Case report: End of life care via a mid-thigh femoral midline catheter

Maintaining peripheral vascular access represents a major challenge for medical providers and patients leading to the emergence of ultrasound guided vascular access teams. Upper extremity peripheral vascular access options are often limited in the chronically ill patient population with end stage cancer, patients with severe contractures, tracheostomies, and feeding tubes and patients referred for palliative care are just some examples of patients who live with difficult access. The following is a case description of a mid-thigh superficial femoral vein midline catheter for comfort care medications in a patient with exhausted peripheral vasculature on hospice.

Catheterization of PICC through a superficial femoral vein for patients with superior vena cava syndrome using ECG positioning and ultrasound-guided technologies

Objective: We herein demonstrate the efficacy of PICC placement through a superficial femoral vein in patients with superior vena cava syndrome using ultrasound guidance and electrocardiographic localization. The treatment of PICC disconnection was also discussed. Methods: The study enrolled 51 patients with superior vena cava syndrome. Ultrasound-guided technology and ECG positioning technology are employed to help these patients in catheterization. The puncture time, the number of punctures, and catheter tip position were recorded. The patient was followed up for at least 2 years. The complications and treatment during follow-up were recorded. Result: The average puncture time was 32.13 ± 3.91 min. A total of 49 patients were successfully punctured once, while 2 patients failed in the first puncture. The main reason for puncture failure is that the inability of a guide wire to pass through. After the nurse removed the needle and pressed the puncture point until no rebleeding occurred, the puncture above the original puncture point was successful. X-ray examination revealed that the catheter tip was located in the inferior vena cava, above the diaphragm, near the right atrium. The success rate of catheterization was 100%. The visual analog scale (VAS) score was (2.44 ± 0.73) at the time of puncture, which was tolerable during the operation, and the patient did not complain of obvious pain following the operation. One patient developed complications of broken tube half a year after the puncture. Interventional physicians utilized angiography to locate the broken catheter. Conclusion: It is safe and feasible to place PICC through a superficial femoral vein under ultrasound combined with ECG positioning technology in patients with superior vena cava syndrome.

Recurrent Pulmonary Embolism Caused by Superficial Femoral Vein Aneurysm

Venous aneurysms (VA), particularly superficial femoral VAs (SFVAs), are rare vascular lesions. A 65-year-old woman with a history of pulmonary embolism (PE), treated with tissue plasminogen activator and oral anticoagulation, was admitted to hospital for dyspnea. Enhanced computed tomography showed recurrent PE and right SFVA with a mural thrombus. The SFVA was not identified during the first PE. The PE was not massive and was treated with direct oral anticoagulants. The thrombus in the SFVA caused the PE, and surgical repair was performed to prevent further embolic events. Under general anesthesia, the SFVA was excised, and direct anastomosis was performed. PE recurrence, venous aneurysmal changes, and thrombosis were not noted at the 1-year follow-up.

Living donor liver transplantation for Budd‒Chiari syndrome with right posterior segment graft and patch plasty using the superficial femoral vein: a case report

Background In living donor liver transplantation (LDLT) for patients with Budd‒Chiari syndrome (BCS), there are several concerns about reconstruction of the inferior vena cava (IVC) and hepatic veins. Herein, we report the case of a patient with BCS who underwent LDLT with right posterior segment graft (RPSG) and patch plasty for reconstruction of the hepatic venous outflow, using the patient’s own superficial femoral vein (SFV). Case presentation A 19-year-old man, who was diagnosed with primary BCS, underwent LDLT. His main hepatic veins were totally obstructed, and membranous stenosis was seen in the IVC. The LDLT donor was his mother; however, liver volumetric analysis showed that only her RPSG was appropriate. In the recipient surgery, 16 cm of the left SFV was harvested and was cut longitudinally and opened. The right hepatic vein (RHV) of the RPSG was anastomosed to the sidewall of the SFV graft. After explantation of native diseased liver was completed, the stenotic and thickened wall of the IVC was widely resected, and a large anastomotic orifice was created. Patch cavoplasty was performed with the RHV‒SFV graft patch. After portal reperfusion started, hepatic venous outflow was satisfactory, and there was no venous graft congestion. Both his postoperative course and his long-term course after discharge were uneventful. Conclusions In LDLT for BCS patients, ingenuity is required for the reconstruction of venous outflow. The SFV patch can be safely harvested from liver transplant recipients and is suitable for venous reconstruction. In addition, RPSG is an alternative type of liver graft for LDLT if a conventional right- or left-lobe graft cannot be used.

