Direct true lumen cannulation in type A acute aortic dissection: A review of an 11 years' experience

Objectives

Direct true lumen cannulation (DTLC) of the aorta is an alternative cardiopulmonary bypass cannulation technique in the context of type A acute aortic dissection (A-AAD). DTLC has been reported to be effective in restoring adequate perfusion to jeopardized organs. This study reports and compares operative outcomes with DTLC or alternative cannulation techniques in a large cohort of patients with A-AAD.

Methods

All patients who underwent surgery for A-AAD between January 2006 and January 2017 in Mainz university hospital were reviewed. The choice of cannulation technique was left to the operating surgeon, however DTLC was our preference in patients who were in state of shock or showed signs of tamponade or hypoperfusion, in cases of potential cerebral malperfusion, as well as in patients who were under resuscitation.

Results

A total of 528 patients (63% males, mean age 64±13.8 years) underwent emergency surgery for A-AAD. The DTLC technique was used in 52.4% of patients. The DTLC group of patients had worse clinical status at the time of presentation with more shock, tamponade, true lumen collapse, cerebral and other malperfusion states. New neurologic events were diagnosed in around 8% of patients in each group following surgery, but there was a trend for quicker neurological recovery in the DTLC-group. Early mortality rates, short-term and long-term survival rates did not differ between the two groups.

Conclusions

DTLC is a safe cannulation technique that enables effective antegrade true lumen perfusion in complicated A-AAD scenarios, and is an advantageous addition to the aortic surgeons’ armamentarium.

Application of pigtail catheter tailing combined with long-wire swapping technique in cerebral angiography via the right radial artery

The safety and feasibility of transradial approach for cerebral angiography has been confirmed previously. However, this approach has been limited used due to the difficulty during the procedure. This study aimed to introduce a pigtail catheter tailing and long-wire swapping technique to improve the success rate without increasing complications.From August 2015 to December 2018, 560 patients who underwent cerebral angiography via transradial approach were recruited. The data including the type of aortic arch, type of Simmon catheter were collected.The loop was successfully constructed in 553 patients using Simmon-2 or Simmon-1 catheter. Of these patients, 72 patients successfully underwent cerebral and renal angiography, while 481 patients underwent cerebral angiography. The time for angiography was 52.87 ± 11.23 minutes and 47.8 ± 11.8 minutes, respectively. There were 369 (66.7%), 135 (24.4%), and 49 (8.9%) patients with type I, type II, and type III aortic arches, respectively, and their success rates of looping using Simmon-2 catheter were 97.8%, 97.0%, and 89.8%, respectively. The success rates of angiography in the right internal carotid artery, right vertebral artery, left internal carotid artery, and left vertebral artery were 100%, 100%, 98.9%, and 98.9%, respectively. No serious complications were observed in all patients.The pigtail catheter tailing and long guidewire swapping is considered as a safe procedure with high success rate for loop construction using a Simmon-2 catheter through the right radial artery, subsequently improving the success rate as well as the efficiency of angiography.

Predictors of Universal Catheter Failure in Transradial Coronary Angiography

BACKGROUND

Use of a universal diagnostic catheter may decrease procedural time and catheter-exchange related spasm when compared with a dual-catheter strategy. The aim of this study was to identify preprocedural predictors of failure to complete a coronary angiogram with a universal catheter alone.

METHODS

Consecutive patients (n = 782) who underwent a right transradial/transulnar coronary angiogram with a single operator were retrospectively reviewed. Multivariable predictors of failure to complete the procedure with a universal catheter alone were identified using logistic regression analysis and presented as odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Of the study population (n = 558), a total of 216 (38.7%) required exchange to a coronary-specific catheter (44.4% for right coronary artery alone, 25.5% for left coronary artery alone, 30.1% for both) and 342 (61.3%) underwent angiography with a universal catheter alone. Patients who required a catheter exchange were more likely to have the following characteristics compared with patients who underwent an angiogram with a universal catheter alone: age >75 years (27.3% vs 16.4%; P<.01), female sex (34.3% vs 23.1%; P<.01), diabetes mellitus (50.0% vs 38.3%; P<.01), hypertension (88.0% vs 74.6%; P<.001), and chronic kidney disease (29.2% vs 17.8%; P<.01). After multivariable adjustment, age ≫75 years (OR, 1.92; 95% CI, 1.21-3.04), female sex (OR, 1.94; 95% CI, 1.20-3.14), hypertension (OR, 2.08; 95% CI, 1.22-3.57), and chronic kidney disease (OR, 1.58; 95% CI, 1.01-2.46) predicted failure of a universal catheter alone to complete angiography.

