Preliminary experience with 088 large bore intracranial catheters during stroke thrombectomy

Background and purposeThromboaspiration technology continues to evolve at an accelerated pace with increasing availability of larger and more navigable devices. Herein, we provide our initial experience with the intracranial navigation of a large-bore (.088" inner diameter) catheters during mechanical thrombectomy (MT).MethodsRetrospective review of consecutive large vessel occlusion stroke patients in whom a TracStar™ or Zoom 88™ (Imperative Care, Campbell, CA) large-bore catheters were utilized in MT. The primary outcome was successful reperfusion (eTICI2b-3) at the end of the procedure. Safety measures included procedural complications and rates of symptomatic intracranial hemorrhage.ResultsFive patients (age,∼50–85 years; baseline NIHSS,17-23) were treated. The .088" catheters were used as the primary tool for contact aspiration in two patients (distal basilar artery and proximal MCA occlusions) with complete thrombus ingestion (eTICI3) during the first pass. In two patients, the .088" catheter was used for flow control where it was placed in the distal M1-segment of a patient with M2 occlusion treated with a combination of stent-retriever and .070" aspiration catheter and in the proximal M1 in a patient with distal M1 occlusion treated with .071" aspiration catheter resulting in eTICI3 reperfusion in both cases. In the fifth patient, the .088" catheter was navigated into the cavernous ICA to support .071" aspiration catheter treatment of an M2 occlusion resulting in eTCI2b67 reperfusion. Procedural duration ranged between 14 and 33 minutes. There were no adverse events.ConclusionIntracranial navigation of .088" large-bore catheters in MT appears technically feasible and safe. Larger prospective studies are warranted.     

Use of distal protection filter device for rescue mechanical thrombectomy for symptomatic free-floating thrombus of the cervical internal carotid artery

BackgroundIntraluminal free floating thrombus (FFT) of the cervical internal carotid artery (ICA) is a potentially high-risk lesion for recurrent ischemic strokes, with no single optimal treatment established.ObjectiveTo describe a novel interventional technique for mechanical thrombectomy of intraluminal free floating thrombus using a distal protection filter device and aspiration.MethodsWe identified two cases where anticoagulation was contraindicated in patients with intraluminal FFT and minimal underlying stenosis. In both cases, a distal protection device was used to extract the thrombus under proximal flow arrest and aspiration.ResultsMechanical thrombectomy was successful in both cases, one with “en bloc” removal of the thrombus and one with piecemeal removal. Neither case showed any residual angiographic stenosis or atherosclerotic disease.ConclusionMechanical thrombectomy using a distal protection device is a novel and technically feasible approach for select cases of cervical intraluminal thrombus. This may represent a therapeutic option in select cases with high risk of anticoagulation and in the unusual subset of younger patients with minimal atherosclerotidc disease.     

Diver CE血栓抽吸导管与替罗非班对老年急性心肌梗死患者心肌再灌注的作用和安全性比较

目的比较在老年患者急诊经皮冠状动脉介入(PCI)术中,Diver CE血栓抽吸导管与替罗非班对心肌再灌注水平的作用、安全性和对患者预后的影响。方法 76例接受急诊PCI术的老年ST段抬高型急性心肌梗死患者,造影证实病变处有明显血栓负荷,将患者随机分组,抽吸组39例患者应用Diver CE血栓抽吸导管抽吸血栓后行PCI治疗,替罗非班组37例患者造影后给予替罗非班+PCI治疗。比较两组心肌灌注水平、并发症发生率和随访6个月心血管事件发生率。结果抽吸组和替罗非班组术后无复流现象发生率、罪犯血管TIMI血流帧数(TFC)、心肌呈色分级、2h内ST段回落率分别是2.6%vs.16.2%、48.1±10.3vs.63.2±14.3、2.59±0.48vs.1.68±0.43,84.6%(33例)vs.62.2%(23例),抽吸组心肌灌注水平明显优于替罗非班组(均P<0.05)。替罗非班组出血并发症发生率明显高于抽吸组。随访6个月,两组心血管事件(心绞痛、心肌梗死、心力衰竭、心因性死亡)发生率分别为14.7%和38.2%,差异有统计学意义(P<0.05)。结论在接受急诊PCI术的老年患者中,对血栓负荷重的病变应用Diver CE血栓抽吸导管,与替罗非班相比更安全,并能明显改善患者的心肌再灌注和预后。     

