Introducers and protective sleeves may increase thrombogenicity of pulmonary artery catheters

OBJECTIVE: To investigate the cause of clot formation on the surface of non-heparin coated/bonded pulmonary artery catheters. DESIGN: A controlled, unblinded, open-labeled study. SETTING: Research laboratory at Tulane School of Medicine, New Orleans, LA. PARTICIPANTS: Rhesus and African Green monkeys. INTERVENTIONS: Anesthetized monkeys (n = 24) were assigned to one of two groups. The first group (group A) had a pulmonary artery catheter inserted into a femoral vein through a cutdown without passage through an introducer or protective sleeve before insertion. In the second group (group B), the pulmonary artery catheter was passed through an introducer and protective sleeve before insertion in the femoral vein. After the study, the animals were returned to the primate breeding colony. Laboratory values were measured for each animal, and electron micrographs were taken of selected pulmonary artery catheters before and after passage of these catheters through the introducer sheath and/or protective sleeve. MEASUREMENTS AND MAIN RESULTS: Between the two groups, there was a significant difference in fibrinogen level, but not in hematocrit, prothrombin time, partial thromboplastin time, and platelet count. Clots were visible on 11 of 12 catheters in group B, which was statistically significant (p < 0.01), compared with only 3 of 12 catheters in group A. The average clot weight was 0.014+/-0.014 g in group A (range, 0.00 to 0.170 g), which was statistically significant (p < 0.01), compared with 0.216 < 0.058 g in group B (range, 0.000 to 0.620 g). Electron micrographs taken after catheters were passed through an introducer and/or protective sleeve showed that both significantly altered the surface of the catheter. The surface of the catheter was smooth and homogenous in appearance before insertion. Conversely, both the introducer and protective sleeve produced marked furrowing and a nodular appearance on the catheter surface, as shown by electron micrographs. CONCLUSION: The data from this study show that the incidence of clot formation and amount of clot formed on the surface of non-heparin-coated pulmonary artery catheters are significantly greater after passage through an introducer and/or protective sleeve. The electron micrographs also show that both introducers and protective sleeves abraded the catheters and were associated with thrombus formation on the catheter. Designing less traumatic valves on these devices is warranted and recommended.     

Treatment of air embolism with a special pulmonary artery catheter introducer sheath in sitting dogs

The treatment of venous air embolism by aspiration from central venous catheters is well established. However, some anesthesiologists prefer to use a pulmonary artery catheter to monitor patients undergoing a neurosurgical procedure in the sitting position. While offering certain advantages, pulmonary artery catheters may be of limited use in the treatment of venous air embolism because the small diameter of the proximal port is poorly suited for efficient air aspiration. The authors have designed a special pulmonary artery catheter introducer sheath which can be positioned by intravascular electrocardiography to provide an efficient and effective means of air aspiration, while permitting the simultaneous use of a pulmonary artery catheter for pressure monitoring. The flow characteristics of this sheath, with and without side holes, were tested in vitro by measuring the time required to aspirate 50 ml of blood. The introducer sheath was compared to a Sorenson CVP catheter, a Bunegin-Albin Air Aspiration CVP Catheter, and the proximal port of a pulmonary artery catheter. The rank order of flow rate was: Bunegin-Albin CVP greater than introducer sheath without side holes = introducer sheath with side holes greater than Sorenson CVP greater than pulmonary artery catheter (P = 0.0001). The introducer sheath was then compared to a pulmonary artery catheter for the treatment of a 4 ml/kg venous air embolism in sitting, anesthetized dogs. The mean proportion of air retrieved by the sheath with or without side holes, 57% and 80%, respectively, was significantly greater than that retrieved by simultaneous aspiration of atrial and distal ports of the pulmonary artery catheter, 16% (P = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Management of an unusual complication during placement of a pulmonary artery catheter