CONCLUSION

Consideration may be given to use an initial dual-catheter strategy if one or more of the following are present: elderly age, female sex, hypertension, and chronic kidney disease.

Nursing Practice With Transthoracic Intracardiac Catheters in Children: International Benchmarking Study

BACKGROUND

Transthoracic intracardiac catheters are central catheters placed in the operating room at the conclusion of cardiac surgery for infants and children. Complications associated with these catheters (eg, bleeding, migration, premature removal, infection, leakage, and lack of function) have been described. However, no researchers have addressed the nursing management of these catheters in the intensive care unit, including catheter dressing and securement, mobilization of patients, and flushing the catheters, or the impact of these interventions on patients' outcomes.

OBJECTIVES

To internationally benchmark current nursing practice associated with care of infants and children with transthoracic intracardiac catheters.

METHODS

In a cross-sectional, descriptive study of nursing practice in infants and children with transthoracic intracardiac catheters, a convenience sample of bedside and advanced practice nurses was recruited to complete an online survey to benchmark current practice. The survey included questions on criteria for catheter insertion and removal, dressing care, flushing practice, securement, and mobilization of patients.

RESULTS

Transthoracic intracardiac catheters are used by most centers that provide care for infants and children after open heart surgery. A wide range of practices was reported.

CONCLUSIONS

Standardizing the use and care of transthoracic intracardiac catheters can improve the safety and efficacy of their use in infants and children and promote safe and early postoperative mobilization of patients.

Mother-and-Child Catheter-Induced Retrograde Dissection of the Left Main Coronary Artery During Optical Coherence Tomography Examination

Optimal GuideLiner positioning for OCT acquisition in tortuous vessels requires special attention to avoid iatrogenic dissection.

Longitudinal Deformation of Distal Edge in a New-Generation Stent Caused by Guidewire Entrapment

Longitudinal stent deformation, described in some older stent geometries, prompted design modifications such as reinforcing struts on the proximal end. However, distal edges of stents-also subject to longitudinal force-have not been reinforced. We report a case of guidewire entrapment that deformed the distal edge of a new-generation stent during percutaneous coronary intervention, and we describe our efforts to restore the stent to its initial length. This case highlights the risk of manipulating equipment beyond the position of a newly deployed stent, the ongoing potential for deformation of distal edges in newer stent platforms, and the advisability of treating distal lesions before proximal ones.

Catheter-Induced Coronary Spasm: Serious But Preventable

While catheter-induced spasm is considered to be rare, it needs to be ruled out (especially in cases of left main stenosis) to avoid unnecessary revascularization. We present a patient where the underlying tendency for coronary spasm was so high, the severe spasm was possibly the underlying cause of a prior cardiac arrest episode.

Coronary Intervention Complicated by Pressure Wires Caught Within Stent Struts

Coronary guidewire fracture or entrapment is a recognized complication of percutaneous coronary intervention that can result in abrupt vessel closure, thrombosis, or stent deformation. Developments in pressure-wire (PW) design have enabled their use for coronary intervention. We describe two cases where the pressure sensor became trapped against stent struts during PW removal.

Impact of QRS Duration on Decision of Early Removal of Pacing Catheter After Transcatheter Aortic Valve Replacement With CoreValve Device

