Comparison of Standard Technique, Ultrasonography, and Near-Infrared Light in Difficult Peripheral Vascular Access: A Randomized Controlled Trial

Objectives: Successful placement of a peripheral intravenous catheter (PIVC) on the first attempt is an important outcome for difficult vascular access (DVA) patients. This study compared standard technique, ultrasonography (USG), and near-infrared light (NIR) in terms of success in the first attempt in patients with DVA. Methods: This was a prospective, randomized controlled study. The study was conducted in a tertiary care hospital. Emergency department patients who describe DVA history, have no visible or palpable veins, and were assessed by the nurse to have a difficult PIVC were included to study. The PIVC procedure was performed on patients by standard, USG, or NIR device techniques. For all approaches, the success of the first attempt was the primary aim. Total procedure time, the total number of attempts, and the need for rescue intervention were secondary aims. Results: This study evaluated 270 patients. The first attempt success rates for USG, standard, and NIR methods were 78.9%, 62.2%, and 58.9%, respectively. The rate of first attempt success was higher in patients who underwent USG (USG versus standard, P = .014; USG versus NIR, P = .004; standard versus NIR, P = .648). The total median (IQR) procedure time for USG, standard, and NIR methods was 107 (69-228), 72 (47-134), and 82 (61-163) seconds, respectively. The total procedure time was longer in patients undergoing USG (standard versus USG, P <.001; NIR versus USG, P = .035; standard versus NIR, P = .055). The total median (IQR) number of attempts of USG, standard, and NIR methods were 1 (1-1), 1 (1-2), and 1 (1-2), respectively. A difference was found among the groups regarding the total number of attempts (USG versus NIR, P = .015; USG versus standard P = .108; standard versus NIR, P = .307). No difference was found among groups in terms of the need for rescue methods. Conclusion: It was found that USG increases the success of the first attempt compared with the standard method and NIR in patients with DVA.

Automating Endoscope Motion in Robotic Surgery: A Usability Study on da Vinci-Assisted Ex Vivo Neobladder Reconstruction

Robots for minimally invasive surgery introduce many advantages, but still require the surgeon to alternatively control the surgical instruments and the endoscope. This work aims at providing autonomous navigation of the endoscope during a surgical procedure. The autonomous endoscope motion was based on kinematic tracking of the surgical instruments and integrated with the da Vinci Research Kit. A preclinical usability study was conducted by 10 urologists. They carried out an ex vivo orthotopic neobladder reconstruction twice, using both traditional and autonomous endoscope control. The usability of the system was tested by asking participants to fill standard system usability scales. Moreover, the effectiveness of the method was assessed by analyzing the total procedure time and the time spent with the instruments out of the field of view. The average system usability score overcame the threshold usually identified as the limit to assess good usability (average score = 73.25 &gt; 68). The average total procedure time with the autonomous endoscope navigation was comparable with the classic control (p = 0.85 &gt; 0.05), yet it significantly reduced the time out of the field of view (p = 0.022 &lt; 0.05). Based on our findings, the autonomous endoscope improves the usability of the surgical system, and it has the potential to be an additional and customizable tool for the surgeon that can always take control of the endoscope or leave it to move autonomously.

COMPARATION OF EFFICACY OF DIFFERENT PERIOPERATIVE MEDICAL PREPARATION SCHEMES FOR TRANSPAPILLAR ENDOSCOPIC INTERVENTIONS

The intensity of peristaltic activity has significant impact on the duration of transpapillar endoscopic interventions and in some cases (juxtapapillary diverticulum, stenotising papillitis or severe oedema of papilla) can impede operations. Therefore, proper inhibition of duodenal peristalsis is one of the important preconditions for successful fulfilment of such procedures. The aim of the study was to carry out comparative analysis of impact of antispasmodic medications used through the perioperative period on the quality of transpapillar endoscopic interventions. Case histories of patients, who were treated at the Surgical Department of Municipal Enterprise “Sklifosovskiy Poltava Regional Clinical Hospital” for 2017-2019, were investigated, and 75 cases were chosen for further analysis. We divided our cohort in two groups depending on medications used for duodenal peristalsis inhibition: I group – hyoscine butyl bromide (1 ml 2% solution intramuscular injection); II – hyoscine butyl bromide (1 ml 2% solution intramuscular injection), and atropine (1ml 0,1% solution intramuscular injection). Time needed for selective cannulation, total procedure length, number and type of adverse events during manipulation and in early postoperative period were compared between the groups. After statistical data processing the following conclusions were made: 1) proper medical preparation significantly facilitates the implementation of transpapillar endoscopic interventions; 2) combined scheme to reduce duodenal peristalsis, which includes hyoscine butyl bromide and atropine, is not superior to hyoscine butyl bromide alone.

