Feasibility and outcomes with subclavian vein access for crescent jugular dual lumen catheter for venovenous extracorporeal membrane oxygenation in COVID-19 related acute respiratory distress syndrome

INTRODUCTION

Femoral-femoral Veno-Venous ExtraCorporeal Life Support (V-V ECLS) has been associated with higher infections rates, vascular site bleeding complications, and restricted patient mobility. Jugular or bicaval dual lumen V-V ECLS conceptually overcomes some of these adverse factors, but experience has shown that jugular vein cannulation still limits mobility and has increased bleeding complications. Technique and outcomes of subclavian vein single-cannulation with Crescent jugular dual-lumen V-V ECLS is described.

METHOD

five patients with COVID-19 related acute respiratory distress syndrome (ARDS) underwent right subclavian vein V-V ECLS placement with the Crescent 32 French jugular dual-lumen V-V ECLS catheter. A standardized percutaneous technique was developed that allowed efficient insertion without need for any specialized imaging (i.e. transesophageal echocardiogram) and outcomes assessed.

RESULTS

Mean age of the five patients was 41.2 years, all obese with an average basal mass index of 45.2 kg/m2 and mean days to decannulation of 24.2 days. Outcomes discovered included; improved patient mobility allowing physical rehabilitation, no vascular access site related complications requiring surgery or endovascular intervention, and none had evidence of superior vena cava syndrome. One patient had subclavian/axillary vein thrombosis with resolution after 3 months of direct-acting oral anticoagulants, and one patient had blood cultures positive at day 37, nearing decannulation.

CONCLUSION

Subclavian vein access for crescent jugular dual lumen V-V ECLS catheter appears to be safe and feasible with added benefits of decreased bleeding and increased mobility over jugular or femoral-femoral access site for long term V-V ECLS support in COVID-19 related ARDS patients.

A Neonatal Rodent Model of Retroorbital Vein Injection

Intravenous (iv) injection is the most used route of drug administration in neonates in the clinical setting. Therefore, retroorbital vein injection is an important method for compound administration in research, where successful proof-of-concept studies can progress into much-needed neonatal clinical trials. Most intravenous studies in neonatal rodents use the superficial temporal/facial vein. However, retroorbital injection becomes unreliable in neonatal rodents older than 2 days after the skin darkens and the vein is no longer visible. In the present protocol, we describe the retroorbital injection of the venous sinus in both the neonatal mouse and rat at ages when the superficial temporal vein is no longer visible, but the eyes have not opened yet. Eye-opening facilitates retro-orbital injection by enabling the researcher to clearly see that they are not perforating the eye when inserting the needle. We demonstrate that this technique can be performed in a reliable and reproducible manner without adverse effects. Additionally, we show that it can be used in many studies, such as administering compounds to study neonatal brain injury.

Percutaneous infraclavicular subclavian vein catheters in paediatric cancer patients in comparison with critically ill children: a one-year experience from a Tunisian hospital

BACKGROUND

Paediatric cancer and critically ill patients frequently require central venous catheters for prolonged intravenous therapy. The aim of this study is to compare the difficulty of catheter insertion and the morbidity related to this procedure in these two populations and to investigate risk factors for complications.

METHODS

This prospective observational study was conducted at the Hedi Chaker University Hospital in Sfax, Tunisia, from July 2021 to July 2022. We included all patients aged three months to 14 years who required an infraclavicular subclavian vein catheterization. Patients were divided into two groups: Group 1 included children with malignancies; and Group 2 included critically ill paediatric patients. Then, we compared the demographic data, the difficulty of the catheterization procedure, and catheter-related complications. We also investigated risk factors for complications using a logistic regression model. The significance level was P<0.05.

RESULTS

We included 65 infants and children requiring central venous access, 28 of whom suffered from malignancies. The demographic parameters were comparable. However, the time for the procedure and the number of attempts were higher in the malignancy group with P<0.001. Central venous catheter complications were present 46.4% of the time in Group 1 compared to 21.6% in Group 2 (P=0.032). Malignancies were associated with an increased risk of complications (aOR = 2.95; 95%CI: 0.63-13.8).

CONCLUSIONS

This study showed increased difficulty and higher morbidity related to infraclavicular subclavian vein catheterization among infants and children suffering from cancer.

Drainage Pattern of Craniofacial Veins With Emphasis on its Influence on Facial Reconstruction Procedures

As the facial transplantation procedures are becoming more popular and frequent in recent years, for repairing facial trauma, variations in the veins of head and neck needs to be reported time and again. This study was undertaken to examine the course and drainage pattern of the facial vein and external jugular vein on this context and emphasize its surgical implications. The authors studied the head and neck region of 50 embalmed cadavers of both sexes to document normal and variant anatomy of facial, retromandibular, and external jugular veins. In 30% of the head and neck regions, different draining pattern of the above-mentioned veins were observed. One of the rare variation discovered was the splitting of the retromandibular vein to embrace the external carotid artery within the parotid gland. The data about variations in the termination of facial vein, retromandibular vein, and external jugular vein, as observed in the present study might be useful in avoiding accidental injury to these vessels during any surgical intervention in the face as well as neck. Level of Evidence: IV.