The purpose of this study was to determine the predictability of QRS duration (QRSd) for temporary pacing catheter removal in patients implanted with CoreValve. Permanent pacemaker implantation is a known complication after transcatheter aortic valve replacement (TAVI) with CoreValve. Although post-TAVI QRSd is highly predictive for advanced atrioventricular block (AVB), management of delayed AVB after TAVI remains unclear. We conducted a multicentric, prospective study of 156 consecutive patients who underwent TAVI with CoreValve between December 2010 and January 2013. Patients who had acute AVB after TAVI were excluded (n = 25). We classified the patients into 2 groups based on the post-TAVI QRSd. Patients with QRSd <120 ms were assigned to early pacing catheter removal group (n = 34), and patients with QRSd ≥120 ms were assigned to keep the pacing catheter with monitoring group (n = 97). No patient required permanent pacemaker implantation in the early pacing catheter removal group, whereas 38 patients with QRSd ≥120 ms had a delayed AVB (QRSd <120 ms vs ≥120 ms: 0% vs 39%, p = 0.0001). The intensive care unit stay length, 30-day mortality, and incidence of complications were lower in the early catheter removal group. Post-TAVI QRSd allows patient selection for early removal of pacing catheter in patients implanted with CoreValve.

Management of Guidewire Entrapment With Laser Atherectomy

A 62-year-old man was referred for percutaneous coronary intervention of a severe circumflex lesion. The guidewire became entangled in the previously implanted left anterior descending artery stent. The left main was engaged with a second guide catheter, followed by balloon dilations, various microcatheters, and laser atherectomy. The wire eventually fractured without protruding into the aorta. The circumflex lesion was stented with two stents, followed by left main stenting that covered the fragment. Caution should be used when wiring through stents; wire fracture can be treated with stent implantation, as long as the wire fragment does not protrude into the aorta.

Initial clinical experience of CrossBoss catheter for in-stent chronic total occlusion lesions: A case report

BACKGROUND

The CrossBoss coronary chronic total occlusion (CTO) crossing catheter has been demonstrated to have greatly improved the success rate of crossing CTO lesions, but there are no published data on its application for in-stent CTO lesions.

METHODS

In the current study, we retrospectively reviewed the clinical data of 8 patients with in-stent CTO lesions that were managed with the CrossBoss catheter and herein we report the efficacy and safety of the CrossBoss crossing and re-entry system for this clinically challenging condition.

RESULTS

The CrossBoss catheter was used for 8 patients with in-stent CTO lesions, which resulted in success in 6 cases and failure in 2 cases, with a 75% success rate. Of the 6 patients with successful treatment, 5 cases had the occlusive lesions crossed with the CrossBoss catheter through a proximal lumen-to-distal lumen approach, whereas the remaining case had his occlusive lesions penetrated by the CrossBoss catheter and the guidewire. Two cases failed in treatment as the CrossBoss catheter could not cross the occlusive lesions. The 6 cases with successful treatment included 3 cases with occlusive lesions in the left anterior descending artery, 1 case with occlusive lesions in the obtuse marginal branches, and 2 cases with occlusive lesions in the right coronary artery, and the 2 cases with failure in treatment had their occlusive lesions in the right coronary artery. In addition, patients with a higher Japan chronic total occlusion score were found to have a lower success rate of crossing the occlusive lesions. None of the patients developed complications.

CONCLUSION

Our study demonstrates that the CrossBoss catheter has a high success rate and is safe for in-stent CTOs and can be recommended for this rather clinically challenging condition.

Catheter Entrapment During Posterior Mitral Leaflet Pushing Maneuver for MitraClip Implantation

MitraClip (Abbott Vascular) therapy has been reported to be an effective procedure for mitral regurgitation, especially in high-risk patients. Recently, the novel pushing maneuver technique has been described for approaching restricted and short posterior leaflets with a pigtail catheter in order to facilitate grasping of the clip. However, complications or unexpected situations may occur. We report the case of an 84-year-old patient who underwent MitraClip implantation wherein the pushing maneuver was complicated by the clip accidentally gripping the pigtail catheter along with the two leaflets.

Sudden iatrogenic suicidal right ventricle

It is important to obtain a good withdrawal pressure tracing while performing cardiac catheterization in cases with right ventricular outflow tract (RVOT) obstruction to document the site and severity of obstruction. However efforts to manipulate the catheter in the RVOT (either to obtain the gradients or to position the catheter for an outflow angiogram) can sometimes precipitate severe dynamic RVOT obstruction with complete cessation of forward flow leading to life threatening hypotension. The following hemodynamic traces highlight this rare phenomenon which needs to be borne in mind at all times while performing cardiac catheterization in such patients.

