Novel treatment for glance necrosis due to priapism; presentation and review of literature

Introduction: Glans necrosis in association with priapism is very rare and its appropriate treatment is not known. There is a secondary cause in most cases. Case description: We treated a 65-year-old man with priapism and glans necrosis using a closed shunt (Winter), continuous penile irrigation with normal saline, and heparin for 48 h and waited for the necrotic area to resolve spontaneously. The treatment outcome was much better compared to previous cases in whom open surgery, irrigation with pure normal saline, and/or resection of the necrotic area were performed. Conclusion: In cases with priapism and glans ischemia, we recommend treating the condition with continuous covernose irrigation with heparinized saline and avoiding open surgery.

Use of heparinized saline flush during endovascular thrombectomy for acute ischemic stroke; a survey of clinical practice in the Netherlands

Background and introduction Information about optimal use of heparin in flush fluids during endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) is lacking. Variables that determine total heparin dose entering the patient by flush fluids are mostly unknown. We aim to provide insight in these unknown but highly relevant variables. Methods and results We performed a survey including all Dutch interventionists performing EVT (n = 79) collecting data on used concentration of heparin in infusion bags, number of infusion bags connected, timing of connecting the flush line and the dripping rate (ml/sec). We calculated potential heparin dose entering the patient per hour through flush fluids (IU/h). Twenty-eight interventionists (35%) representing 17 Dutch stroke centers completed the survey. Eight interventionists responded not to add any heparin to flush fluids (18%). The highest amount of heparin entering the patients was 13,500 IU/h, reported by 2 interventionists from the same center (4%). Conclusions We provide insight in the use of heparinized flush during EVT in the Netherlands. Total amounts of heparin administered via flush fluids may go up to 13,500 IU/h. With this paper we intend to set a starting for future research and development of guidelines on the use of heparinized flush fluids during EVT for AIS.

Stroke rate after thoracic endovascular aortic repair using de-airing of stentgrafts with high-volume of saline solution

Summary: Background: Our aim was to determine the rate of ischemic stroke following thoracic endovascular aortic repair (TEVAR) after reducing gas volume released during stentgraft deployment by de-airing of thoracic stentgrafts with high-volume of 0.9% heparinized saline solution. Patients and methods: A single center retrospective analysis of all consecutive patients undergoing TEVAR from 2014 to 2019 was performed. All thoracic stentgrafts were flushed with 120 ml 0.9% heparinized saline solution before implantation, according to our institutional protocol. Endpoints were in-hospital rates of ischemic stroke and spinal cord ischemia (SCI), and all-cause mortality. Results: One hundred and fifty-four patients (mean age: 66.8 ± 13.6 years, 64.9% males) were treated with TEVAR during the study period. Indications for treatment were thoracic aortic aneurysms (n = 75, 48.7%), acute type B aortic dissections (n = 46, 29.9%), aortic arch aneurysms and penetrating aortic ulcers (n = 28, 18.2%), and blunt traumatic aortic injuries (n = 5, 3.2%). Timing of procedure was urgent in 75 patients (48.7%). Proximal landing zone were zone 0–1–2 (n = 75, 48.7%), zone 3 (n = 66, 42.9%) and zone 4 (n = 13, 8.4%). Supra-aortic vessels were revascularized with custom-made fenestrated stentgrafts in 9 patients (5.8%), using chimney technique in 4 patients (2.6%), and with debranching procedures in 19 patients (12.3%). Left subclavian artery was covered without revascularization in 46 patients (29.9%). In-hospital stroke occurred in two patients (1.3%) and SCI in another two patients (1.3%). In-hospital mortality rate was 0.6%. No further in-hospital events were noted. Conclusions: De-airing of stentgrafts with high-volume of 0.9% heparinized saline solution seems to be safe and can be used as an adjunct to keep occurrence of neurological events after TEVAR as low as possible.

COMPARISON OF INTRACORONARY VERAPAMIL VS ADENOSINE FOR RESTORATION OF CORONARY BLOOD FLOW POST PERCUTANEOUS CORONARY INTERVENTION (PCI) IN PATIENTS WITH NO-REFLOW