We describe an unusual complication during flotation of a pulmonary artery catheter through a preexisting percutaneous introducer sheath. A malfunctioning pulmonary artery catheter, which was placed through an introducer sheath in the right internal jugular vein, was removed. Attempts at repositioning a second pulmonary artery catheter met with resistance, and we were unable to either advance or withdraw it. Chest radiograph showed a bent introducer sheath going from the right internal jugular vein into the right subclavian vein and a pulmonary artery catheter loop. Under continuous fluoroscopy, the introducer sheath and the pulmonary artery catheter were withdrawn as one unit, which resulted in relaxation of the acute angulation in the introducer sheath and allowed the pulmonary artery catheter to unfold, thus facilitating their complete extraction. We conclude that complications may occur during placement of a pulmonary artery catheter through a well positioned introducer sheath and that fluoroscopy is a valuable tool for safe management of such a complication.     

Nicardipine or nitroglycerin in patients with failed percutaneous coronary angioplasty: effect on myocardial diastolic function

OBJECTIVE: To evaluate whether intracoronary vasodilators can improve diastolic function in 32 patients with failed percutaneous transluminal coronary angioplasty (PTCA). DESIGN: Clinical trial. SETTING: Single-institution, academic hospital. PARTICIPANTS: Failed PTCA patients undergoing emergency coronary artery bypass grafting surgery. INTERVENTIONS: Patients were divided into 2 groups: group A received 0.1 mg of intracoronary nicardipine, and group B received 20 microg of intracoronary nitroglycerin. Both drugs were administrated via a coronary dilatation perfusion catheter inserted in the catheterization laboratory by the cardiologist. Subsequently, they were continuously infused via the side port of the introducer of the pulmonary artery catheter and titrated to keep systolic blood pressure at about two thirds of the control value. Transesophageal echocardiography (Power Vision/6000, 9-mm 5MHZ Probe; Toshiba, Elmsford, NY) was used in this study. MEASUREMENTS AND MAIN RESULTS: Left ventricular ejection fraction, cardiac index, tissue Doppler imaging velocity of the left ventricle and mitral annulus, and troponin levels were measured before and after administration of the 2 vasodilators and after cardiopulmonary bypass. Diastolic dysfunction was found preoperatively in all the patients and responded only to intracoronary nicardipine. Ea of mitral annulus velocity significantly increased in group A patients from 7.5 +/- 0.02 to 11.8 +/- 0.01 (p < 0.005) and decreased in group B patients from 8.0 +/- 0.03 to 7.5 +/- 0.02 after nicardipine or nitroglycerin administration. Left ventricular ejection fraction and cardiac index increased significantly (p < 0.005) only after nicardipine administration. Troponin levels were significantly lower in group A than in group B patients (p < 0.005). CONCLUSION: Intracoronary nicardipine improves diastolic function and myocardial flow velocity in patients with failed PTCA undergoing emergency coronary artery bypass graft surgery.     

三种扩皮送鞘法在肿瘤患者PICC置管中的应用效果观察

目的 探讨三种扩皮送鞘法在超声引导下改良塞丁格技术PICC置管中的应用效果,为临床操作提供参考。方法 将384例肿瘤科行PICC置管患者随机分为A、B、C三组,各128例。A组采用微插管鞘中的扩张器与传统穿刺针的外鞘组装后直接扩张穿刺点后送鞘的钝性分离法;B组采用扩张器与导管鞘组件扩张穿刺点后送鞘的钝性分离法;C组采用扩皮刀扩张穿刺点后推进血管鞘的方法。比较三组患者一次性送鞘成功率、置管后24 h穿刺点渗血情况及置管术中疼痛评分。结果 A组和C组一次性送鞘成功率100%,B组一次性送鞘成功率95.31%。三组穿刺点渗血情况、局部渗液发生率比较,差异有统计学意义（均P<0.01）,A组和B组显著低于C组。A组和B组术中疼痛评分低于C组。结论 采用微插管鞘中的扩张器与传统穿刺针的外鞘组装后直接扩张穿刺点后送鞘的钝性分离法行PICC置管,不仅一次性送鞘成功率高,且患者置管术中疼痛及术后穿刺点局部渗血渗液等并发症发生率较低。     

The Effect of Urethral Introducer Tip Catheters on the Incidence of Urinary Tract Infection Outcomes in Spinal Cord Injured Patients

Purpose

We attempted to determine whether an introducer tip catheter reduces urinary tract infection in spinal cord injured patients on intermittent catheterization.

