Prospective series of two hours supine rest after 4fr sheath-based                     diagnostic cerebral angiography: Outcomes, productivity and cost

There is no standard of care for catheter size or post-procedure supine time in cerebral angiography. Catheter sizes range from 4-Fr to 6-Fr with supine times ranging from two to over six hours. The objective of our study was to establish the efficacy, safety, and cost savings of two-hour supine time after 4-Fr elective cerebral angiography. A prospective, single arm study was performed on 107 patients undergoing elective cerebral angiography. All cerebral angiograms were performed with a 4-Fr sheath-based system without closure devices. Ten minutes of manual compression was applied to the femoral access site, with further compression held as clinically indicated. Patients were then monitored in a nursing unit for two hours supine and subsequently mobilized. Nursing discretion was allowed for earlier mobilization. Patients were called the next day to assess delayed hematoma and bleeding. Estimates of cost savings and productivity increases are provided. All patients ambulated in two hours or less. There were no strokes or vessel dissections. Five patients (4.7%) experienced a palpable hematoma, three patients (2.8%) experienced bleeding immediately following the procedure requiring further compression, and one patient (0.9%) experienced minor groin oozing at home. No patient required transfusion, thrombin injection, or endovascular/surgical management of a groin complication. A two-hour post-procedure supine time resulted in cost savings of $952 per angiogram and a total of $101,864. 4-Fr sheath based cerebral angiography with two-hour post-procedure supine time is safe and effective, and allows for a considerable increase in patient satisfaction, cost savings and productivity.

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Flip Techniques: Obtaining Antegrade and Retrograde Femoral Access Through a Single Access Site

10.1093/med/9780199986071.003.0024 ◽

2018 ◽

Author(s):

S. Lowell Kahn

Keyword(s):

Standard Of Care ◽

Common Femoral Artery ◽

Fogarty Catheter ◽

Technical Success ◽

Access Site ◽

Femoral Access ◽

Technical Success Rate ◽

The Third ◽

The Common ◽

Buddy Wire

Retrograde access of the common femoral artery for ipsilateral iliac and up-and-over contralateral iliac-to-tibial interventions has been the standard of care for lower extremity procedures. However, ipsilateral antegrade access has gained popularity for infrainguinal occlusive disease. Proximity of the access site to the point of occlusion confers a higher technical success rate. Interestingly, there are times where conversion of a single femoral access from retrograde to antegrade or antegrade to retrograde may be desired. Three techniques are reviewed in this chapter: the first technique involves using a reverse curve catheter in conjunction with a Glidewire. The second technique is a “rebound” method whereby a Fogarty catheter is inflated just beyond the tip of a retrograde sheath to deflect a side-by-side Glidewire in the opposite direction. The third technique describes converting an antegrade sheath back to retrograde using a “buddy wire.”

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Transradial intraoperative cerebral angiography: a multicenter case series and technical report

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015207 ◽

2019 ◽

Vol 12 (2) ◽

pp. 170-175

Author(s):

Joshua W Osbun ◽

Bhuvic Patel ◽

Michael R Levitt ◽

Alexander T Yahanda ◽

Amar Shah ◽

...

Keyword(s):

Radial Artery ◽

Cerebral Angiography ◽

Carotid Arteries ◽

Case Series ◽

Patient Positioning ◽

Interventional Cardiology ◽

Access Site ◽

Femoral Access ◽

Technical Success Rate ◽

Access Site Complication

BackgroundUse of the radial artery as an access site for neurointerventional procedures is gaining popularity after several studies in interventional cardiology have demonstrated superior patient safety, decreased length of stay, and patient preference compared with femoral artery access. The transradial approach has yet to be characterized for intraoperative cerebral angiography.ObjectiveTo report a multicenter experience on the use of radial artery access in intraoperative cerebral angiography, including case series and discussion of technical nuances.Methods27 patients underwent attempted transradial cerebral angiography betweenMay 2017 and May 2019. Data were collected regarding technique, patient positioning, vessels selected, technical success rate, and access site complications.Results24 of the 27 patients (88.8%) underwent successful transradial intraoperative cerebral angiography. 18 patients (66.7%) were positioned supine, 6 patients (22.2%) were positioned prone, 1 patient (3.7%) was positioned lateral, and 2 patients (7.4%) were positioned three-quarters prone. A total of 31 vessels were selected including 13 right carotid arteries (8 common, 1 external, 4 internal), 11 left carotid arteries (9 common and 2 internal), and 6 vertebral arteries (5 right and 1 left). Two patients (7.4%) required conversion to femoral access in order to complete the intraoperative angiogram (1 due to arterial vasospasm and 1 due to inadvertent venous catheterization). One procedure (3.7%) was aborted because of inability to obtain the appropriate fluoroscopic views due to patient positioning. No patient experienced stroke, arterial dissection, or access site complication.ConclusionsTransradial intraoperative cerebral angiography is safe and feasible with potential for improved operating room workflow ergonomics, faster patient mobility in the postoperative period, and reduced costs.