Systematic Review of the BridgePoint System for Crossing Coronary and Peripheral Chronic Total Occlusions

BACKGROUND

The BridgePoint system consists of the CrossBoss coronary catheter and Stingray CTO system (Boston Scientific) for coronary chronic total occlusions (CTOs), and the Viance crossing catheter and Enteer re-entry system (Covidien) for peripheral CTOs.

METHODS

We performed a systematic review of the literature on the BridgePoint system published between October 2008 and August 2014, in accordance with the standards set forth in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

We identified a total of 20 studies: 12 studies on coronary CTOs (10 retrospective with 2 prospective case series) and 8 studies on peripheral CTOs (all retrospective). Among 320 patients undergoing coronary CTO intervention, pooled technical success and major adverse cardiac event rates were 77.1% and 3.8%, respectively. Among 175 patients undergoing peripheral CTO intervention, pooled technical success and major adverse events were 82.2% and 4.6%, respectively. Only 1 study reported long-term outcomes after use of the coronary BridgePoint system, demonstrating similar incidence of major adverse cardiac events between BridgePoint-treated and non-BridgePoint treated patients; however, the study had low power.

CONCLUSIONS

The BridgePoint system is associated with high procedural success rates and low complication rates when used for crossing both coronary and peripheral CTOs.

Safety Testing of Left Ventricular Vent Valves

Vent vacuum relief valves (VRVs) are used to limit the negative pressure at the ventricular vent catheter tip as well as prevent reversal of blood flow and prevention of air embolism. The purpose of this study was to evaluate the performance of three commercially available ventricular vent valves. The negative pressure at which the vent valve opened was measured at the valve inlet using high-fidelity pressure transducers. Also, the flow rate at which air entrainment occurred due to valve opening was recorded. Using a 51.5 cm column of saline, the resistance for each valve was calculated. The mean ± SD opening negative pressures were -231.3 ± 35.2 mmHg for the Quest Medical valve, -219.8 mmHg ± 17.2 for the Sorin valve, and -329.6 · 38.0 mmHg for the Terumo valve. The red Quest Medical valve opened at a lower flow (1.44 ± .03 L/min) than the dark blue Sorin valve (2.93 ± .01 L/min) and light blue LH130 Terumo valve (2.36 ± .02 L/min). The Sorin valve had the least resistance of 34.1 dyn-s/cm, followed by the Terumo LH130 valve resistance of 58.1 dyn·s/cm5, and the Quest Medical VRV-II valve with a resistance of 66.5 dyn·s/cm. We found that the valves are significantly different in the negative pressure generated. Understanding the limitations of these devices is important to reduce the occurrence of adverse events associated with venting and to select the best device for a specific clinical application.

Application of lidocaine jelly on chest tubes to reduce pain caused by drainage catheter after coronary artery bypass surgery

The objective of this study was to assess the effect of lidocaine jelly application to chest tubes on the intensity and duration of overall pain, chest tube site pain and the required analgesics for postoperative pain relief in coronary artery bypass graft (CABG) patients. For patients in group L, we applied sterile 2% lidocaine jelly on the chest tubes just before insertion, and for patients in group C, we applied normal saline. Overall visual analogue scale (VAS), maximal pain area with their VAS were documented postoperatively, and the frequency that button of patient-controlled analgesia was pressed (FPB) and total fentanyl consumption were assessed. The number of patients who complained that tube site was the most painful site was significantly higher in group C than in group L (85% vs. 30% at extubation, P<0.001). The overall VAS score was significantly higher in group C than in group L (39.14±12.49 vs. 27.74±13.76 at extubation, P=0.006). After all of the tubes were removed, the VAS score decreased more in group C (5.74±4.77, P<0.001) than in group L (3.05±2.48, P<0.001). FPB and total fentanyl consumption were significantly higher in group C than in group L (73.00, 59.00-78.00 vs. 34.00, 31.00-39.25, P<0.001; 2,214.65±37.01 vs. 1,720.19±361.63, P<0.001, respectively). Lidocaine jelly application is a very simple way to reduce postoperative pain by reducing chest tube site pain after CABG. (Clinical Trials Registry No. ACTRN 12611001215910).

