the coronary venous system: an alternative route of access to the myocardium

The purpose of this paper is to review what is known regarding the anatomy of the coronary venous system, and the commonly used techniques for its selective catheterization. This is with regard to new innovative percutaneous techniques that have led to a burgeoning interest in methods of access to the coronary veins. Anatomical variation in the epicardial system exists, and the additional role of the Thebesian venous system may have important clinical implications. Catheter-based techniques for coronary vein retroperfusion may provide alternative treatment modalities for patients with no option for revascularization using conventional techniques. Furthermore, the use of the coronary venous system has now been reported for the regional delivery of drugs, cells and genes to protect and/or regenerate the myocardium. Finally, the use of the coronary venous system by the cardiac electrophysiologist is reviewed.     

An alternative to continuous subcutaneous infusion of desferrioxamine in thalassaemic patients

Sixteen patients with thalassaemia major were treated with subcutaneous desferrioxamine (DF) 50 mg/kg/d, 5 consecutive days a week, for 8 weeks. Every other week the total dose was administered by 12 h infusion pump or by rapid injection of the same dose (25 × 2 mg/kg) twice a day. The two methods of DF administration produced no significant differences in urinary iron excretion. No significant changes in serum ferritin levels were observed at the end of the study. Compared with continuous infusion, rapid injection is equally efficacious, does not induce serious side-effects, is better accepted by the patients, and can improve their compliance to the iron-chelating therapy.     

Calculation of infusion rates of vasoactive substances

We present a framework for understanding calculations of continuous infusions of vasoactive substances. Several simplified methods for establishing initial concentrations and infusion rates of drug are derived, their applicability is discussed, and examples are given.     

Technical limitations in the rapid infusion of intravenous fluids

We compared fluid delivery, both in vitro and in vivo, using various combinations of fluid sets and intravenous catheters. Administration sets were a minidrip, a maxidrip, and a blood infusion set. The catheters included 14-, 16-, 18-, and 20-gauge short catheters, 16- and 19-gauge long catheters, and an 8 French catheter introducer for flow-directed pulmonary arterial lines. Blood infusion tubing alone delivered fluid at 3.12 +/- .07 mL/second, significantly faster than either the maxidrip (2.59 +/- .06, P less than .01) or the minidrip (0.56 +/- .02, P less than .001). The 8 French introducer provided no additional resistance to the flow of the maxidrip or blood infusion set when used in combination with an anesthesia extension. All the other catheters slowed flow significantly. Percutaneous insertion of an 8 French catheter introducer connected to blood administration tubing allows for rapid delivery of fluids and for subsequent insertion of a Swan-Ganz catheter, which is often necessary in critically ill patients.     

Transbrachial hepatic arterial chemotherapy using an implanted infusion pump

Two patients with hepatic metastases from colonic cancer were treated with hepatic arterial FUDR using an innovative drug infusion system. The two patients reported underwent transbrachial hepatic artery catheterization with a 5 French polyethylene catheter. This catheter was amputated just distal to its exit from the brachial artery and attached to a totally implantable, percutaneously refillable drug infusion pump placed in the infraclavicular position. The patients received FUDR at flow rates of 3–4 ml/day. The pumps were refilled weekly by percutaneous injection. One patient was treated for seven weeks, and another for ten weeks without technical difficulties. This innovative approach offers marked improvement in comfort and convenience for patients who are candidates for long-term hepatic artery chemotherapy, and avoids the morbidity of laparotomy for direct hepatic arterial catheterization.     