A short history of thrombectomy – Procedure and success analysis of different endovascular stroke treatment techniques

BackgroundThe historical development of interventional stroke treatment shows a wide variation of different techniques and materials used. Thus, the question of the present work is whether the technical and procedural differences of thrombectomy techniques lead to different technical and clinical results.Methods and resultsAnalysis of a mixed retrospective/prospective database of all endovascular treated patients with an occlusion of the Carotid-T or M1 segment of the MCA at a single comprehensive stroke center since 2008. Patients were classified regarding the technical approach used. Six hundred sixty-eight patients were available for the final analysis. Reperfusion rates ranged between 56% and 100% depending on the technical approach. The use of balloon guide catheters and most recently the establishment of combination techniques using balloon guide catheters, aspiration catheters and stent retrievers have shown a further significant increase in the rates of successful recanalization, full recanalization and first-pass recanalization. Additionally, the technical development of interventional techniques has led to a subsequent drop in complications, embolization into previously unaffected territories in particular.ConclusionTechnical success of MT has improved substantially over the past decade owing to improved materials and procedural innovations. Combination techniques including flow modulation have emerged to be the most effective approach and should be considered as a standard of care.Level of evidence: Level 3, retrospective study.     

Laboratory analysis of catheters for percutaneous abscess drainage

Summary

A laboratory model was designed to evaluate factors contributing to catheter efficacy as they pertain to percutaneous abscess drainage (PAD). Sixteen commercially available and commonly used catheters were studied, with controlled pressure gradients and fluid viscosities as predicted by Poiseuille's law. Factors that influenced flow through these catheters included catheter length, inner lumen diameter, applied pressure gradient and fluid viscosity. The type of suction (continuous v. intermittent) and surface area available for fluid entry also affected the overall drainage efficiency. The catheters with the largest inner lumen diameter (the 16 F Medi-tech sump and 14 F Malecot catheters) demonstrated the best drainage characteristics, especially when draining a viscous solution. When PAD is to be used, the efficacy of drainage is influenced in large part by the physical characteristics of the catheter used.     

Urokinase infusion restores function of thrombotically-occluded inferior vena cava apheresis catheters refractory to bolus urokinase therapy

Translumbar inferior vena cava catheters have been shown to be safe and effective in providing venous access for apheresis collection of peripheral blood stem cells for transplantation. Thrombotic occlusion of these catheters can limit their effectiveness for apheresis. While some of these occlusions respond to installation of the 5000 unit “Open-Cath^®” dose of urokinase, there are no guidelines for therapy of occluded catheters not responding to this treatment. We have performed low-dose urokinase infusion on 11 IVC apheresis catheters radiographically documented to be occluded by thrombus. These catheters had failed a mean of 1.5–5000 unit boluses of urokinase. Seven catheters underwent urokinase infusion at 40,000 units/ h for 12 h. All had complete restoration of catheter function and 6 had total dissolution of thrombus on post-therapy X-ray. Because of the initial success of the 12 h infusion, we treated 4 catheters with the same dose of urokinase for 6 h. All 4 had complete restoration of catheter function and 2 had total thrombus dissolution on X-ray. No bleeding complications were seen.For occluded IVC apheresis catheters, initial therapy should be the installation of at least one 5000 unit bolus of urokinase. For catheters not responding to this therapy, radiographic evaluation should be conducted. If thrombotic occlusion is found, a 40,000 unit/h infusion of urokinase for 6–12 h can safely salvage catheter function and allow continued apheresis.     