MO212LATE EVIDENCE OF SARS-COV-2 INFECTION IN A PATIENT WITH ACUTE KIDNEY INJURY (AKI) AND MASSIVE DEEP VEIN THROMBOSIS (DVT) STARTING FROM A HEMODIALYSIS CENTRAL VENOUS CATHETER (CVC)

Background and Aims COVID-19 has heterogeneous clinical manifestations. SARS-CoV-2 related AKI and hypercoagulability are negative prognostic factors. The incidence of thromboembolic events is about 30%, of AKI up to 20%. We report a patient with severe AKI who required hemodialysis (HD) and developed a massive DVT developing from the femoral CVC, and belatedly testing positive for SARS-CoV-2 in the absence of typical pulmonary involvement. Method A 53-year-old male with a clinical history of hypertension, type II diabetes mellitus, in therapy with metformin and ace-inhibitor, was admitted to our E.R. with diarrhea, nausea and vomiting for about 2 days. Main signs: ideomotor slowdown, mild hypohydration and reduced urine output (unrelevant sediment). Initial blood tests showed severe AKI with hyperkalemic metabolic acidosis and hyponatremia (sCreatinine 18.76 mg/dl, BUN 161 mg/dl, K+ 7.8 mmol/l, Na+ 128 mmol/L, HCO3- 9.8 mmol/l). Mild neutrophilic leukocytosis with lymphopenia was detected, with slightly increased inflammation indices (CRP 1.05 mg / dl, D-dimer 720 ng / ml). CT scan: absence of typical SARS-CoV-2 signs, normal kidneys, no dilation of urinary tract. SARS-CoV-2 rapid antigen test and the first molecular swab test were negative. After femoral CVC insertion, HD was needed for a few sessions. Broad range antibiotic therapy was also set. On Day 3: a second SARS-CoV-2 PCR swab test resulted negative. He never manifested fever or dyspnea. On Day 6, despite an improvement of renal function (sCr 2.7 mg/dl), the patient, although he walked, presented right leg pain with signs of DVT. Ultrasound and angio-CT scan documented peri-catheter DVT extended to the common femoral and external iliac vein and superficial femoral vein involvement, without pulmonary embolism. I.v. therapy with sodium heparin was therefore started with quite a difficulty in reaching the expected range. On day 8, massive flittene appeared, the CVC was removed and a caval filter was placed; marked neutrophilic leucocytosis and increased inflammatory indices (CRP 11.50 mg/dl) was documented. Nevertheless, thrombosis has progressed to the entire venous axis and the inferior cava. Through a tibial vein introducer local i.v. alteplase was also started. Just after, copious bleeding from the site of the removed CVC followed by haemorrhagic shock occurred and the patient was transferred to the ICU (D-dimer 219800 ng/ml). The same day a third swab for SARS-CoV-2 resulted positive while a further CT-scan did not show signs of virus-like interstitial pneumonia. On the following day (day 9) the patient underwent thrombus aspiration (Aspirex®S device) and fasciotomy of the right leg for a compartment syndrome. Results Despite the continuation of heparin, PTT ratio was never >1.5, with an extension of DVT and also involvement of the contralateral iliac vein, as well as a worsening of the clinical-laboratory picture and patient’s death on day 14. Serum complement, autoantibodies (ANA, ANCA, ENA, ANTI-dsDNA, anti-cardiolipin, AMA, anti-B-glycoprotein) and factor V Leiden test were normal. All blood cultures were found to be sterile. Conclusion Our case confirms the heterogenicity of COVID-19 manifestations, often without pulmonary involvement. According to our experience from the onset of the pandemic, SARS-CoV-2 can also be found later in patients with already advanced organ damage. In this case, in the absence of other possible factors, AKI and intestinal involvement may have been early signs of COVID-19, with a virus initially not detectable in the nasopharyngeal mucosa. Furthermore, the increased thromboembolic risk of COVID-19 should not be underestimated in the presence of risk factors as external devices, also given the difficult management of anticoagulation target. Anticoagulant prophylaxis in cases with doubtful symptomatology and CVC must be considered even in non-bedridden patients, due to the current risk of SARS-CoV-2 infection.

