Reuse of angioplasty catheters and risk of Creutzfeldt-Jakob disease

Detrimental Effects of Sterilization Types on Single-Use Coronary Angioplasty Catheters for Reuse: An Electron Microscopic Study

Objective

Reuse of medical devices poses risks concerning technical issues and patient safety. In this study, we aimed to examine the structural changes in catheters that occur due to the reuse with the aid of electron microscopy.

Materials and Methods

The effects of hydrogen peroxide (HP) and ethylene oxide (EO) sterilization on four percutaneous transluminal coronary angioplasty (PTCA) catheters and control PTCA catheters were examined by scanning electron microscope (SEM). Each catheter sample was divided into four parts during the SEM examination, and a total of 20 pieces were examined. Catheters were reprocessed through every regular sterilization step and used solely for the study, not in patients. Statistical evaluations of histological scoring made on images obtained from scanning electron microscopic images were made using the GraphPad Prism 8 program.

Results

Electron microscopical examination showed that HP sterilization caused more robust and deeper lines compared to EO. These distortions increased directly with the increase in the reprocessing cycle. In EO, no significant damage was detected within five cycles in contrast to HP; however, the harmful effects of EO were seen over five cycles. Unprocessed samples had no damage. Outer and inner deterioration was significantly higher in the EO>5 group and HP>5 group than in the control group. However, the bacterial contamination score in the EO>5 group was higher than the control group.

Conclusion

Our findings showed that HP and EO sterilizations caused some deterioration in the inner and outer surfaces of PTCA catheter samples. We recommend reprocessing using EO, the least damaging method, when necessary, and paying attention not to exceed five cycles when necessary.

A cost effectiveness based safety and efficacy study of resterilized intra-parenchymal catheter based intracranial pressure monitoring in developing world

Background:

The management of traumatic brain injury (TBI) aims to maintain the normal cerebral perfusion in spite of the mass lesions that may occur (haematoma, contusion, and oedema). The monitoring of the intracranial pressure (ICP) is a step in that direction. The intra-parenchymal catheters have the lowest incidence of infection compared to intra-ventricular/subdural catheters with reliable and accurate pressure recordings. The major disadvantage of the intra-parenchymal catheters is the cost, especially in developing nations.

Hypothesis:

Resterilized intra-parenchymal strain gauge catheters can be used safely for ICP monitoring without any added risk of meningitis. The reusage of catheters can bring down the costs. Resterilized catheters/equipment have been approved for usage in cardiac usage, but such study on ICP catheters has not been carried out so far in any part of the world.

Methodology:

A total of 100 consecutive cases of severe TBI receiving ICP monitoring at a level 1 trauma center of a developing nation were prospectively studied (34 cases had fresh catheters, and 66 had resterilized [using ethylene oxide] catheters).

Observations:

The use of reused resterilized catheters was not associated with increased incidence of meningitis or fever (the surrogate marker for infection in this study). Also, there was concordance between the pressure recording of reused catheters and operative finding/subsequent computed tomography scans. These catheters after sterilization could be reused 2–4 times and reliably recorded the ICP (insignificant drift) with no increase in the incidence of meningitis.

Conclusions:

Usage of resterilized intra-parenchymal ICP catheters is feasible, safe, efficacious, and cost effective and brings down the cost of monitoring significantly.

Late-in-life surgery associated with Creutzfeldt-Jakob disease: a methodological outline for evidence-based guidance

Background

There is increasing epidemiological evidence of etiological links between general surgery and sporadic Creutzfeldt-Jakob disease (sCJD) with long incubation periods. The purpose of this study was to identify specific surgical procedures potentially associated with sCJD to be targeted for preventive presurgical-intervention guidance.

Results

We propose a three-step clinical guidance outline where surgical procedures associated with sCJD clinical onset – potentially more contaminant - are taken into account. Data on hospital discharges and surgical procedures were obtained from Danish and Swedish national in-patient hospital registries for 167 sCJD cases, onset 1987–2003, and for 835 matched and 2,224 unmatched population controls. Surgery was allocated to different life-time periods as previously reported, and frequencies were compared using logistic regression analysis. In the year preceding clinical onset, persons with sCJD underwent a statistically significant higher number of minor surgical interventions (OR (95% CI): 17.50 (3.64-84.24)), transluminal endoscopies (OR: 2.73 (1.01–7.37)) and gastrointestinal operations (OR: 3.51 (1.21–10.19)) compared to matched controls. Surgical discharges clustered towards clinical onset. These differences increased during the clinical period, with statistically significant higher frequencies for both endoscopies and minor surgery (OR: 13.91 (5.87-32.95), and for main surgical procedures (OR: 2.10 (1.00-4.39)), particularly gastrointestinal surgery (OR: 6.00 (1.83-19.66)), and surgery contacting skeletal muscle. Comparisons with unmatched controls yielded similar results for neurosurgery in the clinical period (OR: 19.40 (2.22-168.34)).

Conclusions

These results suggest that some types of surgical procedures are associated with sCJD, after clinical onset or particularly just before onset. Selective planning of such surgery to minimize instrument/device contamination or quarantining might be feasible. Conditional to progress in sCJD etiological research, results are relevant for guidance development.

Impact of FDA policy change on the reuse of single-use medical devices in Michigan hospitals

BACKGROUND

Reuse of single-use devices (SUDs) was a common practice in many health care centers in the United States. In August 2000, the FDA presented a guidance document indicating their policy change that meant the FDA would regulate centers that reprocess SUDs.