An audit of central venous catheter insertion and management practices in an Australian tertiary intensive care unit: A quality improvement project

IntroductionCentral venous catheters are often used in managing critically ill patients. Clinical practice guidelines and care bundles exist to prevent central line associated blood stream infections; however, detailed adherence to these guidelines and care bundles is unclear.AimThis study was aimed to describe clinicians’ adherence to recommended practices in central venous catheter insertion and management.MethodA cross-sectional prospective observational study was conducted in the intensive care unit of an Australian tertiary hospital over a four-month period. We observed a total of 50 nurses during post insertion management, and 10 physicians during central venous catheter insertion using purposely designed observation tools.ResultsOur audit identified 90% adherence to recommended practices in central venous catheter insertion and 60% to post insertion management. However, there were areas where participants’ practices were not congruent with evidence-based recommendations, including choice of central venous catheter insertion site, type of central venous catheters, dressing choice, aseptic technique, and documentation.ConclusionOur audit showed a detailed picture of clinician’s adherence to recommended practices in central venous catheter insertion and management. A clearer understanding of the barriers and facilitators of issues identified is needed to inform the design of future interventions to reduce central line related blood stream infections in the unit.     

Interventional stroke treatment – Is it also safe for arteries? Looking at thrombectomy wall damage through clot histology

Background and purposeThe aim of this study was to investigate whether morphological evidence of intracranial vascular injury can be found in the occluding thrombi of patients with ischemic stroke.MethodsFrom 2015 until 2018 specimens of thrombi from patients with large vessel occlusion treated either by stent-assisted aspiration thrombectomy (TE) or by aspiration thrombectomy were prospectively collected. Thrombus specimens were formalin-fixed, paraffin-embedded and stained. Architectural features, presence of parts of vessel wall or atheromatous material, organisation of the thrombi, technique and number of thrombectomy manoeuvers were evaluated.ResultsThrombus specimens from 302 patients were analyzed. 238 (80%) patients were treated with stent-assisted aspiration TE and 64 (20%) patients with aspiration TE only. 286 (95%) had fresh thrombi, 14 (4.6%) showed initial/complete thrombus organisation and multi-staged thrombi were found in 2 (<1%) patients. In 8 patients (2.6%) we found atypical thrombus content after a time interval longer 6 hours after onset and final thrombectomy manoeuvre: 4 with atheromatous material and 4 with parts of a vessel wall. In 1 patient with parts of vessel wall angiographically a dissection was detected. No parts of the vessel wall were found after sole aspiration thrombectomy.ConclusionsThe overall risk of arterial vessel wall injury aspiration thrombectomy was low in our study. Aspiration thrombectomy and the procedure related with a retrieving device together with an ischemia time longer than 6 hours may increase the risk of vessel injury through the thrombectomy procedure. Further investigations are necessary to elucidate the influence of the mentioned aspects.     

Unnecessary removal of vascular access devices due to suspected infection in Australian intensive care units