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Elimination of pneumothorax and hemothorax during placement of implantable venous access ports using ultrasound and fluoroscopic guidance

Vascular ◽

10.1177/1708538112472279 ◽

2013 ◽

Vol 21 (6) ◽

pp. 345-348 ◽

Cited By ~ 3

Author(s):

Grant T Fankhauser ◽

Richard J Fowl ◽

William M Stone ◽

Samuel R Money

Keyword(s):

Medical Records ◽

Ultrasound Guidance ◽

Jugular Vein ◽

Cost Savings ◽

Venous Access ◽

X Rays ◽

Ultrasound Guided ◽

Access Site ◽

Post Procedure ◽

Valuable Adjunct

Implantable venous access ports are essential for patients requiring chronic venous access. Ultrasound guided catheter placement has been recognized as a valuable adjunct for reducing complications during placement of access ports in the radiology and critical care medicine literature. We reviewed the medical records of patients undergoing insertion of implantable venous access ports from June 2006 through June 2009. All procedures were performed using ultrasound guidance with the internal jugular vein as the access site. There were 500 implantable venous access ports placed and included for review. There were no post-procedure pneumothoraces or hemothoraces. Carotid puncture was documented in 4 (0.8%)cases. Routine use of ultrasound guidance during placement of implantable venous access ports has eliminated the complications of pneumothorax and hemothorax during placement of internal jugular venous access ports on our vascular surgery service. Elimination of these complications and decreased use of chest x-rays should also provide increased cost savings for this procedure.

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Medicolegal implications of radial and femoral access for coronary angiography and intervention in 2016: Focus on retroperitoneal hemorrhage

Journal of Translational Internal Medicine ◽

10.1515/jtim-2016-0007 ◽

2016 ◽

Vol 4 (1) ◽

pp. 29-34 ◽

Cited By ~ 2

Author(s):

Konstantinos V. Voudris ◽

Mladen I. Vidovich

Keyword(s):

Coronary Angiography ◽

Standard Of Care ◽

Coronary Intervention ◽

The United States ◽

Access Site ◽

Transfemoral Approach ◽

Retroperitoneal Hemorrhage ◽

Femoral Access ◽

Percutaneous Coronary ◽

Wrongful Death

Abstract Background and Objectives Retroperitoneal hemorrhage is a rare but serious complication of transfemoral approach (TFA) and TFA percutaneous coronary intervention (PCI). Radial approach for coronary angiography and intervention (transradial approach, TRA) is associated with lower access site complications and reduced blood transfusion rates. Retroperitoneal bleeding has not been described with TRA. This study sought to evaluate the relationship between femoral access for coronary angiography (TFA) and PCI-induced retroperitoneal hemorrhage and the resulting medical litigation in the United States. Methods From 342 lawsuit claim records identified in LexisNexis database search, 17 cases of TFA and TFAPCI-related retroperitoneal hemorrhage decided between 1995 and 2015 were included in the study. Claims were thoroughly reviewed and information about the date the case was decided, patient outcome, the plaintiff, the defendant, the claim, and the trial outcome were extracted. Results The most common filled claim was medical malpractice (53% of the cases), followed by wrongful death (18%) and review of the Commissioner's decision to deny the application for supplemental security income (12%). Forty-seven percent of the cases were won by the defense, 29% by the plaintiff, and 24% were remanded for a new trial. In 82% of the cases, physicians were sued, but only 14% of the cases were won by the plaintiff. In 59% of the claims, the patient died; however, 70% of those cases were decided in favor of the defending physician and hospital. Conclusion Retroperitoneal hemorrhage is an uncommon complication of TFA and TFA PCI and is associated with high mortality rates. Physicians should able to identify this complication early and address it in a timely manner based on the applicable standard of care. TRA and TRA PCI is a reliable alternative and may potentially reduce medicolegal liability related to access site choice.