Subclavian Vein Blood Sampling in Conscious Rats

There are several established methods for obtaining repeated blood samples from rats, with the most commonly employed methods being lateral tail vein sampling without anesthesia and jugular vein sampling with anesthesia. However, most of these methods require assistance and anesthetic equipment and sometimes pose difficulties in terms of blood collection or the poor quality of blood samples. In addition, these methods of blood collection consume significant time and human resources when repeated blood sampling is required for a large number of rats. This study presents a technique for repetitive blood sampling in non-anesthetized rats by a single proficient individual. Highly satisfactory blood samples can be obtained by puncturing the subclavian vein. The method demonstrated an impressive overall success rate of 95%, with a median time of merely 2 min from rat restraint to the completion of blood collection. Furthermore, performing consecutive blood collections within the designated range does not inflict any harm on the rats. This method is worth promoting for blood collection, especially in large-scale pharmacokinetic studies.

Can subclavian/infraclavicular axillary vein collapsibility index predict spinal anesthesia-induced hypotension in cesarean-section operations?

OBJECTIVE

Spinal anesthesia-induced hypotension (SAIH) is relatively common in pregnant women and has serious maternal and fetal side effects. In patients who are hypovolemic during spinal anesthesia, there may be a significant decrease in blood pressure caused by the decrease in preload. Subclavian vein sonography is a useful method for evaluating preoperative intravascular volume status. This study aimed to evaluate the efficacy of the pre-operative subclavian vein or infraclavicular axillary vein (SCV-AV) collapsibility index for predicting SAIH in cesarean-section (C-section).

PATIENTS AND METHODS

In this prospective observational study, 82 women undergoing elective C-sections were recruited. Sonographic evaluation of SCV-AV was assessed before spinal anesthesia. After spinal anesthesia, changes in blood pressure were noted. The main outcome was the association between the SCV-AV measurements (diameter and collapsibility index) and SAIH.

RESULTS

Hypotension developed in 53 (64%) patients after spinal anesthesia. The collapsibility index of the SCV-AV during spontaneous breathing and deep inspirium was not a significant predictor of a decrease in mean blood pressure (MBP) after spinal anesthesia (p<0.979, p<0.380).

CONCLUSIONS

It was found that the SCV-AV collapsibility index is not a predictor of SAIH in pregnant women undergoing elective C-sections.

Temporary pacemaker implantation via median cubital vein: A simple safe and effective technique

BACKGROUND

Temporary cardiac pacemaker implantation (PM) via the femoral and subclavian veins is widely used in clinics to treat patients with severe bradycardia or tachycardia, but it is technically challenging and potentially associated with various complications.

HYPOTHESIS

This study investigated the feasibility and safety of a novel method of PM implantation via the median cubital vein.

METHODS

A total of 279 patients of the First Affiliated Hospital of Xiamen University between March 2020 and December 2021 who required no-emergency PM implantation were enrolled. The patients were divided into three groups based on the temporary PM implantation routes: F-control (n = 107), via the femoral vein; S-control (n = 67), via the subclavian vein, and N-group (n = 105), via the median cubital vein. The sheath placement time (SPT), electrode placement time (EPT), electrode arrival rate (EAR), rate of sensing and pacing (RSP), radiation quantity (RD), electrode dislocation rate (EDR) and average electrode retention time (AERT) were recorded and evaluated. In addition, the Hamilton Anxiety Scale (HAMA) and Self-Rating Depression Scale (SDS) were used to evaluate the comfort levels of patients in the three groups.

RESULTS

There were no significant differences between the groups with regard to age, EAR, RSP, EPT, RD, and AERT (p > 0.05). However, the N-group had significantly lower SPT than the F-control and S-control groups (67.0 ± 22.0 s vs. 321.7 ± 122.2 s and 307.3 ± 128.5 s, p = 0.000). Additionally, the F-control had significantly higher EDR than the S-control group and the N-group (11 (10.3%) vs. 2 (3.0%) and 3 (2.9%), p = 0.036). Besides, comparison of the HAMA and SDS scores before and after PM implantation showed significant differences in the S-control group (p = 0.010) and the N-group (p = 0.000).

CONCLUSIONS

Temporary PM implantation via the median cubital vein is safe, effective, and less time-consuming.

Microsurgical Creation of Giant Bifurcation Aneurysms in Rabbits for the Evaluation of Endovascular Devices

Giant aneurysms are dangerous lesions requiring endovascular treatment, with high rates of aneurysm recanalization and re-rupture. Reliable in vivo models are rare but are required for testing new endovascular devices. We demonstrate the technical aspects of the creation of giant bifurcation aneurysms in New Zealand white rabbits (2.5-5.5 kg). A 25-30 mm long venous pouch is taken from the external jugular vein, and a bifurcation between both carotid arteries is created microsurgically. The pouch is sutured in the bifurcation to mimic a giant aneurysm. This protocol summarizes our previously published standard technique for venous pouch true arterial bifurcation aneurysms and highlights its essential modification steps for giant aneurysms. Using this modified technique, we were able to create an animal model for giant aneurysms with high comparability to humans regarding the hemodynamics and coagulation systems. Furthermore, low morbidity and high aneurysm patency rates were achieved. The proposed giant aneurysm model offers an excellent possibility for testing new endovascular devices.