Materials and Methods

The introducer tip catheter bypasses the colonized 1.5 cm. of the distal urethra. Enrolled patients were prospectively entered into the study in alternate groups depending on whether they reflex voided: group 1-on intermittent catheterization with the introducer tip catheter but not voiding spontaneously or wearing an external urinary catheter, group 2-same as group 1 but using a nonintroducer tip catheter; group 3-on intermittent catheterization with the introducer tip catheter, voiding by reflex and wearing an external urinary catheter, and group 4-same as group 3 but using a nonintroducer tip catheter.

Results

Statistical significance was shown when comparing patients using versus not using the introducer tip catheter regardless of whether an external urinary catheter was worn (p = 0.0121). A greater difference was noted between patients using and not using the introducer tip catheter in the intermittent catheterization only group (p = 0.0093).

Conclusions

The introducer tip catheter decreased urinary tract infections in hospitalized men with spinal cord injury on intermittent catheterization.     

A microsurgical technique for catheter insertion in the rat femoral artery

Purpose:To modify a surgical catheterization method using the bent needle introducer in small animals.Methods:Eight-week-old male Lewis rats were used in the study. A needle introducer was created by bending a 21G injection needle at 45°. The bent needle introducer was used for catheter insertion into the left femoral artery of the rats under anesthesia. As a control, a catheter was directly inserted into the blood vessel without the introducer. The insertion time of each method was measured. Blood pressure and heart rate were measured 24 h after catheter insertion using the telemetry system.Results:Using the introducer, the catheter was successfully inserted within a short time in all rats. Without the introducer, a longer duration was required for catheter insertion. The frequency of the insertion with no catheter-based errors with the introducer tended to be higher than that without the introducer. The mean arterial pressure and heart rate 24 h after catheter insertion in each group were almost the same.Conclusions:We developed a surgical catheterization method using the introducer in small animals. This could potentially reduce the frequency of the insertion with catheter-based errors and insertion time.Key words: Catheterization, Microsurgery, Telemetry, Vital Signs, Rats     

A pulmonary artery catheter does not affect the intravascular electrocardiogram from the air aspiration introducer sheath

The air aspiration introducer sheath allows the use of a pulmonary artery (PA) catheter for monitoring during sitting neurosurgical procedures while providing a means of air aspiration that is more efficient than aspiration from the proximal and distal ports of the PA catheter alone. To place the 25-cm long introducer sheath safely into the right atrium, the PA catheter should be positioned first and used as a guide for the introducer sheath, which is then advanced into the atrium and positioned by observation of the intravascular electrocardiogram (IVECG). Placement of the introducer sheath with the IVECG has been described previously without a PA catheter in the lumen of the introducer sheath. In this study, performed in dogs, we have demonstrated that the presence of a PA catheter in the lumen of the introducer sheath does not affect the IVECG recorded from the introducer sheath.     

Insufficient length of pulmonary artery introducer in an obese patient

A 38-year-old, morbidly obese woman underwent surgery for debridement of necrotizing fasciitis of the abdominal wall. A pulmonary artery catheter was placed because of increasing fluid requirements. Despite multiple debridements and fluid resuscitation, the patient exhibited severe systemic inflammatory response. It was discovered that fluid placed in the introducer had extravasated into the subcutaneous tissues. In this obese patient, the pulmonary artery introducer was too short.     

Left superior vena cava: a vascular abnormality discovered following pulmonary artery catheterization

Purpose

This report deals with the case of a patient who presented persistence of left superior vena cava (LSVC). This disorder was discovered following placement of a catheter in pulmonary artery via the left subclavian vein.

Clinical features

The patient was a 67-yr-old woman who, while in the intensive care unit after undergoing coronary revascularization with extracorporeal circulation, required pulmonary artery catheterization to guide resuscitation. Placement of the catheter proved to be difficult as the advance of the catheter was impeded. A normal pulmonary artery pressure wave was eventually detected at a distance of approximately 70 cm. Chest x-ray showed a catheter route suggestive of persistent LSVC.