Distal superficial femoral vein versus axillary vein central catheter placement under ultrasound guidance for neonates with difficult access: A randomized clinical trial

Background: Epicutaneo-caval catheters (ECCs) are extensively used in premature and ill neonates. This prospective, randomized, observational study aimed to compare the outcomes of ECC placement in the distal superficial femoral and axillary veins in neonates with difficult ECC access. Methods: In a neonatal intensive care unit at a tertiary referral center, 60 neonates with difficult ECC access were randomized into two groups with catheters placed using the ultrasound-guided modified dynamic needle tip positioning (MDNTP) technique: distal superficial femoral vein (DSFV) and axillary vein (AV) groups. Results: The first attempt success rate was significantly higher in the DSFV group than in the AV group [23/30 (76.7%) vs 11/30 (36.7%), p = 0.001; odds ratio (OR), 0.176; 95% confidence interval (CI) 0.057–0.543]. The mean procedural duration was significantly shorter in the DSFV group than in the AV group [mean: 308.5 (standard deviation: 81.1) s vs 522.74 (134.8) s, t = −7.17, p < 0.001]. The incidence of complications was significantly lower in the DSFV group than in the AV group [4/30 (13.3%) vs 12/30 (40.0%), p = 0.019; OR, 4.333; 95% CI 1.203–15.604]. The number of attempts was significantly fewer in the DSFV group than in the AV group ( p = 0.012). Conclusions: The distal superficial femoral and axillary veins are two alternative and safe access points for ECC placement in premature neonates (weight < 2.5 kg) with difficult access. However, access through the distal superficial femoral vein was quicker, easier, and had fewer complications than through the axillary vein.

Ultrasound-guided cannulation of the superficial femoral vein for central venous access

Background: In some clinical conditions, central venous access is preferably or necessarily achieved by threading the catheter into the inferior vena cava. This can be obtained not only by puncture of the common femoral vein at the groin, but also—as suggested by few recent studies—by puncture of the superficial femoral vein at mid-thigh. Methods: We have retrospectively reviewed our experience with central catheters inserted by ultrasound-guided puncture and cannulation of the superficial femoral vein, focusing mainly on indications, technique of venipuncture, and incidence of immediate/early complications. Results: From June 2020 to December 2020, we have inserted 98 non-tunneled central venous catheters (tip in inferior vena cava or right atrium) by ultrasound-guided puncture of the superficial femoral vein at mid-thigh or in the lower third of the thigh, all of them secured by subcutaneous anchorage. The success of the maneuver was 100% and immediate/early complications were negligible. Follow-up of hospitalized patients (72.5% of all cases) showed only one episode of catheter dislodgment, no episode of infection and no episode of catheter related thrombosis. Conclusions: The ultrasound approach to the superficial femoral vein is an absolutely safe technique of central venous access. In our experience, it was not associated with any risk of severe insertion-related complications, even in patients with low platelet count or coagulation disorders. Also, the exit site of the catheter at mid-thigh may have advantages if compare to the exit site in the inguinal area.

CLINICAL ANATOMY OF THE PERFORATING VEINS OFTHE PROXIMAL LOWER LIMBS

Objective. To clarify the topographic and anatomical feature of the perforating veins (PVs) in the proximal part of the lower extremity. Methods. 70 amputated lower extremities from the patients with severe ischemia were subjected to sectional anatomical study; 2800 patients with varicose disease underwent lower extremity sonography. Results. PVs were primarily located on the medial surface of the thigh. In the upper third of the thigh PVs drain into superficial femoral vein. It was detected that one or two PVs occur sin the lower third of the hip draining into superficial femoral vein and originating from the great saphenous vein in 73.6% cases. All PVs were accompanied by an arterial branch from the superficial femoral artery. Anatomical sectional study revealed that a nervous branch accompanied PVs in the lower third of the thigh. Two or four PVs were detected on the lateral surface of the thigh. PVs in the popliteal fossa could be referred to as “atypical” due to their rare occurence (0.4% of cases at sonography) in combination with absent typical sapheno-popliteal junction. PVs in this area were not supported by the intermuscular septa. PVs drained laterally into popliteal vein of the lower limb in 100% cases, while small saphenous vein drained into great saphenous vein in the upper third of the leg or into the intersaphenous vein. Conclusion. Perforating veins constitute perforating bundles (PV, arterial branch, nervous branch), which are predominantly located along the intermuscular septa, which create a constant and strong orientation along the direction of the great vessels. This ensures stable hemodynamics of great vessels and perforating complexes and does not allow squeezed tham togeter during physical exertion. What this paper adds For the first time it has been proved that the perforating veins of the gluteal region pass through the fascia and the thickness of the gluteus maximus muscle and enter the superior and inferior gluteal veins, being transmuscular perforating veins. For the first time it has been established that the location of the femoral perforating veins along the intermuscular septa allows preserving the hemodynamics of the perforating complexes without any squeezed in physical exertion.