[Venous access routes for cardiac implantable electronic devices]

Various venous access routes in the region of the clavicle are available for cardiac device treatment. After many years of choosing access via the subclavian vein, current data explicitly show that lateral approaches such as preparation of the cephalic vein or puncture of the axillary vein are clearly superior in terms of probe durability and risk of complications. This article describes the preparation and performance of the various access techniques and is intended to provide a practical guide for the work in cardiac pacemaker operations. This work continues a series of articles designed for advanced training in specialized rhythmology.

Axillary vein puncture versus cephalic vein cutdown for cardiac implantable electronic device implantation: A meta-analysis

INTRODUCTION

Cephalic vein cutdown (CVC) and axillary vein puncture (AVP) are both recommended for transvenous implantation of leads for cardiac implantable electronic devices (CIEDs). Nonetheless, it is still debated which of the two techniques has a better safety and efficacy profile.

METHODS

We systematically searched Medline, Embase, and Cochrane electronic databases up to September 5, 2022, for studies that evaluated the efficacy and safety of AVP and CVC reporting at least one clinical outcome of interest. The primary endpoints were acute procedural success and overall complications. The effect size was estimated using a random-effect model as risk ratio (RR) and relative 95% confidence interval (CI).

RESULTS

Overall, seven studies were included, which enrolled 1771 and 3067 transvenous leads (65.6% [n = 1162] males, average age 73.4 ± 14.3 years). Compared to CVC, AVP showed a significant increase in the primary endpoint (95.7 % vs. 76.1 %; RR: 1.24; 95% CI: 1.09-1.40; p = .001) (Figure 1). Total procedural time (mean difference [MD]: -8.25 min; 95% CI: -10.23 to -6.27; p < .0001; I2  = 0%) and venous access time (MD: -6.24 min; 95% CI: -7.01 to -5.47; p < .0001; I2  = 0%) were significantly shorter with AVP compared to CVC. No differences were found between AVP and CVC for incidence overall complications (RR: 0.56; 95% CI: 0.28-1.10; p = .09), pneumothorax (RR: 0.72; 95% CI: 0.13-4.0; p = .71), lead failure (RR: 0.58; 95% CI: 0.23-1.48; p = .26), pocket hematoma/bleeding (RR: 0.58; 95% CI: 0.15-2.23; p = .43), device infection (RR: 0.95; 95% CI: 0.14-6.60; p = .96) and fluoroscopy time (MD: -0.24 min; 95% CI: -0.75 to 0.28; p = .36).

CONCLUSION

Our meta-analysis suggests that AVP may improve procedural success and reduce total procedural time and venous access time compared to CVC.

Modified Tail Vein and Penile Vein Puncture for Blood Sampling in the Rat Model

Blood samples are required in most experimental animal designs to assess various hematological parameters. This paper presents two procedures for blood collection in rats: the lateral tail vein puncture and the dorsal penile vein puncture, which offer significant advantages over other previously described techniques. This study shows that these two procedures allow for fast sampling (under 10 min) and yield sufficient blood volumes for most assays (202 μL ± 67.7 μL). The dorsal penile vein puncture must be done under anesthesia, whereas the lateral tail vein puncture can be done on a conscious, restrained animal. Alternating these two techniques, therefore, enables blood draw in any situation. While it is always recommended for an operator to be assisted during a procedure to ensure animal welfare, these techniques require only a single operator, unlike most blood sampling methods that require two. Moreover, whereas these previously described methods (e.g., jugular stick, subclavian vein blood draw) require extensive prior training to avoid harm to or death of the animal, tail vein and dorsal penile vein puncture are rarely fatal. For all these reasons, and according to the context (e.g., for studies including male rats, during the perioperative or immediate postoperative period, for animals with thin tail veins), both techniques can be used alternately to enable repeated blood draws.

Right Atrial and Endocardial Lead Mass Secondary to Anterior Mediastinal Mass Encasing Left Subclavian Vein

INTRODUCTION

Multimodality cardiac imaging is a valuable tool for the noninvasive evaluation of right atrial masses (tumor, vegetation, or thrombus).

CASE PRESENTATION

We report a case of right atrial mass that was discovered on a transthoracic echocardiogram ordered for pacemaker-pocket erythema in a 101-year-old man with heart failure/reduced left-ventricular ejection fraction and a dual-chamber pacemaker. Transthoracic and transesophageal echocardiogram showed a large hypoechoic mobile RA mass extending from the superior vena cava, with pacemaker device lead attachment. Infective endocarditis was excluded (no symptoms of systemic infection; negative blood cultures). CT angiography of the chest revealed an anterior mediastinal mass, highly suspicious for malignancy, encasing the left subclavian vein. The patient chose not to pursue invasive assessment of the mediastinal mass. Role of anticoagulation is unclear.

CONCLUSION

Computed tomography complemented echocardiographic assessment and management of a right atrial mobile echo density due to a large anterior mediastinal mass.