Optimized Intraoperative Imaging for Stereotactic Planning with a Multiaxial Robotic C-arm System: Technical Note and Case Series

Background The preoperative preparation of the planning dataset for frame-based stereotactic brain biopsy is often associated with logistical effort and burden on the patient. Intraoperative imaging modalities need to be investigated to overcome these limitations. Objective The objective of the study was to develop and apply a new method for the intraoperative acquisition of the planning dataset with the multiaxial robotic C-arm system Artis zeego. Methods An indication-customized dose-reduced protocol for Artis zeego was developed and implemented into the workflow. A sample of 14 patients who had undergone intraoperative imaging with Artis zeego was analyzed. A sample of 10 patients with conventional preoperative imaging by cranial computed tomography (CT) was used as a control group. Outcomes were compared with regard to target deviation, diagnostic value of the biopsies, complications, and procedure time. Results In all patients, a suitable intraoperative planning dataset could be acquired with Artis zeego. Total procedure time was shorter for the Artis zeego group (p = 0.01), whereas time in the operating room area was longer in the Artis zeego group (p = 0.04). Biopsy results were diagnostic in 12 patients (86%) in the Artis zeego group and in 8 patients (80%) in the control group. There were no significant differences in target size, trajectory length, or target deviation. Conclusion Intraoperative imaging for frame-based stereotactic brain biopsy with Artis zeego is an easy and feasible method. Accuracy is comparable to conventional CT, whereas radiation exposure could be additionally reduced. It allows a significant reduction of the total procedure length and improves the comfort for the patient and staff.

LSI guided-high power short duration is safe and improves pulmonary vein isolation efficiency

Introduction High-power short-duration (HPSD) is an increasingly used ablation strategy for pulmonary vein isolation (PVI) procedures, but Lesion Index (LSI)-guided HPSD radio-frequency (RF) application has not been described in this clinical setting. Purpose We evaluated the procedural efficiency and safety of an LSI-guided HPSD strategy for atrial fibrillation (AF) ablation. Methods Paroxysmal and persistent AF patients scheduled for AF ablation were prospectively enrolled and divided in two groups, according to the ablation power used. The LSI-HP Group included patients ablated with a RF power of 50 Watts and the LSI-LP Group included patients ablated with 35 Watts. All patients underwent only PVI under LSI guidance (LSI between 5.5 and 6 anteriorly; LSI between 4.5 and 5 posteriorly) with a point by point strategy and an inter-lesion distance &lt;6 mm. Procedural efficiency parameters were compared between groups. Results Forty-six patients with AF (60% paroxysmal) were prospectively enrolled, 25 in the LSI-HP Group and 21 in the LSI-LP Group. They were usually male (78%) with a low-intermediate CHA2DS2-Vasc score (1.8±1.1), a preserved ejection fraction (60±6%) and moderate left atrial dilatation (45±6 mm). Baseline clinical characteristics resulted comparable between groups (p=NS). PVI was successful in all patients. RF time (30.22±9.04 vs 47.85±11.87 min, p&lt;0.0001), total procedure time (138.7±33.2 vs 177.6±49.77, p=0.006) and fluoroscopy time (13.92±5.34 vs 23.14±10.97 min, p=0.006) were significantly lower in the LSI-HP Group. No complication or steam pops was seen in either group. Conclusions LSI-HP AF ablation significantly improves procedural efficiency, reducing ablation time, total procedural duration and fluoroscopy use, while maintaining a comparable safety profile as lower powers. FUNDunding Acknowledgement Type of funding sources: None. Figure 1 Figure 2

Zero-fluoroscopy ablation in patients with cardiac electronic implantable devices