BackgroundVascular access devices suspected of infection are often removed unnecessarily and frequently require replacement. The aim of this study was to identify the prevalence and economic impact of premature, unnecessary device removal due to suspected infection in adult patients admitted to the intensive care unit.MethodsSecondary data analysis of a prospectively collected data set detailing central venous catheters and peripheral arterial catheters in 1458 adult patients was conducted in nine Australian intensive care units. Data extracted from the parent database included patient demographics, device, and infection-specific data including the reason for device removal. Cost estimates were based on a recently published review of device utilisation and associated costs in Queensland public hospitals.ResultsA total of 6144 central venous catheter days and 4696 arterial catheter days were studied. Median device dwell time was 7.2 (interquartile range: 5.6–9.0) days for central venous catheters and 6.5 (interquartile range: 4.8–8.5) days for arterial catheters. Device removal due to suspected infection occurred at a rate of 25.7 and 15.3 episodes/1000 catheter days in central venous and arterial catheters, respectively. Central venous and arterial catheter–related bloodstream infections occurred at a rate of 1.8 and 0.2 episodes/1000 catheter days, respectively. Central line–associated bloodstream infection occurred at a rate of 3.3 episodes/1000 catheter days. Local central venous and arterial catheter infection occurred at 0.16 and 0.02 episodes/1000 catheter days, respectively. The difference in incidence between devices suspected of infection and those responsible for infection resulted in AUD$67,087 unnecessarily spent on device replacement.ConclusionsUnnecessary device removal due to suspected infection presents a substantial clinical problem which is costly for the healthcare organisation and time-consuming for clinicians and places the patient at an increased risk of iatrogenic complications. There is a need for robust evidence and clinical practice guidelines to inform clinical decision-making to reduce unnecessary device removal.     

CT IVC venogram: normalized quantitative criteria for patency and thrombosis

Purpose

Establish normal attenuation ratios for vein to artery on CT IVC venogram and determine a vascular attenuation ratio diagnostic of thrombus.

Methods

This retrospective, HIPAA-compliant study included 56 CT IVC venograms. Images were reviewed for the presence of femoral vein or IVC thrombus. Attenuation ratios for each vein and its corresponding artery were calculated by two observers and averaged in four venous stations (right and left femoral veins, and IVC at the confluence of the iliac veins and at the left renal vein). The reference standard for the absence of thrombus was clinical follow-up and for the presence of thrombus it was thrombectomy or catheter venogram. Receiver operating characteristic (ROC) analysis was performed using ratios from one venous station and threshold for thrombus was determined using the Youden’s index.

Results

36 of 56 CTs demonstrated no thrombus. 20 CTs demonstrated thrombus, confirmed in eight patients. For CTs with no thrombus, median ratios among the venous stations ranged from 0.89 (IQR 0.83–0.93) to 0.91 (IQR 0.86–0.94). ROC analysis of ratios from a single representative station (left femoral vein, n = 4 confirmed clots) demonstrated an area under the curve (AUC) of 0.994 (p = 0.001) and a threshold of 0.67 for diagnosing thrombus [sensitivity 100% (95% CI 39.76–100%), specificity 97.5% (86.84–99.94%)].

Conclusion

The normal attenuation ratio of vein to artery in the absence of venous thrombus on a 3-min delay CT IVC venogram is approximately 0.91. A ratio less than 0.67 is highly suggestive of thrombus.

     

Evaluation of a regional oxygen saturation catheter for monitoring SJVO2 in head injured patients

Objectives. Monitoring jugular venous oxygen saturation (SjvO₂) has been useful for the early identification and treatment of cerebral ischemia in patients with severe head injury. However, the catheters that have been used for this purpose have not performed optimally. The purpose of this study was to evaluate the performance of a new regional oxygen saturation catheter for monitoring SjvO₂.Methods. Eighteen regional oxygen saturation catheters, 4-Fr in diameter (Baxter Healthcare Corporation, Edward Critical Care), were used in this study. Each catheter was inserted percutaneously into the dominant jugular vein and the catheter's tip position in the jugular bulb was verified by radiograph. The catheter was calibratedin vitro prior to insertion using the optic calibrator provided by the manufacturer. The catheter was recalibrated every 8 to 12 hours by comparing the oxygen saturation value from the catheter with that measured by a cooximeter in a blood sample drawn through the catheter.Results. In vitro calibration using the optic calibrator was not always successful. Five catheters could not be calibrated. The remaining 13 catheters could all be calibrated, but only 9 provided a value that was within 4% of the oxygen saturation derived from the blond sample. After the firstin vivo calibration, the correlation between the catheter and the blond sample values was improved. A total of 196 comparisons were made. The median, 25th, and 75th quartile differences between the catheter and the blond sample measurement of SjvO₂ were 0.00, –1.15, and 1.25%, respectively. Using longitudinal data regression, the overall slope of the regression between the catheter and blood values was 0.997 (p = 0.001).Conclusions. The new regional oxygen saturation catheter provided reliable measurement of SjvO₂ 83% of the time when the signal quality index was 3, and may be useful for continuous monitoring of SjvO₂.This work was supported by NIH grant #PO1-NS26716.     