[Not Available]

Pseudoaneurysms and thrombosis in the jugular vein are very rare. This case report presents a case of a 57-year-old female with a thrombosis in the internal jugular vein and a pseudoaneurysm in the external jugular vein. The diagnosis is often delayed due to the less-frequent occurrence of either. Ultrasound and/or computer tomographic scan are useful in the diagnostic process. Pseudoaneurysms in the external jugular vein are often benign and treatment spans from none to surgical removal. The treatment of venous thrombosis is anticoagulant medication.

Current Perspective and Strategy on Management of Spontaneous Jugular Venous Ectasia: A Systematic Review

BACKGROUND

Spontaneous jugular venous ectasia (SJVE) is characterized by dilation of the internal jugular vein (IJV) and external jugular vein. It is generally considered a benign anomaly. There is no accepted categorization for this disorder.

METHODS

We conducted a case series study and a systematic review of available articles on SJVE to understand the main characteristics, clinicopathologic classifications, and therapeutic approaches.

RESULTS

From January 2001 to December 2021, 14 patients in our hospital were analyzed. A total of 110 original articles (295 cases/311 lesions) were included in the systematic review. We proposed a classification and categorized SJVE into 4 main types (type I-IV) plus one (type V) in which the specific ectasia was located around the jugular bulb at the IJV.

CONCLUSIONS

Conservative treatment is preferred for patients with type I (without thrombus) SJVE and asymptomatic patients who can be treated without anticoagulants. The therapeutic efficiency of surgery was high, and the best surgical modalities were chosen according to the type of SJVE.

A Modified Technique for Arteriovenous Fistula Construction in Rabbits

Juxta-anastomotic stenosis is a challenging problem that often causes non-maturation and decreases the patency of an arteriovenous fistula (AVF). Injury to the veins and arteries during the operation and hemodynamic changes can lead to intimal hyperplasia, leading to juxta-anastomotic stenosis. To reduce injury to the veins and arteries during the operation, this study proposes a new modified no-touch technique (MNTT) for AVF construction that can decrease the rate of juxta-anastomotic stenosis and improve the AVF patency. To unravel the hemodynamic changes and mechanisms of the MNTT, this study presented an AVF procedure using this technique. Although this procedure is technically challenging, 94.4% procedural success was achieved after adequate training. Ultimately, 13 out of 34 rabbits had a functional AVF 4 weeks after the surgery, leading to a 38.2% AVF patency rate. However, at 4 weeks, the survival rate was 86.1%. Ultrasonography showed active blood flow through AVF anastomosis. Furthermore, the spiral laminar flow was observed in the vein and artery near the anastomosis, suggesting that this technique may improve the hemodynamics of the AVF. On histological observation, significant venous intimal hyperplasia was observed at the AVF anastomosis, whereas no significant intimal hyperplasia was observed at the proximal external jugular vein (EJV) of the anastomosis. This technique will improve the understanding of the mechanisms underlying the use of MNTT for AVF construction and provide technical support for the further optimization of the surgical approach in AVF construction.

Agreement between ultrasonic bubble grades using a handheld self-positioning Doppler product and 2D cardiac ultrasound

INTRODUCTION

Intravascular bubble load after decompression can be detected and scored using ultrasound techniques that measure venous gas emboli (VGE). The aim of this study was to analyse the agreement between ultrasonic bubble grades from a handheld self-positioning product, the O'Dive™, and cardiac 2D ultrasound after decompression.

METHODS

VGE were graded with both bilateral subclavian vein Doppler ultrasound (modified Spencer scale) and 2D cardiac images (Eftedal Brubakk scale). Agreement was analysed using weighted kappa (Kw). Analysis with Kw was made for all paired grades, including measurements with and without zero grades, and for each method's highest grades after each dive.

RESULTS

A total of 152 dives yielded 1,113 paired measurements. The Kw agreement between ultrasound VGE grades produced by cardiac 2D images and those from the O'Dive was 'fair'; when zero grades were excluded the agreement was 'poor'. The O'Dive was found to have a lower sensitivity to detect VGE compared to 2D cardiac image scoring.

CONCLUSIONS

Compared to 2D cardiac image ultrasound, the O'Dive yielded generally lower VGE grades, which resulted in a low level of agreement (fair to poor) with Kw.

Anatomical basis of retrograde thoracic veins flow and its implications in complex thoracic wall reconstructive surgery

Purpose

Internal thoracic veins are increasingly used as recipient’s vessels in chest wall reconstructive surgery due to their predictable anatomy and to the possibility to make a double venous anastomosis, exploiting the retrograde flow within them. Over the years, retrograde flow had been explained by the absence of valves in internal thoracic veins, which have been found recently instead. Therefore, our aim is to analyze the retrograde flow and its relationship with valves in the internal thoracic veins.

Methods

We evaluated 32 internal thoracic veins of 16 fresh-frozen specimens with undamaged thoracic cages by dynamic analysis focused on retrograde flow assessment through a partial external circulation system obtained cannulating the subclavian veins. Gross anatomical and morphological evaluations about the presence of valves and their pattern were then made.

