Managing Unintentional Iatrogenic Triple Lumen Central Venous Catheter (TLCVC) Arterial Puncture

Unintentional arterial puncture by central venous catheter insertion/placing can result in destructive complications especially if a large bore (>7F) catheter was used. Unplanned immediate catheter ejection with manual external compression is hazardous due to potential torrential blood leakage or formation of a pseudoaneurysm. Endovascular removal with a vascular closure device deployment is preferred in this situation. The aim of this case report is to discuss the alternative strategies if the vascular closure device fails to secure hemostasis.

Zone III REBOA and the COBRA-OS™: Safety of Inadvertent Iliac Artery Device Deployment

Background: REBOA is an emerging technique in trauma. However, inadvertent iliac artery balloon inflation can lead to complications. This study aims to investigate the safety characteristics of the COBRA-OS™ compared to a 7 Fr commercially available device during purposeful iliac artery balloon overinflation. Methods: In vitro: the COBRA-OS™ was inflated in explanted porcine iliac arteries and intentionally overinflated until balloon or vessel rupture occurred. In vivo: the COBRA-OS™ and 7 Fr device were deployed in the iliac arteries and intentionally overinflated until rupture of the balloon or blood vessel. Results: In vitro: an average volume of 1mL was required for occlusion using the COBRA-OS™ and the mean balloon rupture volume was 32.5mL. The COBRA-OS™ partially migrated into the aorta in all cases. In vivo: the COBRA-OS™ and 7 Fr device occluded the iliac arteries with a mean volume of 3.5 mL. Overinflation resulted in no iliac ruptures with the COBRA-OS™ (mean balloon rupture volume = 10mL). Overinflation with the 7 Fr device resulted in 1 iliac rupture at 5mL. The other two 7 Fr devices had a mean balloon rupture volume of 5 mL. All COBRA-OS™ devices moved partially up into the aorta during inflation while all 7 Fr devices remained in the iliac artery. Conclusions: The COBRA-OS™ allows for significant overinflation when deployed in the common iliac artery of a porcine model due to its unique design. This ultimately may help to prevent balloon and blood vessel rupture during clinical use, however further studies are required.

Transcatheter Closure of Residual and Iatrogenic Ventricular Septal Defects: Tertiary Center Experience and Outcome

Aim This study aimed to review our center experience in transcatheter closure of post-surgical and post-intervention residual and iatrogenic VSDs and to report on their 12-month long-term outcome. Methods All patients who underwent transcatheter closure of residual ventricular septal defects (R-VSDs) and iatrogenic ventricular septal defects (I-VSDs) after either surgical corrections or transcatheter interventions for any congenital heart disease (CHD) between January 2015 and January 2020 were included in the study. Patients' medical records were reviewed and analyzed. Results Twenty-three patients with a mean age of 14.3 ± 8.8 years, a mean weight of 36.2 ± 20.4 Kg, and a mean body surface area of 1.18 ± 0.36 m2 were included. Thirteen (56.5%) patients were males. The VSD was residual in 18 (78.3%) patients and iatrogenic in 5 (21.7%) patients, post-operative in 19 (82.6%) patients and post-transcatheter in 4 (17.4%) patients. The remaining VSD site was peri-membranous in 9 (39.1%) patients, high-muscular in 6 (26.1%) patients, mid-muscular in 4 (17.4%) patients, and Gerbode shunt in 4 (17.4%) patients. The QP/QS ratio was 2.5 ± 0.7, and the VSD diameter was 6.1±2.1 mm with a VSD-aorta rim of 5.4 ± 2.0 mm. Most, 16 (71.43%) patients underwent antegrade device deployment, and 7 (28.57%) patients underwent retrograde transaortic device deployment, with only 3 (13.0%) patients required two devices/patient. Amplatzer™ Muscular VSD devices were used in 16 (69.6%) patients, Amplatzer™ Duct occlude-I devices were used in 4 (17.4%) patients, and Amplatzer™ Duct Occluder-II devices were used in 3 (13.0%) patients with a mean device size of 8.8 ± 2.8 mm. The mean procedural time was 55.1 ± 16.2 minutes, fluoroscopy time was 16.3 ± 4.0 minutes, and the contrast used was 33.8 ± 10.9 ml. Concomitant balloon pulmonary valvuloplasty was done at the same catheterization set in 2 (8.7%) patients. Acute procedural success, satisfactory immediate were achieved in all patients. During follow-up (23.3 ± 15.9 months), no patient required re-intervention or exhibited mortality. Conclusions Transcatheter closure of post-operative, and post-intervention residual and iatrogenic VSDs represents an attractive therapeutic approach. This approach is safe, feasible, effective, and less invasive alternative treatment option for such remaining VSDs.