持续血管腔内肝素灌注治疗老年急性下肢缺血的效果分析

目的评价持续血管腔内肝素灌注疗法对老年急性下肢缺血(ALI)患者的安全性及效果。方法入选2015年7月至2017年2月陆军总医院血管外科ALI接受腔内治疗的老年患者67例。按手术方式将患者分为标准导管溶栓组(对照组,n=35)和持续腔内肝素输注组(肝素组,n=32)。对照组患者应用尿激酶以100万IU/d持续导管内泵入,且皮下应用低分子肝素100 IU/(kg·12 h),肝素组患者应用肝素以18 U/(kg·h)泵入。术后随访患者30 d、3个月及1年。记录2组患者一般资料、缺血严重程度分级、踝肱指数(ABI)、术中持续治疗时间、完全血栓溶解例数、并发症,并进行组间比较。采用SPSS23.0软件对数据进行统计分析。根据数据类型,组间比较采用t检验或χ~2检验。结果 2组患者一般资料及缺血严重程度分级差异均无统计学意义(P0.05)。与对照组比较,肝素组患者持续治疗时间显著增加[(53.24±10.49)vs(35.67±9.25)min,P=0.010],大出血率[0.0%(0/32)vs 11.4%(4/35),P=0.001]显著下降。治疗后,2组完全血栓溶解率、ABI增加值、心血管事件发生率、30 d截肢率、30 d死亡率、随访1年免于截肢率比较,差异无统计学意义(P0.05)。结论持续血管腔内肝素输注治疗可以获得良好的近期效果,大出血率明显降低,是高出血风险ALI老年患者微创治疗的一种安全、有效的方法。     

Preferential short cut or alternative route: the transaxillary access for transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) has gained widespread acceptance as a treatment option for patients at high risk for conventional aortic valve replacement. The most commonly used access site for TAVI is the common femoral artery. Yet, in a significant number of patients the transfemoral access is not suitable due to peripheral vascular disease of the lower extremity. In these cases the transaxillary approach can serve as an alternative implantation route. By considering the anatomical requirements and providing an adequate endovascular “safety-net” during the procedure the transaxillary TAVI approach results in excellent procedural and clinical outcome. However, whether the transaxillary access for TAVI is superior to other non-transfemoral approaches (e.g., transapical or direct aortic) needs to be studied in the future in a prospective randomized trial.     

Evaluation of NovoRapid infusion as a treatment option in the management of diabetic ketoacidosis

This study evaluates the clinical efficacy and safety of NovoRapid (insulin aspart) compared to Actrapid? (human neutral insulin) for diabetic ketoacidosis (DKA). In this retrospective study involving 40 patients, no statistically significant differences were observed between biochemical variables, infusion duration or complications in patients treated with insulin aspart or human neutral insulin. These results support the use of insulin aspart as an effective and safe alternative to human neutral insulin in DKA.     

Insulin infusion set: the achilles heel of continuous subcutaneous insulin infusion

Continuous subcutaneous insulin infusion from an insulin pump depends on reliable transfer of the pumped insulin to the subcutaneous insulin depot by means of an insulin infusion set (IIS). Despite their widespread use, the published knowledge about IISs and related issues regarding the impact of placement and wear time on insulin absorption/insulin action is relatively small. We also have to acknowledge that our knowledge is limited with regard to how often patients encounter issues with IISs. Reading pump wearer blogs, for instance, suggests that these are a frequent source of trouble. There are no prospective clinical studies available on current IIS and insulin formulations that provide representative data on the type and frequency of issues with infusion sets. The introduction of new IISs and patch pumps may foster a reassessment of available products and of patient problems related to their use. The aim of this review is to summarize the current knowledge and recommendations about IISs and to highlight potential directions of IIS development in order to make insulin absorption safer and more efficient.     

Outside of the intensive care unit: the safety and effectiveness of an insulin-dextrose infusion protocol

A review of patients who were on an insulin-dextrose (I-D) infusion protocol in general hospital wards over a 6-month period was conducted to compare glycaemic control before, during and following I-D infusion. Among the 34 cases identified, blood glucose levels during the period of I-D infusion were significantly better than those before or after I-D infusion. This I-D infusion protocol was shown to be effective and safe in maintaining good glycaemic control for patients outside intensive care unit.     