Introduction: Utilizing a 3-dimensional (3-D) mapping system and intracardiac echocardiography (ICE) has allowed ablation procedures with less or without fluoroscopy; however, there is limited data for patients with cardiac electronic implantable device (CIED) leads regarding the suspected risk of lead injury. Therefore, we sought to explore technics to perform safe trans-septal approach and catheter manipulation technique in patients with CIED leads. Methods and Results: This study comprised 68 consecutive patients (45 [66.2%] males, median [interquartile range] 73 [68–77] years old) with CIED who underwent catheter ablation for supraventricular tachycardia, 16 without fluoroscopy (zero-fluoro group) and 52 with fluoroscopy (conventional-fluoro group), between July 2019 and April 2021. All procedures were performed under a 3-D mapping system and ICE guidance. We compared the differences in treatment and development of complications between the two groups. The procedures were mainly atrial fibrillation (73.6%) and atrial tachycardia. The median time from venipuncture to trans-septal procedure (zero-fluoro vs. conventional-fluoro group: 27.0 min vs. 23.5 min, P=0.71) and total procedure time (215 min vs. 172 min, P=0.55) were not different between the two groups. The acute procedural success rate (100% vs. 98.1%, P=1.00) and reduction of atrial high-rate episodes at 6 months (3.2 [0.3–93.9]% vs. 1.0 [0.0–14.9]%, P=0.33) did not differ between the two groups. No patient showed lead-related complications in both groups. Conclusions: Zero-fluoro ablation for supraventricular arrhythmia using 3-D mapping and ICE in patients with CIED leads was feasible under careful catheter manipulation.

Diagnostic Performance of Endoscopic Ultrasound-Guided Tissue Acquisition by EUS-FNA versus EUS-FNB for Solid Pancreatic Mass Without ROSE: A Retrospective Study.

Background: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is an established diagnostic procedure for solid pancreatic mass. However, the diagnostic yield between fineneedle aspiration (FNA) and fine-needle biopsy (FNB) remains unclear. Thus, we aimed to evaluate and compare the diagnostic yields between FNA and FNB using conventional FNA and Franseen needles of the same size (22 gauge), respectively, in patients with solid pancreatic mass who underwent EUS-TA without rapid onsite cytopathology evaluation (ROSE). Methods: All cases of EUS-TA by FNA or FNB for solid pancreatic mass between January 2017 and October 2020 in a single center university hospital were retrospectively reviewed. The procedure was performed without an onsite cytologist. After macroscopic onsite evaluation (MOSE), the endoscopist finished the procedure. The diagnostic yield and the average number of needle passes between FNB and FNA were then compared. Results: A total of 151 patients (FNA, n = 77; FNB, n = 74) with solid pancreatic mass detected by cross-sectional imaging underwent EUS-TA. The mean age was 62.3 ± 12.8 years, with 88 (58.3%) males. Age, gender, mass location, tumour size and disease stage from imaging were not significantly different. The diagnostic performance was dramatically higher in EUS-FNB (100%) than in EUS-FNA (89.6%). The mean number of needle passes was clearly fewer in FNB than FNA (2.8 vs. 3.8, p < 0.001). The total procedure time was less in FNB (34.7 minutes) than in FNA (41 minutes). The adverse event rate between FNB and FNA was not significantly different. Conclusions: The diagnostic performance for solid pancreatic mass without ROSE was significantly higher in FNB than in FNA. The number of needle passes and the total procedure time was also lesser in FNB.

CLinical Assessment of WEB device in Ruptured aneurYSms (CLARYS): results of 1-month and 1-year assessment of rebleeding protection and clinical safety in a multicenter study