OBJECTIVE

Our objective was to survey Michigan health care centers to determine the level of action that has been taken regarding this policy change and determine whether there has been a shift in the extent of reuse of SUDs.

METHODS

We developed a telephone survey tool and contacted the infection control personnel in the 54 Michigan hospitals that had more than 200 beds.

RESULTS

The response rate to the telephone survey was 48 of 54 (89%). Prior to the FDA policy change, 46%, 17%, and 37% performed on-site, third-party, or no reprocessing of SUDs, respectively. Currently, 21%, 35%, and 44% performed on-site, third-party, or no SUD reuse, respectively. The major shift has been to utilization of third-party reprocessors as opposed to stopping reuse of SUDs. In the 27 centers that currently reprocess SUDs, the most common items included the following: compression sleeves, 13 of 27; pulse oximeters, 8 of 27; PTCA cardiovascular catheters, 7 of 27; and biopsy forceps, 5 of 27. There were 61% (11/18) that resterilized open but unused SUDs with an equal split between on-site versus third-party resterilization. There were 3 sites that stopped reprocessing SUDs completely as a result of the FDA policy change and 4 that previously did not reprocess SUDs that started using a third-party reprocessor.

CONCLUSIONS

The FDA policy change has impacted how SUD reprocessing is being performed in Michigan. Few centers (1/48) reprocessing any high or medium-risk SUDs on-site at the time of the survey. There has been little overall reduction in SUD reprocessing, but there has been a shift to use of third-party reprocessors.

Safety issue of re-sterilization of polyurethane electrophysiology catheters: a cytotoxicity study

The reuse of electrophysiology catheters could result in significant cost savings. However, re-sterilization of catheters could lead to several adverse consequences, including toxicity related to potential chemical reactions that occur during sterilization due to toxic residues remaining on the surface of catheters. The objective of this study was to investigate in vitro cytotoxicity of polyurethane (PU)-based catheter extracts on macrophages after their re-sterilization. We have compared three sterilization methods: steam autoclave, ethylene oxide (EtO) and hydrogen peroxide plasma (Sterrad system). Our results showed that the viability of cells varied from 90% to 99% as a function of incubation time and number of sterilization cycle. While there was no statistical difference based on the sterilization procedure, the number of sterilization cycles (up to 10 cycles) presents a statistically significant effect on the viability of J774 macrophages. However, extract obtained after resterilization of PU-based catheters had a low cytotoxic effect on J774 macrophages, since the overall cell mortality remained under 10%. An inhibitory effect on cell growth was also observed, which was not significant either as a function of incubation time, sterilization technique or the number of sterilization cycles. Finally, extracts of PU-based catheters had no statistically significant effect on TNF-alpha release by J774 macrophage. Even though there were some statistically significant differences between the control and processed samples, and among processed samples, our data suggest that one single reprocessing of PU-based catheters may not induce clinically significant changes in their cytotoxicity behaviour.

Change of the mechanical properties of two different balloon catheters with increasing numbers of cycles of resterilization

An increasing number of centers are reusing PTCA catheters even though manufacturers warrant single use only. This prospective bench laboratory trial addresses the quality of PTCA balloon catheters after up to three resterilization cycles in order to determine whether a larger trial is warranted to discern whether catheters should be reused. Forty PTCA catheters from two different manufacturers (nominal diameters 1.5 and 3.0 mm) were taken from the shelf. An independent institute tested mechanical properties such as burst pressure, nominal diameter, crossing profile, and balloon surface. The crossing profile increased by 22.5%-39.2% with no additional deterioration after repeated sterilizations. The nominal diameter either increased or decreased by a maximum of 47%. In all 1.5 mm balloons, the burst pressure remained above the manufacturers' values, whereas in the 3.0 mm balloons, the value dropped below the rated burst pressure in 40%-50% of the trials. In conclusion, in both catheter types analyzed, reuse was associated with a considerably worse quality, which puts in question their routine clinical use.

In vitro performance characteristics of reused ablation catheters

BACKGROUND

Prior studies have found that there is a widespread practice of catheter reprocessing in cardiac electrophysiology laboratories. Effects of reprocessing of ablation catheters on temperature sensing and mechanical deflection are not fully known.

METHODS

Twenty-four new and used ablation catheters were studied. Deviation of temperature sensing by catheters from the temperature of a heated saline bath was measured. The angle of deflection of digitally scanned catheters at 75% and 100% handle deflection was also measured. New and used catheters were compared with respect to their temperature sensing accuracy and deflection characteristics.

RESULTS

Overall, there was 0.7 +/- 0.1 degrees C (mean +/- standard error) deviation of the sensed temperature from the bath temperature, with no significant difference between new and used catheters. Similarly, there was no significant difference in the angle of deflection between new (66.7 degrees +/- 6.2 degrees and 24.3 degrees +/- 6.8 degrees at 75% and 100% deflections, respectively) and used (59.6 degrees +/- 5.6 degrees and 28.7 degrees +/- 9.9 degrees at 75% and 100% deflections, respectively) catheters. The difference in the angle of deflection between matched new and used catheters was 18.9 degrees +/- 4.2 degrees and 10.9 degrees +/- 2.4 degrees at 75% and 100% deflections, respectively, with a relatively broad range (5.0 degrees -35.6 degrees and 0.4 degrees -19.0 degrees at 75% and 100% deflections, respectively).

CONCLUSIONS

This study found no significant overall difference in temperature sensing accuracy and deflection angle of new and used ablation catheters. Nevertheless, individual differences in deflection characteristics between new and used catheters are occasionally seen and warrant screening of reprocessed catheters prior to their reuse.