Results

Efficient, partial, and absent retrograde flow was, respectively, found in 17/30, 8/30 and ITVs and 5/30 internal thoracic veins. Following Arnez’s classification, 20/32 Type I and 12/32 Type II internal thoracic veins were identified. Valves were observed in 10/16 specimens (62.50%) corresponding to 36.67% of examined veins (11/30). Three valves were found between the 2nd intercostal space and 12 valves in the 3rd intercostal space. 13/15 valves were bicuspid, 2/15 tricuspid. A significant correlation (p < 0.001) between the retrograde flow and the presence of valves in internal thoracic veins was observed.

Conclusion

Our study suggests a possible influence of the presence and the number of valves in the efficient retrograde flow of the internal thoracic veins, suggesting that, especially for more complex cases, a preoperative or intraoperative evaluation of the chest wall drainage should be recommended.

Retrospective Assessment of Patient and Catheter Characteristics Associated With Malpositioned Central Venous Catheters in Pediatric Patients

OBJECTIVES

The primary objective was to determine the prevalence and characteristics associated with malpositioned temporary, nontunneled central venous catheters (CVCs) placed via the internal jugular (IJ) and subclavian (SC) veins in pediatric patients.

DESIGN

Single-center retrospective cohort study.

SETTING

Quaternary academic PICU.

PATIENTS

Children greater than 1 month to less than 18 years who had a CVC placed between January 2014 and December 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the CVC tip position located on the first postprocedural radiograph. CVC tip was defined as follows: "recommended" (tip location between the carina and two vertebral bodies inferior to the carina), "high" (tip location between one and four vertebral bodies superior to the carina), "low" (tip position three or more vertebral bodies inferior to the carina), and "other" (tip grossly malpositioned). Seven hundred eighty-one CVCs were included: 481 (61.6%) were in "recommended" position, 157 (20.1%) were "high," 131 (16.8%) were "low," and 12 (1.5%) were "other." Multiple multinomial regression (referenced to "recommended" position) showed that left-sided catheters (adjusted odds ratio [aOR], 2.00, 95% CI 1.17-3.40) were associated with "high" CVC tip positions, whereas weight greater than or equal to 40 kg had decreased odds of having a "high" CVC tip compared with the reference (aOR, 0.45; 95% CI, 0.24-0.83). Further, weight category 20-40 kg (aOR, 2.42; 95% CI, 1.38-4.23) and females (aOR, 1.51; 95% CI, 1.01-2.26) were associated with "low" CVC tip positions. There was no difference in rates of central line-associated blood stream infection, venous thromboembolism, or tissue plasminogen activator usage or dose between the CVCs with tips outside and those within the recommended location.

CONCLUSIONS

The prevalence of IJ and SC CVC tips outside of the recommended location was high. Left-sided catheters, patient weight, and sex were associated with malposition. Malpositioned catheters were not associated with increased harm.

Leadless Pacemaker Implantation in a Patient With Diminutive Subclavian Veins

Conventional pacemakers have a longstanding history of preventing morbidity and mortality in patients with bradyarrhythmia and conduction disorders. While decades of advancements have improved pacemaker technology and implantation technique, insertion of transvenous leads and formation of a pectoral pocket can lead to complications, including pocket hematoma, pneumothorax, or infection. Leadless pacemakers were introduced in 2012 to address these complications; however, early leadless systems only provided single-chamber ventricular pacing. In 2020, an accelerometer-based atrial sensing feature was developed to allow for atrioventricular (AV) synchrony with these devices. Early evidence suggests that patients with sinus rhythm and AV block can benefit from single-chamber leadless pacing systems with an AV synchrony algorithm. As availability of these devices continues to broaden, identification of appropriate recipients has become increasingly relevant.

Implantation Of The Permanent Pacemaker; From Superior Vena Cava In A Patient With Fibrosis Of Both Subclavian Veins

Overall life span has increased with improved management of cardiac diseases all over the world which has opened the door of degenerative cardiac diseases. On the other hand, stat of the art corrective congenital cardiac disease also increased the volume of adult living with treated congenital heart diseases. Both these factors lead to a new epidemic in cardiology of complete heart block (CHB). Permanent pacemakers (PPM) implantation is a life-saving procedure for CHB. Permanent pacemakers are usually implanted from upper limb veins. But at time upper limb veins are not suitable for implantation due to various anatomical and pathological reasons, so alternative methods are used for implantation of devices. We are reporting a case of PPM implantation from Superior Vena Cava (SVC).

Aberrant Trajectory Of A Central Venous Catheter

During placement of a central venous catheter into the right subclavian vein it was found to be impossible to extract the guidewire. An Angio-Computed Tomography was performed, showing an aberrant guidewire path, as the image shows. An urgent mini-sternotomy was performed to extract both catheter and guidewire under direct visualization.

[Thromboembolic event following in vitro fertilisation]

Thromboembolic events constitute a serious complication to assisted reproductive technology, and this is a case report of thrombosis after in vitro fertilisation. A 30-year-old woman had a positive pregnancy test, but she experienced shortness of breath 12 days after oocyte retrieval. D-dimer concentration was elevated, and lung scintigraphy demonstrated an infarction. Low-molecular-weight heparin (LMWH) treatment was initiated, but one week later the patient noticed pain in her left upper extremity. Despite LMWH treatment, ultrasonic examination showed thrombosis in the left subclavian and internal jugular vein.