Objective: To determine the efficacy of intracoronary verapamil vs adenosine in restoration of coronary blood flow, post PCI in patients with No-Reflow. Study Design: Double blind (patient/operator blind) randomized control trial. Place and Duration of Study: Cath lab of AFIC & NIHD Rawalpindi, from Feb 2019 to Aug 2019. Methodology: A total of ninety (n=90) patients of either gender between age 25-80 years of age who underwent angioplasty for STEMI/NSTEMI demonstrating No-Reflow (thrombolysis in myocardial infarction 0,1,2) post PCI were enrolled and were randomized into two groups. Group A received verapamil 500 µg in 10 ml heparinized saline, given slowly over 1 minute and group B received adenosine 60 µg in 10 ml of heparinized saline, given quickly. After the administration of both drugs repeat angiogram was carried out and thrombolysis in Myocardial Infarction flow was assessed. Restoration of blood flow was defined as achievement of thrombolysis in myocardial infarction 3 grade. Results: Efficacy (restoration of thrombolysis in Myocardial Infarction grade 3) was better with intracoronary administration of verapamil when compared with intracoronary administration 2 of adenosine (84.4% vs 80%). The difference was, however, not statistically significant (p=0.581). Conclusion: Efficacy (restoration of thrombolysis in myocardial infarction grade 3) was not statistically significant between intracoronary administration of verapamil and adenosine in no-reflow cases after PCI in patients with STEMI/NSTEMI.

Abstract TP371: Stroke Center Heparin Flush Use in Transfemoral Angiography Survey

Background and Purpose: The drug concentration of heparinized saline used for transfemoral catheter angiography flush during different types of cerebral endovascular interventions varies among operators and centers worldwide. While heparin use is recommended during cerebral angiograms to minimize the risk of thromboembolic events, there is a paucity of information regarding protocols for administration of heparinized saline. Higher concentrations of heparinized saline may benefit patients undergoing elective intracranial aneurysm embolization by decreasing the risk of thromboembolism. However, it may place patients undergoing revascularization procedures for acute ischemic stroke at higher risk of symptomatic intracerebral hemorrhage, particularly if they received intravenous tissue plasminogen activator immediately prior. Methods: After obtaining permission from the Association for Radiologic and Imaging Nursing (ARIN) Board of Directors, a survey was electronically distributed by ARIN to its members via the ARIN List Serve. Response to the survey was identified as consent to participate. Subjects were asked to participate if they were currently involved in the management of patients undergoing cerebral angiography with a variety of interventions. Results: The most frequently used concentration of heparinized saline flush was 2 units/ml (32.8%-34.8% range, depending on endovascular intervention), and the least frequently utilized concentrations were 3 units/ml and higher than 5 units/ml (4.3%- 5.7% range, depending on endovascular intervention). Mixing and labeling bags with heparinized saline flush was noted to be the responsibility of interventional radiology registered nurse (39%, n= 46), pharmacy (26.3%, n= 31), or the angiography technologist (8.5%, n= 10). Conclusions: There are no standard protocols across stroke centers identifying optimal heparinized saline flush solution concentration, preparation and documentation. Replication of this survey among members of the American Society of Neuroradiology is recommended to validate the findings from the current study. If confirmed, a consensus on safety of heparinized saline flush use during neuroradiology interventions is advised.

Complete Heart Block Due to Coronary Air Embolism during Trans-catheter Closure of Atrial Septal Defect

Coronary air embolism is a dreadful complication of cardiac intervention despite careful prevention. In literature reported complications of coronary air embolism ranges from clinically non significant events to cardiogenic shock, myocardial infarction and death. We report a case of massive coronary air embolism in right coronary artery, which results in hypotension and complete heart block in a 33 -year-old female undergoing elective closure of atrial septal defect (ASD) by percutaneous transcatheter intervention. The patient stabilized after timely measures like oxygen support, dopamine infusion, cardiac compression and repeated bolus injection of heparinized saline. She then underwent successful percutaneous ASD device closure.

Locking of venous port systems in breaks between infusion cycles: heparinized or normal saline?

BACKGROUND. For many years, the use of heparinized saline was considered as standard practice for flushing and locking of implantable venous port systems, although this approach is not substantiated. As an alternative to heparin solution, one can use a normal saline. MATERIALS AND METHODS. A literature analysis was carried out, including practical recommendations for the care of port systems, scientific articles and clinical studies on the comparative effectiveness and safety of heparinized and normal saline for locking port systems in adult patients. RESULTS. Long-term use of even low doses of heparin can lead to bleeding and thrombocytopenia, especially in dialysis and cancer patients, which can lead to serious or life-threatening complications. The use of heparin is associated with errors in dosage, the formation of S. aureus biofilms, and incompatibility with other drugs. The results of retrospective and randomized prospective studies indicate that the use of normal saline for locking of port systems is effective and safe and is not associated with an increased risk of complications. CONCLUSIONS. In patients of various profile (with malignant tumors and other pathologies), the use of a normal solution for locking implantable venous ports instead of a heparinized solution is effective and safe. Refusal of heparin eliminates the risks associated with its use, saves time and costs for medical staff and patients.