Mechanism of pulsatile flushing technique for saline injection via a peripheral intravenous catheter

BackgroundThe underlying mechanism of pulsatile flushing technique has not been fully elucidated, and the partial understanding of the mechanism has been confined to hydrodynamic simulation, ignoring the dynamic interaction among the catheter, blood vessel, blood stream, and saline.MethodsThe peripheral intravenous catheter and vein models and their internal flow fields were assessed using a commercial software. The parameters of both fluid and structural mechanics were calculated and compared in the push and pause phase. The effect of different flushing volumes per bolus before each pause (0.5, 1.0, 1.5, and 2.0 mL) were compared, respectively corresponding to group (A, B, C and D).FindingsIn groups C and D, the wall shear stress value (≥2 Pa) and enhanced shear rates (peaks up to 10,000 s⁻¹) were higher in the vessel wall near the catheter tip, which may be at risk of vascular endothelial injury. Furthermore, extraluminal flushing might be attributed to the recirculation of jet from the catheter outlet. The vortices of all groups faded away in an extremely short period (≤0.1 s) if the push was suddenly discontinued. Finally, overlarge displacement of the catheter tip in groups C and D (0.91 and 1.1 mm, respectively) caused the peripheral intravenous catheters to angle with the venous wall.InterpretationThe pulsatile flushing technique can facilitate intra- and extraluminal flushing of peripheral intravenous catheters. Furthermore, an insufficient volume per bolus can lead to inefficient flushing, and an overdose of single push may cause mechanical endothelial injury.     

The 100 top-cited systematic reviews/meta-analyses in central venous catheter research: A PRISMA-compliant systematic literature review and bibliometric analysis

ObjectiveThe central venous catheter is used extensively worldwide. The purpose of this bibliometric analysis was to identify the 100 top-cited systematic reviews/meta-analyses in the literature on central venous catheters and to capture the most important trends in this area of research.Research methodologyA search was performed in the Web of Science Core Collection on studies published prior to November 12th, 2019. The search terms included central venous catheter, systematic review and meta-analysis. Retrieved studies were ranked by citation number and selected by two of the authors. Information such as citation number, author, institution, country and year of publication was collected.ResultsThe 100 top-cited studies published between 1992 and 2017 were reviewed, with the largest proportion published in 2008 (n = 17). The number of citations ranged from 14 to 660. The country with the largest number of studies was the United States of America (n = 36). Critical Care Medicine published the greatest number of these studies (n = 13). The largest number of these studies were focused on central venous catheter-related infection (n = 56) and thrombosis (n = 19).ConclusionDeveloped countries were the most productive in the field of central venous catheters. Most meta-analyses focused on complications associated with central-venous catheters such as infection and thrombosis.     

Minimizar el volumen de descarte para la extracción de muestras sanguíneas en los pacientes críticos: ¿es factible?