Supraclavicular approach for subclavian vein catheterization in pediatric anesthesia: The reborn of an ancient technique with the ultrasound's assistance

The insertion of a central venous catheter is a procedure frequently performed in paediatric anaesthesia. The most frequent approach for this procedure is the internal jugular vein. However, some specific factors in children, such as the short neck and the easy collapse of this vein, which is accentuated in situations such as hypovolaemia and changes in the respiratory pattern, can lead to greater difficulty. The supraclavicular approach of the subclavian vein was described more than 50 years ago. However, it is not often considered nowadays, even after the introduction of ultrasound, and despite the obvious advantages with respect to the internal jugular approach due to the lower incidence of thrombosis and infection. This document reviews the considerations of the supraclavicular approach according to the available evidence in paediatric anaesthesia, discusses the feasibility and safety of the procedure, and finally describes the technique of ultrasound--guided puncture.

Spontaneous bilateral subclavian vein thrombosis in a 40-year-old man: A case report

RATIONALE

Paget-Schroetter syndrome (PSS) is an uncommon condition that refers to primary (spontaneous) thrombosis of the deep veins that drain the upper extremities because of anatomical anomalies or repetitive strenuous arm activity. Bilateral spontaneous upper extremity deep-vein thrombosis (UEDVT) is an extremely rare phenomenon in adults, which may be misdiagnosed by physicians in acute settings.

PATIENT CONCERNS

A 40-year-old man presented to our emergency department because of progressive left upper arm swelling for 1 day. He denied fever, chest pain, dyspnea, trauma, or any other systemic disease before. The swollen left arm also had no local heat or redness with normal radius pulsation. He was a laborer who lifted heavy objects.

DIAGNOSES

Blood examination included tests for complete blood count, renal function, liver function, blood coagulation profile, cardiac enzyme levels, and D-dimer level. Results showed that the white blood cell count, renal and liver functions, and cardiac enzyme levels were all within their normal ranges, except for the elevated D-dimer level (1.93 mg/L). Chest radiography and electrocardiography were performed with nonspecific findings. Subsequently, computed tomographic angiography was recommended for the suspected deep-vein thrombosis. The report showed venous thrombosis involving the bilateral subclavian and internal jugular veins.

INTERVENTIONS

Heparin and enoxaparin were prescribed for this patient, with loading and maintenance doses. He was then admitted to our cardiovascular ward for further treatment.

OUTCOMES

The patient was discharged 9 days later in a stable condition.

LESSONS

Emergency physicians should consider the rare condition of UEDVT when a healthy patient presents with acute arm swelling. Patient history taking should be thorough, especially concerning the risk factors of secondary causes and possible frequent vigorous heavy lifting and overhead motion. Without secondary risk factors, primary upper deep-vein thrombosis might be suspected. Further laboratory tests and imaging studies, especially bilateral imaging, should be arranged to exclude secondary causes and to confirm the diagnosis.

Venous System Interventions for Device Implantation

Subclavian obstruction is common after lead implantation and the need to add or replace a lead is increasing. Subclavian venoplasty (SV) is a safe and effective option for venous occlusion. Peripheral venography overestimates the severity of the obstruction. A wire can usually be advanced into the central circulation for SV. Compared with dilators, SV improves the quality of venous access, providing unrestricted catheter manipulation for His bundle pacing and left ventricular lead implantation. SV preserves venous access and reduces lead burden. SV can easily be added to the implanting physicians lead management options.

[Complications analysis of subcutaneous venous access port for chemotherapy in patients with gastrointestinal malignancy]

OBJECTIVE

To describe and analyze the complications of subcutaneous venous access port for patients with gastrointestinal malignancy.

METHODS

Data of 1 912 patients with gastrointestinal malignancy who accepted chemotherapy in our department via subcutaneous venous access ports, including 127 cases in upper arm, 865 cases in subclavicular vein and 920 cases in internal jugular vein, from June 2007 to April 2016 were analyzed retrospectively. Associated complications and risk factors were emphatically investigated.