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Treatment of venous leg ulcers using bilayered living cellular construct

Journal of Comparative Effectiveness Research ◽

10.2217/cer-2020-0076 ◽

2020 ◽

Vol 9 (13) ◽

pp. 907-918

Author(s):

Aseel Bin Sawad ◽

Fatema Turkistani

Keyword(s):

Healthcare System ◽

Cost Savings ◽

Standard Of Care ◽

Healthcare Resource Utilization ◽

Psychological Status ◽

Leg Ulcers ◽

Venous Leg Ulcers ◽

Time Period ◽

The Us ◽

Economic Analyses

Background: Venous leg ulcers (VLUs) present a significant economic burden on the US healthcare system and payers (US$14.9 billion). Aim: To evaluate the quality of life (QoL) of patients with VLUs; to analyze the limitations of standard of care (SOC) for VLUs; and to explain how using bilayered living cellular construct (BLCC) with SOC for treatment of VLUs can help heal more VLUs faster (than using SOC alone) as well as help improve QoL and help reduce the burden on the US healthcare system and payers. Materials & methods: This is a review study. The search was conducted in February 2020 by way of electronic databases to find relevant articles that provided information related to QoL of patients with VLUs, limitations of SOC for VLUs and economic analyses of using BLCC for treatment of VLUs. Results: VLUs impact patients’ physical, functional and psychological status and reduce QoL. A total 75% of VLU patients who used SOC alone failed to achieve healing in a timely fashion, which led to increased healthcare costs and healthcare resource utilization. Although the upfront cost is high, the greater effectiveness of BLCC offsets the added cost of the product during the time period of the studies. Therefore, BLCC helps to improve the QoL of VLU patients. As an example, for every 100 VLU patients in a healthcare plan, the use of BLCC can create cost savings of US$1,349,829.51. Conclusion: Payers’ coverage of BLCC results in reduction of the overall medical cost for treating VLU patients.

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Propensity-adjusted cost analysis of radial versus femoral access for neuroendovascular procedures

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016728 ◽

2020 ◽

pp. neurintsurg-2020-016728

Author(s):

Joshua S Catapano ◽

Andrew F Ducruet ◽

Stefan W Koester ◽

Tyler S Cole ◽

Jacob F Baranoski ◽

...

Keyword(s):

Hospital Stay ◽

Hospital Costs ◽

Length Of Hospital Stay ◽

Diagnostic Procedures ◽

Femoral Access ◽

Catheter Size ◽

The Mean ◽

The Difference ◽

Procedure Type ◽

Angiographic Findings

BackgroundTransradial artery (TRA) access for neuroendovascular procedures is associated with fewer complications than transfemoral artery (TFA) access. This study compares hospital costs associated with TRA access to those associated with TFA access for neurointerventions.MethodsElective neuroendovascular procedures at a single center were retrospectively analyzed from October 1, 2018 to May 31, 2019. Hospital costs for each procedure were obtained from the hospital financial department. The primary outcome was the difference in the mean hospital costs after propensity adjustment between patients who underwent TRA compared with TFA access.ResultsOf the 338 elective procedures included, 63 (19%) were performed through TRA versus 275 (81%) through TFA access. Diagnostic procedures were more common in the TRA cohort (51 of 63, 81%) compared with the TFA cohort (197 of 275, 72%), but the difference was not significant (p=0.48). The TRA cohort had a shorter length of hospital stay (mean (SD) 0.3 (0.5) days) compared with the TFA cohort (mean 0.7 (1.3) days; p=0.02) and lower hospital costs (mean $12 968 ($6518) compared with the TFA cohort (mean $17 150 ($10 946); p=0.004). After propensity adjustment for age, sex, symptoms, angiographic findings, procedure type, sheath size, and catheter size, TRA access was associated with a mean hospital cost of $2514 less than that for TFA access (95% CI −$4931 to −$97; p=0.04).ConclusionNeuroendovascular procedures performed through TRA access are associated with lower hospital costs than TFA procedures. The lower cost is likely due to a decreased length of hospital stay for TRA.

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Cardiogenic shock and radial access in patients with an acute ST elevation myocardial infarction

European Heart Journal ◽

10.1093/ehjci/ehaa946.1791 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

R Zahn ◽

M Hochadel ◽

B Schumacher ◽

M Pauschinger ◽

C Stellbrink ◽

...

Keyword(s):