Conclusion

A diagnosis of persistent LSVC should be considered whenever there appears to be some obstacle to central venous or pulmonary artery catheterization, especially in patients with congenital heart disease, since this disorder can have important clinical consequences.     

Adjunctive renal artery revascularization during juxtarenal and suprarenal abdominal aortic aneurysm repairs

Background

We report a 15-year experience with renal artery revascularization during abdominal aortic aneurysm (AAA) repair.

Methods

AAA repairs from 1994 to 2009 were reviewed. Postoperative complications, renal function, patency, and survival in patients undergoing renal artery revascularization were evaluated and compared with a control group of patients undergoing juxtarenal AAA repairs not requiring renal artery revascularization.

Results

Sixty patients underwent renal artery revascularization during AAA repair. Transient postoperative renal insufficiency occurred in 20 patients. Temporary hemodialysis was required in 3 patients, with none requiring permanent hemodialysis. There was 1 postoperative death. There was 1 renal artery revascularization failure at 1 month but no other graft failures at 12 months median follow-up evaluation (1-year patency, 97%). In comparison with the control group, transient renal insufficiency and pulmonary complications (33.3% vs 19.8%; P = .042) were more common with renal artery revascularization, with no differences in long-term renal complications or mortality.

Conclusions

Renal artery revascularization can be performed during AAA repair with excellent patency and minimal morbidity.     

Magnetic resonance imaging angiography in patency evaluation of bronchial artery revascularization grafts

In this report we present our experience of non-invasive magnetic resonance imaging (MR) angiography and selective catheter angiography in assessing the patency of bronchial artery revascularization grafts after an en bloc double-lung and heart-lung transplantation. We studied 8 patients who had undergone pulmonary transplantation with direct bronchial artery revascularization. Catheter angiography was performed 10 days to 63 months postoperatively. MR angiography was performed within 24 h of the catheter procedure and the results were compared with the findings from catheter angiography. Catheter angiography showed the bronchial revascularization graft to be patent in 6 patients and occluded in 2. At MR angiography, the patency of bronchial artery revascularization grafts was reliably identified in 7 of the 8 patients. One patient had inadequate image quality because of void artefacts caused by haemostatic clips. It is concluded that MR angiography is a reliable method for assessing the patency of bronchial artery revascularization grafts.     

Magnetic Resonance Imaging Angiography in Patency Evaluation of Bronchial Artery Revascularization Grafts

In this report we present our experience of non-invasive magnetic resonance imaging (MR) angiography and selective catheter angiography in assessing the patency of bronchial artery revascularization grafts after an en bloc double-lung and heart-lung transplantation. We studied 8 patients who had undergone pulmonary transplantation with direct bronchial artery revascularization. Catheter angiography was performed 10 days to 63 months postoperatively. MR angiography was performed within 24 h of the catheter procedure and the results were compared with the findings from catheter angiography. Catheter angiography showed the bronchial revascularization graft to be patent in 6 patients and occluded in 2. At MR angiography, the patency of bronchial artery revascularization grafts was reliably identified in 7 of the 8 patients. One patient had inadequate image quality because of void artefacts caused by haemostatic clips. It is concluded that MR angiography is a reliable method for assessing the patency of bronchial artery revascularization grafts.     

The patient's position influences the incidence of dysrhythmias during pulmonary artery catheterization

To determine the influence of a patient's position on the incidence of dysrhythmias during pulmonary artery catheterization, 34 adult patients scheduled for elective coronary artery bypass graft surgery and pulmonary artery catheterization were studied. All introducers were inserted via the right internal jugular vein using the Seldinger technique with the patient in the Trendelenburg position. For each patient, the pulmonary artery catheter was advanced twice: once while the patient was in the Trendelenburg (T) position with a 5-10 degrees head-down tilt and another with a 5 degrees head-up and right lateral tilt (R) position. In 13 of the 68 pulmonary artery catheter passages, no dysrhythmias were noted. In 13 patients, a change in dysrhythmia classification was noted between the two positions. In 11 of the 13 patients, the dysrhythmia classification changed from malignant in the Trendelenburg position to benign or absent in the right lateral tilt position. Although the incidence of dysrhythmias was similar in both groups, the Trendelenburg position was associated with a significantly higher incidence of malignant dysrhythmias than the right tilt position (P less than 0.05). The authors conclude that the head-up and right lateral tilt position appears superior to the Trendelenburg position for passage of the pulmonary artery catheter in the awake patient scheduled for elective coronary bypass surgery.     

