication is recurrent incompetence of the GSV, which predisposes varicosity. Therefore, a thorough knowledge of venous anatomy is important for clinicians and sonographers.

Postgraduate educational pictorial review: Ultrasound-guided vascular access

Over the last few years the role of ultrasound has steadily increased and has now an established role in anesthesia and critical care. The various applications of this technology in this field include ultrasound-guided insertion of central lines (internal jugular, subclavian, axillary, femoral) and peripheral venous catheters, arterial line insertion, regional blocks etc. The simple reason of using this technology is “You believe what you see”. In this text we will mainly focus on central line, peripheral venous placement and arterial blood flow patterns under ultrasound guidance.In our institution at KFMC, internal jugular vein cannulation is preferred to cannulation of the subclavian vein because of the higher incidence of pneumothorax and subclavian artery puncture associated with the later. The incidence of carotid artery puncture is higher in children younger than five years than in older children during this procedure. The use of ultrasonography has been shown to increase the success rate and decrease the incidence of complications associated with IJV cannulation in adults.

We will go through a stepwise approach in identifying and confirming the required blood vessels for ultrasound-guided cannulation using B-mode (2D), color flow doppler and Pulse Wave Doppler

The relative position of femoral artery and vein in children under general anesthesia--an ultrasound-guided observational study

BACKGROUND

Femoral artery overlaps femoral vein by varying degrees distal to the inguinal ligament, which may result in difficult venous access and also increases the risk of arterial puncture.

OBJECTIVE

To study the size of femoral vessels and the degree of overlap in children undergoing anesthesia using ultrasound at 1 and 3 cm distal to inguinal ligament.

METHODS

A prospective observational study, 84 children aged <7 years were recruited in six different age groups. An experienced anesthetist identified the femoral vessels and their overlap using ultrasound at two fixed points distal to the inguinal ligament. We also evaluated the correlation of skin puncture site marked as per Advanced Paediatric Life support (APLS) guidance using landmark technique with the ultrasound location of femoral vein beneath the same site.

RESULTS

The percentage of children with overlap of femoral vein by femoral artery increases from 5% to 60% as we move distal to the inguinal ligament. At 3 cm distal to inguinal ligament, the incidence of any degree of overlap was statistically significant (P < 0.05) in children <5 years. In 80% of children, the femoral vein was located by ultrasound beneath the skin puncture site as recommended by APLS guidelines.

CONCLUSION

A significant increase in femoral vein overlap occurs as we move distal to the inguinal ligament. There is one in five chance of failure to locate femoral vein by landmark technique. In children <2 years, a high approach to femoral vein cannulation under ultrasound guidance is recommended.

Ultrasonographic anatomic variations of the major veins in paediatric patients

BACKGROUND

The aim of our study was to describe the anatomic relationships in internal jugular (IJV), subclavian (SCV), and femoral (FV) vein sites.

METHODS

One hundred and forty-two children had a two-dimensional (2D) ultrasound (US) evaluation of IJV, SCV, and FV sites. They were enrolled according to their age: 0-1 month old (n=9), 1 month old to 2 yr old (n=61), 2-6 yr old (n=22), 6-12 yr old (n=32), and 12-18 yr old (n=18).

RESULTS

We found about 7.7% variation for the IJV. The most common anatomic variations were a lateral (nine children) or anterior (nine children) position of the IJV to the carotid artery. Regardless of the age category, about 9.8% of the anatomic variations were found for the FV. The most common anatomic variation in our study was that the FV ran anteromedially to the femoral artery (17 children). Anatomic variation of the SCV, regardless of age category, was about 7.4%. The most common anatomic variation was the SCV, which ran medially (10 children) to the subclavian artery.

CONCLUSIONS

The relevant percentages of anatomic variations obtained for all these areas support at least a systematic US screening before attempting to obtain central venous access, ideally using a US-guided technique.

The dynamic function of the atrial diastole of the heart and motion of venous valves in humans

This study demonstrates dynamic function of atrial diastole for the first time in the history of medicine, following the revelation of ventricular function by Sir William Harvey. This study consists of two parts. First part is the study of humans and the discovery of the rhythmic opening and closing of venous valves in the femoral vein segment during each cardiac cycle under fluoroscopy. Its relationship to the right atrial diastole is discussed. Second part is an experimental model developed in a dog's heart. Experiments are conducted in an erect posture, in which the right atrium is partially and totally isolated physically and/or functionally. The right atrium was found to function as a suction pump, readily demonstrated on graphic curves by voluntary stretching of muscle fibers of the empty atrium, creating considerable negative pressure during diastolic function, and responsible for venous return to the heart. Motive forces in the venous return are common knowledge in present medical literature, but are limited to respiration and skeletal muscle contraction of the extremities. The discovery of the right atrium as a suction force due to stretching of muscle fibers during diastolic function, thereby creating negative pressure, represents a departure from the currently accepted paradigm established by Sir William Harvey (1576-1652), with the heart as an organ functioning solely by contraction of its chambers. This is the first time since then a fundamental new discovery concerning cardiac mechanical function has been made utilizing experimental evidence.