Myocardial Infarction ◽

Hospital Mortality ◽

Cardiogenic Shock ◽

St Elevation Myocardial Infarction ◽

Strong Variation ◽

Access Site ◽

Femoral Access ◽

Radial Access ◽

St Elevation ◽

The Difference

Abstract Background Cardiogenic shock (CS) in patients (pts) with acute ST elevation myocardial infarction (STEMI) is the strongest predictor of hospital mortality. Radial in contrast to femoral access in STEMI pts might be associated with a lower mortality. However, little is known on radial access in CS pts. Methods We retrospectively analysed all STEMI pts between 2009 and 2015 who sufferend from CS and who were included into the ALKK PCI registry. Pts treated via a radial access were compared to those treated via a femoral access. Results Between 2009 and 2015 23796 STEMI pts were included in the registry. 1763 (7.4%) of pts were in CS. The proportion of radial access was 6.6%: in 2009 4.0% and in 2015 19.6%, p for trend <0.0001 with a strong variation between the participating centres (0% to 37%). Conclusions Radial access was only used in 6.6% of STEMI pts presenting in CS. However, a significant increase in the use of radial access was observed over time (2009: 4%, 2015 19.6%, p<0.001), with a great variance in its use between the participating hospitals. Despite similar pt characteristics the difference in hospital mortality according to access site has to be interpretated with caution. Funding Acknowledgement Type of funding source: None

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149 Emergency Clot Retrieval and Stenting for Posterior Circulation Stroke

British Journal of Surgery ◽

10.1093/bjs/znab134.234 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

K Daga ◽

M T Ahmad ◽

M Taneja

Keyword(s):

Treatment Option ◽

Current Literature ◽

Basilar Artery ◽

Cerebral Angiography ◽

Posterior Circulation ◽

Anterior Circulation ◽

Acute Setting ◽

Post Procedure ◽

Basilar Artery Stenosis

Abstract The current literature regarding the morphology and presentations of strokes due to basilar artery stenosis/occlusion is limited. This pathology is a rare cause of stroke and its management is not clearly decided in guidelines or published literature. Moreover, posterior circulation strokes are reported to be more devastating than anterior circulation. We present a case of a 68-year-old male who presented in an acute setting with reduced consciousness, myoclonic jerks, weakness and nausea due to a stroke from an occluded mid-segment basilar artery. MRI showed evidence of left cerebellar and right occipital infarcts. Emergent cerebral angiography was performed, and he was immediately treated by thrombectomy and stenting (Stryker Wingspan stent). The patient made a full recovery within one week and remained well at follow-up 3 months post-procedure. Emergency recanalization of basilar artery strokes, by clot retrieval and stenting, should be considered as a treatment option.

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Radiation Awareness for Endovascular Abdominal Aortic Aneurysm Repair in the Hybrid Operating Room: An Instant Operator Risk Chart for Daily Practice

Journal of Endovascular Therapy ◽

10.1177/15266028211007458 ◽

2021 ◽

pp. 152660282110074

Author(s):

Quirina M. B. de Ruiter ◽

Frans L. Moll ◽

Constantijn E. V. B. Hazenberg ◽

Joost A. van Herwaarden

Keyword(s):

Radiation Dose ◽

Dose Rate ◽

Effect Size ◽

Radiation Risk ◽

Dose Limit ◽

Access Site ◽

Femoral Access ◽

Dose Rates ◽

Rate Prediction ◽

Operator Dose

Introduction: While the operator radiation dose rates are correlated to patient radiation dose rates, discrepancies may exist in the effect size of each individual radiation dose predictors. An operator dose rate prediction model was developed, compared with the patient dose rate prediction model, and converted to an instant operator risk chart. Materials and Methods: The radiation dose rates (DRoperator for the operator and DRpatient for the patient) from 12,865 abdomen X-ray acquisitions were selected from 50 unique patients undergoing standard or complex endovascular aortic repair (EVAR) in the hybrid operating room with a fixed C-arm. The radiation dose rates were analyzed using a log-linear multivariable mixed model (with the patient as the random effect) and incorporated varying (patient and C-arm) radiation dose predictors combined with the vascular access site. The operator dose rate models were used to predict the expected radiation exposure duration until an operator may be at risk to reach the 20 mSv year dose limit. The dose rate prediction models were translated into an instant operator radiation risk chart. Results: In the multivariate patient and operator fluoroscopy dose rate models, lower DRoperator than DRpatient effect size was found for radiation protocol (2.06 for patient vs 1.4 for operator changing from low to medium protocol) and C-arm angulation. Comparable effect sizes for both DRoperator and DRpatient were found for body mass index (1.25 for patient and 1.27 for the operator) and irradiated field. A higher effect size for the DRoperator than DRpatient was found for C-arm rotation (1.24 for the patient vs 1.69 for the operator) and exchanging from femoral access site to brachial access (1.05 for patient vs 2.5 for the operator). Operators may reach their yearly 20 mSv year dose limit after 941 minutes from the femoral access vs 358 minutes of digital subtraction angiography radiation from the brachial access. Conclusion: The operator dose rates were correlated to patient dose rate; however, C-arm angulation and changing from femoral to brachial vascular access site may disproportionally increase the operator radiation risk compared with the patient radiation risk. An instant risk chart may improve operator dose awareness during EVAR.

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