Intraoperative angiography and temporary balloon occlusion of the basilar artery as an adjunct to surgical clipping: technical note.

The direct surgical treatment of intracranial aneurysms is not always possible, especially in posterior circulation aneurysms. This is usually because of their complex anatomy and location next to the skull base and brain stem, where proximal vascular control is usually not attainable. Four patients at our institution underwent intraoperative transfemoral catheterization of the basilar artery with a nondetectable endovascular balloon for proximal control of the basilar artery. The flow control in the basilar artery was excellent and facilitated the surgery. Before surgery, each patient underwent the placement of a 10-cm 8-French femoral introducer sheath and were taken to the operating room where they were placed in a supine position and a subtemporal or pterional craniotomy was performed. After the initial exposure and before aneurysm manipulation, a nondetachable silicone balloon catheter was passed through an introducer catheter and was placed into the rostral basilar artery, using flow direction, microguidewires, and angiographic "road-mapping" techniques. In two patients, temporary basilar occlusion was used to collapse the aneurysm and to facilitate clip placement. In the third patient, intraoperative aneurysm rupture occurred and was controlled by temporary basilar artery occlusion. Using intraoperative angiography, complete aneurysm obliteration and vessel patency was confirmed in all four patients. All patients made a complete recovery except for initial postoperative third nerve palsies in three patients. This technique achieves intraoperative control of the basilar artery proximal to an aneurysm by the use of a nondetachable occlusive balloon in the basilar artery. An added benefit is the ease with which intraoperative angiography can be obtained in this context.(ABSTRACT TRUNCATED AT 250 WORDS)     

Unusual positioning of a central venous catheter

Central venous cannulation, with or without a flow-directed pulmonary artery catheter, is commonly performed in patients undergoing cardiac surgery to measure central filling pressure and cardiac output, and to administer medications and fluids. The complications of central venous cannulation are numerous and include malposition, arterial puncture, pneumothorax, hemothorax, chylothorax, extravasation of infusate, thrombophlebitis, and infection. We describe a single-lumen catheter that was placed through the hemostatic valve of a 9F percutaneous introducer, which inadvertently entered the left internal mammary (internal thoracic) vein. The current case is unique in that it was diagnosed by visualization of the catheter during surgical dissection.     

Hemodynamic responses to etomidate on induction of anesthesia in pediatric patients

Etomidate is often used for inducing anesthesia in patients who have limited hemodynamic reserve. Using invasive hemodynamic monitoring, we studied the acute effects of a bolus of etomidate during induction of anesthesia in children. Twelve children undergoing cardiac catheterization were studied (mean age, 9.2 +/- 4.8 yr; mean weight, 33.4 +/- 15.4 kg); catheterization procedures included device closure of secundum atrial septal defects (n = 7) and radiofrequency catheter ablation procedures for supraventricular tachycardia (n = 5). Using IV sedation, a balloon-tipped pulmonary artery catheter was placed to measure intracardiac and pulmonary artery pressures and oxygen saturations. Baseline measurements were recorded and then repeated after a bolus of IV etomidate (0.3 mg/kg). For the entire group, no significant changes in right atrial, aortic, or pulmonary artery pressure, oxygen saturations, calculated Qp:Qs ratio or systemic or pulmonary vascular resistance were detected after the bolus dose of etomidate. The lack of clinically significant hemodynamic changes after etomidate administration supports the clinical impression that etomidate is safe in children. Further research is needed to determine the hemodynamic profile of etomidate in neonates and in pediatric patients with severe ventricular dysfunction and pulmonary hypertension.     