BackgroundThe primary goal of the CLARYS study is to assess the protection against rebleeding when treating ruptured bifurcation aneurysms with the Woven EndoBridge (WEB) device.MethodsThe CLARYS study is a prospective, multicenter study conducted in 13 European centers. Patients with ruptured bifurcation aneurysms were consecutively included between February 2016 and September 2017. The primary endpoint was defined as the rebleeding rate of the target aneurysm treated with the WEB within 30 days postprocedure. Secondary endpoints included periprocedural and postprocedural adverse events, total procedure and fluoroscopy times, and modified Rankin Scale score at 1 month and 1 year.ResultsSixty patients with 60 ruptured bifurcation aneurysms to be treated with the WEB were included. A WEB device was successfully implanted in 93.3%. The rebleeding rate at 1 month and 1 year was 0%. The mean fluoroscopy time was 27.0 min. Twenty-three periprocedural complications were observed in 18 patients and resolved without sequelae in 16 patients. Two of these complications were attributed to the procedure and/or the use of the WEB, leading to a procedure/device-related intraoperative complication rate of 3.3%. Overall mortality at 1 month and 1 year was 1.7% and 3.8%, respectively and overall morbidity at 1 month and 1 year was 15% and 9.6%, respectively. WEB-related 1-month and 1-year morbidity and mortality was 0%.ConclusionsThe interim results of CLARYS show that the endovascular treatment of ruptured bifurcation aneurysms with the WEB is safe and effective and, in particular, provides effective protection against rebleeding. It may induce profound change in the endovascular management of ruptured bifurcation aneurysms.

Pedunculated colorectal polyps with heads ≤ 1 cm in diameter can be resected using cold snare polypectomy

Background and study aims : Cold snare polypectomy (CSP) is not recommended for the resection of pedunculated colorectal polyp. The aim of this study was to examine the adequacy of CSP compared to hot snare polypectomy (HSP) for the complete resection of pedunculated polyps with heads ≤ 1 cm in diameter. Patients and methods : This was a retrospective study of a cohort of consecutive outpatients who had resection of pedunculated polyps with heads 6-10 mm in diameter using either dedicated CSP or HSP from 2014 through 2019. The primary outcome measure was occurrence of delayed bleeding. Secondary outcome measures included total procedure time, en bloc resection rate, immediate bleeding, and number of clips used. Results : 415 patients with 444 eligible polyps were enrolled; the CSP group (363 patients; 386 polyps) and HSP group (52 patients; 58 polyps). Patient characteristics, polyp characteristics and en bloc resection rate were similar between groups. The mean total procedure time and mean number (range) of hemostatic clips/patient used were significantly lower with CSP than with HSP (18± 8 min vs. 25± 9 min, P<0.001; 1.1 ± 0.6 (1-3) vs.3.1 ± 1.6 (1-5), respectively, P<0.001). Delayed bleeding occurred significantly less frequently in the CSP, 0% (0/363 vs.3.8% (2/52) in the HSP group (P<0.001), although immediate bleeding was significantly higher in CSP than HSP (84% (325/386) vs. 12% (7/58), P<0.001). Conclusion : Pedunculated colorectal polyps with heads ≤ 1 cm can be removed using CSP, which has several advantages over HSP.

Computed Tomography-Navigation™ Electromagnetic System Compared to Conventional Computed Tomography Guidance for Percutaneous Lung Biopsy: A Single-Center Experience

The aim of our study was to assess the efficacy of a computed tomography (CT)-Navigation™ electromagnetic system compared to conventional CT methods for percutaneous lung biopsies (PLB). In this single-center retrospective study, data of a CT-Navigation™ system guided PLB (NAV-group) and conventional CT PLB (CT-group) performed between January 2017 and February 2020 were reviewed. The primary endpoint was the diagnostic success. Secondary endpoints were technical success, total procedure duration, number of CT acquisitions and the dose length product (DLP) during step ∆1 (from planning to initial needle placement), step ∆2 (progression to target), and the entire intervention (from planning to final control) and complications. Additional parameters were recorded, such as the lesion’s size and trajectory angles. Sixty patients were included in each group. The lesions median size and median values of the two trajectory angles were significantly lower (20 vs. 29.5 mm, p = 0.006) and higher in the NAV-group (15.5° and 10° vs. 6° and 1°; p < 0.01), respectively. Technical and diagnostic success rates were similar in both groups, respectively 95% and 93.3% in the NAV-group, and 93.3% and 91.6% in the CT-group. There was no significant difference in total procedure duration (p = 0.487) and total number of CT acquisitions (p = 0.066), but the DLP was significantly lower in the NAV-group (p < 0.01). There was no significant difference in complication rate. For PLB, CT-Navigation™ system is efficient and safe as compared to the conventional CT method.