A unique complication with use of the GuideLiner catheter in percutaneous coronary interventions and its successful management

The "GuideLiner" is an easy-to-use catheter designed for deep seating in coronary arteries. The GuideLiner can be used to provide extra guidance support for equipment delivery during difficult coronary interventions or for coaxial alignment in tortuous vessels. There are a few GuideLiner-related complications reported in the literature, which include stent damage on advancement or on withdrawal, dissection, pressure dampening and ischemia, kinking of the balloon, and displacement of the GuideLiner catheter distal marker. We report another unique and previously unreported GuideLiner-related complication and its successful management. In our case, we experienced dislodgment of the distal cylinder of the GuideLiner from the push rod into the aortic root. The embolized cylinder was removed percutaneously using a novel approach without any complications.

Longitudinal deformation of drug-eluting stents: evaluation by multislice computed tomography

BACKGROUND

Some modifications introduced in the design of the new generation of drug-eluting stent (DES) to improve their flexibility may entail a reduction in their longitudinal strength. This study sought to evaluate the longitudinal deformation of DESs by multislice computed tomography (MSCT).

METHODS

This study included DESs that could have been potentially deformed by mechanical actions such as: (1) catheter impingement; (2) postdilation; (3) kissing balloon; and (4) intravascular imaging after implantation. Patients on atrial fibrillation or with overlapping stents were excluded. All patients underwent stent length evaluation by MSCT 9-12 months after implantation.

RESULTS

Forty-five stents were included: 15 platinum chromium (PtCr-DES), 15 cobalt chromium (CoCr-DES), and 15 stainless-steel (SS-DES). The relative longitudinal deformation by stent type was 6.93 ± 5.82% for PtCr-DES, 6.19 ± 5.79% for CoCr- DES, and 4.03 ± 4.07% for SS-DES (P=.31). Among the mechanical actions studied, only catheter impingement was related to longitudinal stent deformation (P<.01). After adjustment, only catheter impingement (P<.01) and nominal stent length (P=.049) were independently related to longitudinal deformation. There were no stent fractures.

CONCLUSIONS

Longitudinal deformation of DESs is common in all the studied platforms when subject to longitudinal forces. Guiding catheter impingement is the only mechanical action significantly associated with DES shortening.

Removal of intracardiac fractured port-A catheter utilizing an existing forearm peripheral intravenous access site in the cath lab

The intravenous port-A catheters are widely used for long-term central venous access in cancer patients. Spontaneous fracture and migration of implanted port catheters is a known complication and necessitates immediate removal. Percutaneous retrieval of intravascular foreign body has become a common practice and is commonly performed through central venous access, mostly using femoral, subclavian, or internal jugular veins. Although the percutaneous approach is relatively safe, it can lead to potential iatrogenic complications. We report the first case report of percutaneous removal of intravascular foreign body using forearm peripheral intravenous access.

Surgical intervention for embolization of atrial septal defect closure devices: case report

Atrial septal defect (ASD) closure using a percutaneous transcatheter device is used as an alternative to surgery. Various devices are increasingly used in clinical practice, and various types and models of septal occluder devices are available. The Amplatzer device (Amplatzer Medical, Golden Valley, MN, USA) is one with increasing popularity.We report a case of attempted percutaneous transcatheter closure of a large ASD in a 14-year-old girl, complicated by total device embolization to the right ventricle necessitating emergency surgery.

Ablation of atrial fibrillation with cryoballoon or duty-cycled radiofrequency pulmonary vein ablation catheter: a randomized controlled study comparing the clinical outcome and safety; the AF-COR study

AIMS

The urge to facilitate the atrial fibrillation (AF) ablation procedure has led to the development of new ablation catheters specifically designed as 'one-shot tools' for pulmonary vein isolation (PVI). The purpose of this study was to compare the efficacy, safety, and procedure times for two such catheters using different energy sources.

METHODS AND RESULTS

One hundred and ten patients, referred for ablation of paroxysmal or persistent AF, were randomized to treatment with either the cryoballoon or the circular multipolar duty-cycled radiofrequency-based pulmonary vein ablation catheter (PVAC). Complete PVI was achieved in 98 vs. 93% patients in the cryoballoon and PVAC group, respectively, with complication rates of 8 vs. 2% (P = 0.2). Complete freedom from AF, without antiarrhythmic drugs, after one single ablation procedure was seen in 46% in the cryoballoon vs. 34% after 12 months (P = 0.2). Procedure times were comparable, but fluoroscopy time was shorter for the cryoballoon (32 ± 16 min) than for the PVAC procedures (47 ± 17 min) (P < 0.001). A significant improvement of quality of life (QoL) and arrhythmia-related symptoms was seen in both groups after ablation.