Improving Multi-agent Coordination by Learning to Estimate Contention

We present a multi-agent learning algorithm, ALMA-Learning, for efficient and fair allocations in large-scale systems. We circumvent the traditional pitfalls of multi-agent learning (e.g., the moving target problem, the curse of dimensionality, or the need for mutually consistent actions) by relying on the ALMA heuristic as a coordination mechanism for each stage game. ALMA-Learning is decentralized, observes only own action/reward pairs, requires no inter-agent communication, and achieves near-optimal (<5% loss) and fair coordination in a variety of synthetic scenarios and a real-world meeting scheduling problem. The lightweight nature and fast learning constitute ALMA-Learning ideal for on-device deployment.

Utilisation of Image Guidance to Enhance Safety of Deployment of the Mynx Control Vascular Closure Device

The Mynx Control device (Cardinal Healthcare, Dublin, Ohio, USA) was recently licensed and allows for entirely extravascular arteriotomy closure. It uses a polyethylene glycol sealant plug which is absorbed fully within 30 days, alleviating concerns around difficulties with regaining access in future. The Mynx device uses a balloon, inflated within the artery and retracted against the arteriotomy to achieve haemostasis, with the extravascular sealant plug then deployed outside the vessel wall. While the manufacturer’s instructions for use do not include utilisation of imaging guidance, we routinely employ fluoroscopic and/or ultrasound to ensure safe use of the device. These techniques allow confirmation of balloon position against the arteriotomy, hence avoiding inadvertent deployment of the plug partially or fully intraluminally. Visualisation of the balloon within the lumen also eliminates risk of plaque disruption in diseased vessels on retraction of the device. Image guidance adds little time to device deployment, and the safety benefits are such that we recommend that practitioners elsewhere consider adopting our techniques. Here, we describe the process involved in both techniques.

A Good Practice Guide for the Use of DGTs. Sampling of metals in transitional and coastal waters by Diffusive Gradient in Thin films (DGT) technique

This good practice guide is focused on the DGT devices, which are the most widely used passive sampler for metals, covering the following aspects: ■ Principle ■ Handling passive sampling devices for metals ■ Estimation of appropriate field deployment time ■ A Good Practice Guide for the Use of DGTs ■ Passive sampling device preparation and assembly ■ Selection of sampling site and safety precautions ■ Passive sampling device deployment and retrieval ■ Extraction of analytes from passive sampling devices ■ Analysis ■ Calculations

When Two Is Better than One

Background Delivery of most flow diverters (FD) requires larger, and thus stiffer microcatheters (0.021–0.027in.) which can pose challenges to intracranial navigation. The concomitant use of two microwires within one microcatheter, also known as the buddy-wire technique, may be helpful for navigation and support in challenging situations. Methods We analyzed all flow diverter procedures in our prospectively collected database. We recorded all patient-related, anatomical and procedural information. We performed univariate statistics and technical descriptions. Results In total, 208 consecutive patients treated with a FD at our institution between July 2014 and August 2020 were retrospectively analyzed. In 17 patients the buddy-wire technique was used (mean age 63 years, range 31–87 years: 16 female). Aneurysms were located at the petrous, cavernous, supraophthalmic internal carotid artery, and a proximal M2 branch in 2, 7, 7 and 1 patient(s), respectively. In all cases a 0.027in. microcatheter was used for device deployment. In 14 patients with a wide-necked aneurysm the buddy-wire provided additional support to advance the microcatheter and mitigated the ledge between the aneurysm neck and the parent artery or a side branch. In two giant cavernous aneurysms treated with telescoping FDs, the buddy-wire was used to re-enter the proximal end of the foreshortened FD. Conclusion The buddy-wire is a useful technique in FD procedures to prevent herniation of the microcatheter into the aneurysm sack, in wide-necked aneurysms to mitigate the ledge effect between the aneurysm neck and the parent artery where the microcatheter tip may get stuck, or to enable re-entry into a foreshortened FD.

Educational technology for people living with implantable heart device

Objective: To develop an educational technology for people living with an implantable heart device.Methods: This is a methodological study carried out in the period from August 2020 to April 2021, carried out in two stages: integrative literature review and elaboration of educational technology.Results: Based on the evidence, it was possible to list generating themes such as the perception of people living with an implantable cardiac device, which served as the basis for the creation of a podcast entitled “Alphabet of the pacemaker”, with self-care guidelines from A to Z for the after time implantation of the device.Conclusions: The construction of evidence-based educational technology is a strategy to subsidize health educational practices and pacemaker users' understanding of health care after device deployment.

Utility of Eustachian valve for facilitating ASD device closures in defects with borderline mitral rims

A prominent Eustachian valve in the right atrium has been reported to pose significant challenges during device closure of atrial septal defects. We describe the procedural aspects of device closure in an ASD with deficient rims and a redundant Eustachian valve. The prominent Eustachian valve provided extra stability in the anteroinferior aspect during device deployment and hence proved to be helpful for the procedure. It is important to consider this aspect while planning device closure