RESULTS

Postoperative complications were confirmed in 233 patients(12.2%), and complication morbidity was 37.0%(47/127), 15.5%(134/865), 6.7%(62/920) in upper arm group, subclavicular vein group, internal jugular vein group respectively, whose difference was statistically significant (χ²=71.060, P=0.000). Sixty-one(3.2%) patients developed early complications (in the day of insertion, including catheter dislocation, pneumothorax, arterial damage). Early complication morbidity of upper arm group (14.2%, 18/127) was higher as compared to subclavicular vein group (3.4%, 29/865) and internal jugular vein group(1.5%, 14/920) with significant difference (χ²=57.867, P=0.000). Postoperative long-term complications (catheter dislocation, thrombosis, pinch-off syndrome, infusion base exposure, catheter detachment) were found in 182(9.5%) patients. Morbidity of long-term complication was 5.2%(48/920) in internal jugular vein group, which was significantly lower than 22.8% (29/127) in upper arm group and 12.1% (105/865) in subclavicular vein group with statistically significant difference (χ²=50.828, P=0.000). Multivariate analysis indicated that subclavicular vein intubation (OR=0.536, 95%CI: 0.341 to 0.843; P=0.007 OR=0.156, 95%CI: 0.096 to 0.253, P=0.000), internal jugular vein intubation (OR=0.156, 95%CI: 0.096 to 0.253, P=0.000), operation time <40 minutes (OR=0.458, 95%CI: 0.342 to 0.613, P=0.000) and standardized training (OR=0.233,95%CI: 0.171 to 0.318, P=0.000) were protective factors of postoperative complication; besides, subclavicular vein intubation (OR=0.458, 95%CI: 0.342 to 0.613, P=0.000), internal jugular vein intubation (OR=0.233, 95%CI: 0.171 to 0.318, P=0.000) and standardized training (OR=0.313, 95%CI: 0.173 to 0.568, P=0.000) were protective factors of thrombosis.

CONCLUSIONS

Subcutaneous venous access port implantation is a preferable access to central vein. Appropriate intubation approach and standardized training may reduce postoperative complications effectively. Internal jugular vein approach is safer and more reliable than upper arm vein and subclavian vein approach.

A review in emergency central venous catheterization

Central venous catheterization is widely used in the emergency setting. This review aims to assess central venous catheterization from the perspectives of types of catheters, sites of insertion, and techniques. In emergency conditions, non-tunneled catheters are preferred because the technique for its insertion is not complicated and less time-consuming. The size of catheter depends on the purpose of catheterization. For example, a large bore catheter is needed for rapid infusion. The ideal catheterization site should bear fewer thromboses, lower infectious rate, and fewer mechanical complications. Thus the femoral vein should be avoided due to a high rate of colonization and thrombosis while the subclavian vein seems to exhibit fewer infectious complications compared with other sites. The ultrasound-guided technique increases the success rate of insertion while decreases the mechanical complications rate.

[Use of ultrasound for placement of central venous catheters in pediatrics: results of a national survey]

OBJECTIVES

To study the variability of techniques used for vascular access of central venous devices, totally implanted and external tunneled, as well as polling the use of ultrasound by pediatric surgeons in Spain.

MATERIAL AND METHODS

Descriptive study of a survey results, conducted by phone, email and online, about 20 items related to the placement of these devices in children and the use of ultrasound in this procedure.

RESULTS

We analyzed 71 surveys from 31 national hospitals. The response rate was 54%. In 66% of the cases the pediatric surgeon is the one who carries out the vascular access. 75% of the respondents place less than 25 catheters/year. Only 28% have attended to an ultrasound-guided vascular puncture course. The vein used more often is the internal jugular (55%), followed by the subclavian (17.4%), with preference for the right side in most of the cases (87%). 64% perform the ultrasound-guided technique, 29% the venous cutdown and 7% the landmark approach. There is no significant association between the technique chosen (landmark vs ultrasound-guided) and the vein used (p= 0,062). The majority of the respondents does not modify the usual approach in case of coagulopathy. We describe the complications associated with the three techniques.

CONCLUSIONS

The preferred via for the vascular access by pediatric surgeons is the internal jugular vein, being this access ultrasound-guided in most of the cases. 91.5% consider the use of ultrasound decreases the number of associated complications. Nevertheless, just a minority has attended to a training course.

Paget-Schröetter Syndrome, a rare cause of subclavian vein thrombosis

Paget-Schröetter Syndrome, or effort thrombosis of the subclavian vein, is an uncommon condition that affects young, active, healthy individuals. It's a type of Thoracic Outlet Syndrome (TOS), consequence of compression and repetitive injury of the subclavian vein, between the first rib and the clavicle. This paper reports the case of a 27 year-old female presenting with an acutely swollen right upper limb, with no history of trauma or repeated movement of right arm, taking oral contraceptive pills and no history of venous thromboembolic disease. Duplex ultrasound evaluation confirmed right subclavian venous thrombosis with no evidence of cervical rib or other structural abnormalities, diagnosing Paget-Schröetter Syndrome. Following anticoagulation, catheter directed thrombolysis and balloon angioplasty were performed, with no success due to external compression. Therefore, after the correction of the external compression through first rib resection, the luminal flow was restored and the venous obstruction symptoms disappeared. In these case, a prompt treatment was critical for the achievement of the best results.

The changing profile of safe techniques for the insertion of a central venous catheter in pediatric patients - improvement in the outcome with the experiences of 500 insertions in a single institution

BACKGROUND

The ability to safely insert a central venous catheter (CVC) is critical to avoid associated complications. The aim of this study was to explore appropriate technique to maintain the safety of pediatric patients during CVC.

METHODS

We reviewed the surgical records of CVC insertion techniques and associated complications of 503 tunneled CVC insertions performed from 2000 to 2015.