CONCLUSION

Both catheters proved comparably effective and safe in achieving acute PVI, apart from the shorter fluoroscopy times achieved with the cryoballoon. At follow-up, there was no statistically significant difference between the groups regarding freedom from AF and clinical success. The QoL increased to the same levels as for the general Swedish population in both groups.

[Anesthetic management of an emergency open-heart surgery for entrapment of a circular mapping catheter by chordae tendineae with mitral valve damage undergoing atrial fibrillation ablation]

The entrapment of a circular mapping catheter by chordae tendineae during catheter ablation is a very rare but serious complication requiring, in some cases, surgical treatment. We report a case that required open heart surgery for catheter removal and mitral valve repair. A 79-year-old man underwent catheter ablation for paroxysmal atrial fibrillation in other hospital. During the operation, he moved accidentally, despite circular mapping catheter was in the left atrium. The circular mapping catheter was uncontrolable due to resistance interfering with catheter removal, and the patient was brought to our hospital for open heart surgery to remove catheter. General anesthesia was induced and maintained with midazolam, fentanyl. Transesophageal echocardiography was performed to monitor catheter position and mitral valve condition. Transesophageal echocardiography revealed that circular catheter tip was located adjacent to the posterior mitral leaflet and the presence of moderate mitral valve regurgitation. Circular catheter tip was entraped by chordae tendineae and caused posterior mitral leaflet damage. Intracardiac foreign body removal and posterior mitral leaflet repair were completed uneventfully under cardiopulmonary bypass. The postoperative course was uneventful. It is expected that catheter ablation for atrial fibrillation will increase in number. This rare complication of catheter ablation may become a threat to cardiologist, cardiac surgeon and anesthesiologist.

Catheter-induced bilateral coronary ostium dissection in a patient with long-term steroid therapy

Catheter-induced coronary dissection is a very rare and serious complication. We report a case of a 44-year-old man with catheter-induced bilateral coronary dissection that occurred during diagnostic coronary angiography for angina. The coronary dissection was successfully treated by stenting at the left main trunk, the left anterior descending artery, and the right coronary ostium. The patient had been maintained on long-term steroid therapy for nephrotic syndrome. The effect of long-term steroid therapy on bilateral coronary dissection is worthy of discussion.

Intracardiac aspiration for life-threatening air embolism during cardiac catheterization in tetralogy of Fallot: an aborted sudden death

Accidental introduction of air into veins can occur during a variety of surgical operations or diagnostic procedures. High mortality rate results without early diagnosis and appropriate treatment. This is due to "air lock" at the right ventricular outflow tract, compromising the left ventricular filling. We describe a 2-year-old male with Tetralogy of Fallot who developed air embolism due to unexpected rupture of Swan-Gang catheter during a cardiac catheterization study, which was managed successfully by intracardiac aspiration.

Challenges associated with use of the GuideLiner catheter in percutaneous coronary interventions

The GuideLiner catheter is an easy-to-use guide catheter extension that can facilitate vessel engagement and equipment delivery. We present two cases that illustrate two potential challenges associated with use of the GuideLiner catheter: (1) stent loss and deformation during attempts to advance it through the GuideLiner catheter collar; and (2) displacement of the GuideLiner catheter distal marker into a coronary artery. Awareness of these potential complications may render safer the use of this valuable interventional tool.

[The comparison of thrombectomy catheters by primary transcutaneous coronary surgery]

Treatment results of 44 cases of myocardial infarction with ST segment elevation were analyzed. Patients were divided in 2 groups. The first group (n=21) received the transcutaneous coronary intervention with the use of catheters for rheolythic thrombectomy. The second group (n=23) received the intervention with catheters for the manual thrombectomy. Patients from the 1st group demonstrated reliably better results considering adequate reperfusion, registered angio- and electrocardiographically. There were no cases of arterial dissection or vessel perforation in both groups. There were two lethal hospital outcomes among patients of the manual thrombectomy group.