老年2型糖尿病患者胰岛素泵的临床应用

目的 探讨连续皮下胰岛素输注(CSII)在老年2型糖尿病患者中的应用. 方法 老年组415例,非老年组461例,均进行短期CSII强化治疗,比较两组应用CSII的差别和低血糖发生率. 结果 老年组和非老年组血糖达标时间分别为(6.3±2.1)d和(6.8±2.6)d.胰岛素日用量分别为(0.63±0.24)U/kg和(0.69±0.25)U/kg,差异均无统计学意义;老年组夜间基础率较低,且夜间低血糖发生率较高.分别为0.08次/例和0.04次/例. 结论 CSII能有效控制老年2型糖尿病患者的血糖,但应注意减少晚餐前大剂量和夜间的基础率,从而降低低血糖风险.     

Pharmacodynamic effects of clopidogrel in pediatric cardiac patients: A comparative study of platelet aggregation response

Little data on pediatric percent platelet aggregation (%PA) exist in the literature, particularly in cardiac patients and in response to clopidogrel. The objectives were to estimate the %PA range expected in pediatric patients and to measure the clopidogrel effect on %PA in the PICOLO (Platelet Inhibition in Children on Clopidogrel) trial. To estimate a neonatal/infant %PA response range, %PA induced by 5?µM adenosine diphosphate (ADP) was assessed using light transmission aggregometry in 16?cord and 11 normal adult blood samples and prior to clopidogrel therapy in 49 neonatal and 49 infant/toddler cardiac patients enrolled in PICOLO. The %PA induced by 5?µM thrombin receptor-activating peptide (TRAP) was also assessed for 10 neonates and 21 infants/toddlers enrolled in PICOLO and compared with 11 adult samples. Percent inhibition of platelet aggregation (%IPA) induced by 5?µM ADP at steady-state clopidogrel levels was assessed in 33 neonates and 39 infants/toddlers. ADP-induced %PA was lowest in cord blood samples, intermediate in study neonates and infants/toddlers, and highest in adults. Similarly, TRAP-induced platelet aggregation was lower in neonates and infants/toddlers than adults. For all groups, %PA and %IPA were highly variable, with 11% of neonates and 13% of infants/toddlers showing <10% IPA. In conclusion, ADP- and TRAP-induced %PA is lower in pediatric cardiac patients than normal adults, but highly variable in both. The lower baseline %PA may explain why the pediatric clopidogrel dose providing 30–50% IPA (0.20?mg/kg/day) is lower than a simple weight-based extrapolation of the adult dose (75?mg/day) providing similar inhibition.     

经皮射频消融治疗肝脏恶性肿瘤中辅助注入等渗盐水技术的应用价值

目的 探讨经皮射频消融治疗肝脏外周性恶性肿瘤中辅助注入等渗盐水技术以分离肿瘤与外周脏器结构的应用价值.方法 对24例肝脏外周性恶性肿瘤,采用超声引导下穿刺注入等渗盐水的辅助技术,分离肝脏肿瘤局部区域和邻近脏器,完成经皮射频消融治疗.观察术后常见不良反应及其疗效.结果 24例肝脏恶性肿瘤中邻近右肾6例、邻近结肠6例、邻近胃5例、邻近心膈4例、邻近胆囊3例.23例在超声引导下采用22G细针经由肝组织穿刺达肿瘤近旁肝外,注入等渗盐水80 ～ 390 ml,形成0.8 ～ 2.5 cm盐水分隔带,继而完成经皮根治性射频消融治疗.其中5例邻近胃、结肠的肿瘤在消融中需要继续辅助注入等渗盐水.另1例由于有手术切除病史,局部粘连不能分离,辅助注入等渗盐水未能成功,行姑息射频消融治疗.术后平均住院4d,无一例发生周围脏器结构损伤、出血,无一例严重并发症及相关死亡.术后1个月肝脏增强CT/MRI检查显示,辅助注入等渗盐水成功的23例中22例获得完全消融,有效率为95.7％ (22/23);无一例针道转移.结论 邻近肝脏外缘的恶性肿瘤经皮射频消融治疗,采用辅助注入等渗盐水策略,使癌灶与重要邻近脏器分隔,可安全有效地消融肿瘤,从而拓展经皮消融治疗的适应证.     