A clinical study of thrombus formation associated with central venous catheterization

Septic complication is one of the major problems associated with central venous catheterization. Thrombi produced around a catheter are regarded to a predisposing factor. However, few reports have focused on thrombus formation in clinical settings. We studied prospectively thrombus formation associated with central venous catheterization in 56 patients. Thrombus formation was identified in 39 cases (70%). In most cases, this thrombi formed around a catheter and were released into stream when the catheter was removed. However, complications attributable to the thrombi, such as pulmonary embolism were not observed. Then we tested four materials of catheters including vinylchloride, vinylchloride coated with heparine, polyurethane, and silicone to compare the incidence of thrombus formation. Thrombi were found regardless the catheter material when they were placed for more than 10 days. Cultures of blood, catheter tips and parts of catheters placed under the skin were performed to clarify the relation between thrombus formation and catheter-related sepsis. Positive culture was obtained only five cases but they were all associated with thrombus formation. These results suggest that central venous catheterization frequently results in thrombus formation, which would lead to catheter-related spesis.     

Mid-term angiographic comparison of sequential and individual anastomosis techniques for diagonal artery

OBJECTIVE: The mid-term patency rates for individual and sequential grafts as coronary bypass conduits for diagonal arteries were angiographically compared; the impact of native coronary vessel and type of the conduit characteristics are investigated. METHODS: Between March 1992 and April 2000, we performed a total number of 811 distal anastomosis on diagonal arteries of left anterior descending (LAD) artery in 296 patients who underwent coronary artery bypass surgery (CABG) distal anastomosis in our clinic. The patients were divided into two groups in this prospective study. In group A (n = 195) individual anastomosis technique, in group B (n = 101) sequential anastomosis technique was chosen as the myocardial revascularization strategy. At an average of 49.4 +/- 13.2 months after coronary revascularization procedure coronary angiographies were evaluated. Individual and sequential grafting techniques were compared by graft patency rates. RESULTS: The patency rates of sequential conduits were markedly higher than those of individual conduits (66.7% vs. 89.2%, p = 0.0001). This difference was also clear in coronary arteries with poor quality and small (<1.5 mm) diameter (49.1% vs. 66.6%, p = 0.032). Also, the patency rates of sequential radial artery conduits were higher than sequential saphenous vein graft (SVG) conduits (sequential radial artery; 94.1%, sequential SVG; 85.3%, p = 0.043). CONCLUSIONS: Sequential grafting for diagonal artery is technically more demanding but the mid-term results are better than individual grafting especially in coronary arteries with poor quality. Using radial artery as a sequential graft increases the mid-term graft patency rates.     

Influence of aprotinin on early graft thrombosis in patients undergoing myocardial revascularization

One hundred sixty-five patients undergoing primary myocardial revascularization were prospectivelyentered into a randomized, double-blind, placebo-controlled study, in a single institution, in order to determine the influence of high- and low-dose aprotinin application on early coronary artery bypass graft patency. All patients were operated on by the same team and the three treatment groups were comparable in all demographic data and surgical variables. Postoperative chest tube drainage and transfusion requirements were significantly reduced in patients receiving high or low doses of aprotinin. In all patients vein and internal mammary artery graft patency was assessed by control coronary angiograms 4 to 15 days (median 8.2 days) postoperatively. In the high-dose aprotinin group, 140 of 142 vein grafts and in the low-dose aprotinin group all of the 128 vein grafts were patent compared with 138 of 139 in the placebo group. The difference was not statistically significant (P> 0.05). All pedicled internal mammary artery grafts were patent in the three treatment groups. The prevalence of perioperative myocardial infarction was evaluated by serial creatine kinase-myocardial band (CK-MB) isoenzyme measurements and by electrocardiographic recordings. No additional changes that could be attributed to aprotinin were observed. In conclusion, these results suggest that perioperative myocardial infraction secondary to aprotinin-induced native coronary artery or conduit thrombosis is not increased by aprotinin in patients undergoing primary myocardial revascularization.