RESULTS

Two hundred thirty CVCs (45.7%) were inserted into the subclavian vein using the landmark technique for 10years (first period). Only two pneumothoraxes (0.9%) were experienced. In 2009, we adopted ultrasound-guided venous catheterization from the internal jugular vein, and 103 CVCs (20.5%) were inserted (second period). This procedure led to penetration into the innominate vein (1.0%) by dilater sheath. Patient underwent repair of the penetrated vessel. After this serious complication, 170 CVCs (33.8%) were inserted using the venous cutdown procedure except two catheters. We had two cases whose accessible veins were occluded because of frequent catheterization using venous cutdown technique. No mechanical complications were experienced.

CONCLUSIONS

The venous cutdown method is the safest technique for inserting a tunneled CVC in pediatric patients. However, multiple vein occlusions because of repeated catheterizaion by venous cutdown lead to the exhaustion of accessible vessels.

LEVEL OF EVIDENCE

Treatment Study - Level IV.

High traffic congestion in right atrium

A 62-year lady presented with limb swelling and heart failure due to leads induced venous fibrosis and severe tricuspid stenosis, 33 years after pacemaker implantation. After undergoing surgical removal of all leads and tricuspid valve replacement under cardiopulmonary bypass, she regained a normal functional status and tricuspid and right ventricular functions.

Lemierre’s Syndrome: Unusual Cause of Internal Jugular Vein Thrombosis

Lemierre’s syndrome is an uncommon septic thrombophlebitis of the internal jugular vein. The authors present the case of a 52-year-old woman with literature review. She developed flu-like symptoms and fever, and then painful swelling of the left side of her neck and left arm. Contrast-enhanced computed tomography of the neck revealed thrombosis in the left internal jugular vein, subclavian vein, and brachiocephalic vein and diffuse soft tissue inflammation around the veins. No microorganism was identified in the blood and venous thrombus, which was obtained by percutaneous aspiration thrombectomy. Systemic antibiotics and anticoagulation therapy achieved complete resolution of the symptoms. Recanalization of the thrombosed veins with no residual thrombi was observed on duplex scanning after 3 months. No pulmonary embolism or other metastatic infection was observed. Clinical suspicion seems to be essential to make an accurate diagnosis during the early stage of the disease, which is critical to obtain a successful outcome for Lemierre’s syndrome.

Subclavian Vein Central Line Catheter Mistakenly Placed in the Aorta: A Case Report and How to Avoid Complications

An 85-year-old female with multiple medical problems presented with a sigmoid volvulus. While in the ICU, the patient required a central line because of poor peripheral access. The central line was mistakenly placed in the aorta while attempting to use the subclavian approach. In this manuscript we discussed ways of reducing complications and successfully placing subclavian vein catheters.

TrapEase Inferior Vena Cava Filter Placement: Use of the Subclavian Vein

The purpose of this paper was to evaluate the safety and technical success of TrapEase inferior vena cava filter placement via the subclavian vein. As of yet, no reports in the literature have specifically investigated the use of the subclavian vein as a route for deploying TrapEase vena cava filters. Retrospective chart review was conducted of 135 patients with attempted TrapEase inferior vena cava filter placement over a 2-year period. In a majority of cases, the choice of subclavian vein approach was based primarily on surgeon preference. Other circumstances for subclavian vein deployment included cervical immobilization secondary to trauma, desire for concomitant placement of a subclavian long-term central venous access catheter, and patient body habitus limiting exposure to the internal jugular vein. One hundred and thirty-five filters were placed over this 2-year period. The internal jugular vein approach was used in 56 patients, the femoral vein approach in 39 patients, and the subclavian vein approach in 40 patients. Thirty-nine of the 40 TrapEase filter placements using the subclavian vein were successful. Twenty-six were deployed through the right subclavian vein and 14 through the left subclavian vein. The single failed subclavian deployment was due to the inability to pass the guidewire adequately into the inferior vena cava after successful cannulation of the right subclavian vein. The average deployment time for subclavian vein placement was 26 minutes when TrapEase filter placement was the only procedure performed. No insertional complications were encountered, specifically no pneumothoraces confirmed by chest radiography or fluoroscopy. The subclavian vein provides an alternative site of access for the TrapEase inferior vena cava filter. This route is comparable to other alternative methods evaluated both in average deployment time and complication occurrence. Furthermore, the subclavian vein route is valuable in patients with limited central access and where combined long-term central venous catheter placement using the subclavian vein is desirable.

Delayed Pneumothorax: A Complication of Subclavian Vein Catheterization

Subclavian catheterization is a reliable, well-described technique of central venous access for a variety of indications. Significant complications are associated with the procedure. Detection of the majority of complications is afforded by the postinsertion chest x-ray. Delayed pneumothorax, a relatively unrecognized complication of subclavian catheterization, is caused by a slow pleural air leak which appears to be associated with the "difficult" insertion as illustrated by three case reports. A repeat or "delayed" chest roentgenogram should be considered in the following situations: Difficult subclavian insertions requiring multiple attempts. Suspicion of pleural injury such as aspiration of air during insertion or subcutaneous emphysema with a normal postinsertion chest x-ray. The presence of another major complication. If the patient complains of persistent pleuritic or back pain after insertion. Preoperatively after previous difficult insertion of a central venous line. Postoperatively when a subclavian catheter is inserted intraoperatively.