IntroductionDrawing blood samples through a central venous catheter is a customary practice in intensive care units. It is indicated to discard a volume of waste blood to avoid interference in the results.AimTo determine whether a lower discard volume for obtaining blood samples from temporary central venous catheters placed into the internal jugular, femoral or subclavian vein offers valid results.MethodA quasi-experimental prospective cross-sectional study for which 65 patients of over 18 years of age in intensive care units, who had been fitted with a triple lumen central venous catheter, were recruited over a period of 8 months. Two consecutive blood samples were extracted with tubes for biochemistry, coagulation and haemogram from each patient from the distal lumen. The first sample was obtained with a discarded waste of 1.5 ml from a total extracted volume of 10.2 ml, similar to the usual waste in our ambit (10 ml). Subsequently the second sample was obtained. The paired t-test was used to analyse the data. The Bland-Altman plot and intraclass correlation coefficient were used to measure the agreement between methods. The reference change value was established as the admissible limit of variation between the pairs of samples.ResultsA total of 65 sample pairs were drawn (intervention-control). The paired t-test found statistically significant differences with a significance level of α = 0.05 for chlorine (?0.536; 0.012); prothrombin time (?0.092; 0.019) and prothrombin activity (0.284; 1.375). The intraclass correlation coefficient was greater than 0.9 in all the variables and the limit determined for the reference change value was not surpassed by any value.ConclusionsThe results show the reliability of the blood samples drawn with a discard volume of 1.5 ml.     

两种水力流变除栓导管体外除栓效果比较

目的　比较 7FHydrolyser和 8FOasis两种流变血栓清除导管在模拟股静脉的体外流体模型中的除栓效果 ,注入盐水量及回收液体量 ,以及与除栓过程相关的远端栓塞率。方法　用 3天的猪血在模拟股静脉的体外流体模型中形成约 2 0cm长的血栓栓塞 ,分别使用 7FHydrolyser导管和 8FOasis导管进行血栓清除 (每组 10例 )。 结果　平均除栓时间 7FHydrolyser为 ( 30± 8)s ,8FOasis为 ( 48± 16 )s ;平均注入盐水量 7FHydrolyser( 118± 32 )ml,8FOasis为 ( 14 7± 47)ml;平均回收液体量 7FHydrolyser( 15 5± 43)ml ,8FOasis为 ( 2 2 0± 6 9)ml;注入盐水量与回收液体量的比值 7FHydrolyser为 0 .76± 0 .0 5 ,8FOasis为 0 .6 6± 0 .0 2 ;血栓清除率 7FHydrolyser为 ( 96 .2 7± 1.10 ) % ,8FOasis( 97.2 1± 0 .73) % ;除栓后远端微栓子形成率 7FHydrolyser为 ( 3 .5 7± 1.13) % ,8FOasis( 1.94± 0 .70 ) %。 结论　两种流变除栓导管的血栓清除率均较高 ,在清除时间、回收液体量、注入量与回收液体量的比值方面 7FHydrolyser优于 8FOasis ;在远端微栓子形成率方面 8FOasis优于7FHydrolyser。     

Low Levels of Prothrombin Time (INR) and Platelets Do Not Increase the Risk of Significant Bleeding when Placing Central Venous Catheters*

Abstract Background and Purpose:   Central venous catheters are frequently placed in intensive care medicine for multiple indications. The risk of severe bleeding after cannulation is considered to be increased in patients with abnormal coagulation, common in critically ill patients. Patients and Methods:   This open prospective trial, performed at two medical intensive care units and one hematology intermediate care ward, investigated whether insertion of a central venous catheter in patients with coagulopathy (prothrombin time ≤ 50% [International Normalized Ratio, INR, ≥ 1.5] and/or platelets ≤ 50 × 10⁹/l) bears an increased risk of bleeding. Results:   In 196 patients with and without severe disorders of hemostasis, no significant difference in decrease of hemoglobin after catheter placement was observed. In addition, no correlation between a significant drop in hemoglobin and increased levels of creatinine or urea was seen. Mechanical complications were similar in frequency compared to previous publications. Conclusion:   These findings demonstrate that coagulation disorders with altered prothrombin time (INR) or platelets do not increase the risk of significant bleeding when inserting a central venous catheter. Therefore, the prophylactic correction of coagulation by transfusion of blood products or coagulation factors is not necessary before central venous catheter insertion. *Trial registration: ClinicalTrials.gov NCT00448188.