TUPKR—Bt联合髂内动脉灌注化疗治疗多发性膀胱癌临床观察

目的探讨经尿道双极等离子体汽化电切术（TUPKR-Bt）联合髂内动脉灌注化疗治疗多发性膀胱癌的疗效。方法对25例多发性膀胱癌患者行TUPKR-Bt联合髂内动脉灌注化疗,观察手术情况及疗效。结果膀胱肿瘤切除率100％,手术时间20～60min,术中未输血;2a内复发6例,元明显并发症。结论TUPKR—Bt联合髂内动脉化疗治疗多发性膀胱癌,操作简单、损伤小、出血少、术后恢复快,适用于不能或不愿行膀胱全切术者。     

地西他滨加改良CAG方案联合人白细胞抗原半相合淋巴细胞输注治疗老年急性髓系白血病缓解1例

骨髓增生异常综合征（MDS）是一组造血干细胞异常的恶性克隆性疾病,可转化为急性髓系白血病（AML）。MDS转化为AML时,化疗常常不能有效杀灭或抑制肿瘤细胞,且骨髓抑制相当严重,化疗后骨髓抑制期的出血、感染常成为患者临床死亡主要原因。因此,继发于MDS的AML患者预后差,治疗困难。近期笔者应用地西他滨加阿糖胞苷、阿克拉霉素和粒细胞集落刺激因子（CAG）联合半相合淋巴细胞回输,成功诱导缓解1例继发于MDS的AML,并显著缩短化疗后的骨髓抑制期,获得良好疗效。     

初诊与非初诊2型糖尿病患者胰岛素泵的应用

目的探讨短期持续皮下胰岛素输注（CSⅡ）对明显高血糖的初诊和非初诊2型糖尿病（T2DM）患者的应用方法。方法T2DM患者1276例,其中初诊组479例,非初诊组797例,观察两组血糖达标时间、胰岛素用量、低血糖的发生率及其相关因素。结果CSⅡ治疗使初诊和非初诊糖尿病患者血糖达标时间分别为4．76±2．56天和5．87±2．69天,初诊组达标较快（P〈0．05）,两组胰岛素用量相似,平均每天0．69±0．31U／kg,基础用量占全天用量的61％,但初诊组达标后胰岛素减量较早,降幅较大（P〈0．05）;两组低血糖的发生率相差不多（P〉0．05）。结论CSII治疗于高糖急性期的初诊和非初诊患者都能迅速减轻胰岛素抵抗,改善B细胞功能。     

Safety of continuous subcutaneous insulin infusion: Metabolic deterioration and glycaemic autoregulation after deliberate cessation of infusion

Summary To assess the rate of metabolic deterioration and potential risks of failure of continuous subcutaneous insulin infusion during basal insulin delivery, we deliberately stopped infusion in nine insulin dependent diabetics. Plasma glucose, blood 3-hydroxybutyrate and plasma free insulin were measured for 9 h whilst the patients remained supine and fasting. Mean plasma glucose remained unchanged at normal fasting levels for the first hour, then rose to plateau at about 10 mmol/l until the end of the experiment. The final plateau level of glucose varied from patient to patient; two C-peptide secreting diabetics plateaued at low glucose levels. In contrast, blood 3-hydroxybutyrate rose progressively, without plateauing. Plasma free insulin concentrations fell during the withdrawal period and there was a highly significant negative correlation between free insulin and 3-hydroxybutyrate. No patient was more than mildly unwell after 9 h of insulin deprivation. We conclude that under these experimental conditions there is glycaemic autoregulation and that ketones may sometimes be a more appropriate monitor of insulin deficiency or loss of diabetic control than is glucose. Accidental failure of continuous subcutaneous insulin infusion and interruption of basal delivery in resting and fasting diabetics will probably not cause dangerous metabolic or clinical deterioration.     

Tracker tricks: Applications of a novel infusion catheter in coronary intervention

The “Tracker” is a highly trackable and readily exchangeable catheter which can be used to facilitate coronary angioplasty in situations where the guide wire is unable to cross the lesion and is buckling under pressure. In addition it is also useful in assessing the severity of borderline coronary artery stenoses and for local infusion therapy.