PORT-A-CATH catheter rupture: case report

Introduction: The modern management of cancer treatment requires access to the venous system repeatedly for the passage of drugs, fluids and blood components. Peripheral veins are rapidly damaged by repeated punctures and by fluids that pass through them. To solve this problem, long-term vascular accesses avoid repeated punctures. One type of long-term venous access is the Port-A-Cath, which is an implantable device usually in the chest with a central venous catheter. Case report: Next, the case of a 34-year-old female with a diagnosis of breast cancer in the right breast is presented. It is treated with a radical mastectomy, and after the procedure a port-a-cath is placed in the left subclavian route for future treatments. The first cycle of chemotherapy is performed, later the patient reports pain at the catheter placement site with increased volume and progressive increase in pain. The patient goes to her health center for an evaluation, they decide to take a chest X-ray showing the migration of the catheter. The management used was through the seldinger technique at the femoral puncture site with a 6 Fr Amplatz GooseNeck Snare Guide, with which it was possible to extract the foreign body at the level of the left brachiocephalic vein. Conclusion: The implantation of a Port-A-Cath catheter is associated with some risks in the process. Catheter and patient care should be maintained to decrease the incidence of complications.

AI-Enabled, Ultrasound-Guided Handheld Robotic Device for Femoral Vascular Access

Hemorrhage is a leading cause of trauma death, particularly in prehospital environments when evacuation is delayed. Obtaining central vascular access to a deep artery or vein is important for administration of emergency drugs and analgesics, and rapid replacement of blood volume, as well as invasive sensing and emerging life-saving interventions. However, central access is normally performed by highly experienced critical care physicians in a hospital setting. We developed a handheld AI-enabled interventional device, AI-GUIDE (Artificial Intelligence Guided Ultrasound Interventional Device), capable of directing users with no ultrasound or interventional expertise to catheterize a deep blood vessel, with an initial focus on the femoral vein. AI-GUIDE integrates with widely available commercial portable ultrasound systems and guides a user in ultrasound probe localization, venous puncture-point localization, and needle insertion. The system performs vascular puncture robotically and incorporates a preloaded guidewire to facilitate the Seldinger technique of catheter insertion. Results from tissue-mimicking phantom and porcine studies under normotensive and hypotensive conditions provide evidence of the technique’s robustness, with key performance metrics in a live porcine model including: a mean time to acquire femoral vein insertion point of 53 ± 36 s (5 users with varying experience, in 20 trials), a total time to insert catheter of 80 ± 30 s (1 user, in 6 trials), and a mean number of 1.1 (normotensive, 39 trials) and 1.3 (hypotensive, 55 trials) needle insertion attempts (1 user). These performance metrics in a porcine model are consistent with those for experienced medical providers performing central vascular access on humans in a hospital.

Percutaneous insertion of peritoneal dialysis catheters by the nephrologist (modified Seldinger technique)

A proper functioning access to the peritoneal cavity is the first and foremost requirement to start peritoneal dialysis. Most commonly, peritoneal dialysis catheters are inserted using a surgical approach. Laparoscopic peritoneal dialysis catheter insertion is the recommended surgical technique because it offers to employ advanced adjunctive procedures that minimize the risk of mechanical complications. In patients with low risk of mechanical catheter complications, such as patients without prior history of abdominal surgery or peritonitis, and in patients ineligible for general anesthesia, the percutaneous approach of peritoneal dialysis catheter insertion is an alternative to surgical catheter insertion. Percutaneous insertion of peritoneal dialysis catheters can be performed by a dedicated nephrologist, interventional radiologist, surgeon or nurse practitioner under local anesthesia, either with or without image guidance using ultrasound or fluoroscopy. Several reports show similar catheter function rates, mechanical and infectious complications and catheter survival for percutaneously inserted peritoneal dialysis catheters compared to surgically inserted peritoneal dialysis catheters. This article describes the percutaneous insertion of peritoneal dialysis catheters technique adopted at Universitair Ziekenhuis Brussel since 2015. Our technique is a simple low-tech modified Seldinger procedure performed by the nephrologist and not using fluoroscopy guidance. We describe the excellent outcomes of our percutaneously inserted peritoneal dialysis catheters and offer a practical guide to set up your own percutaneous catheter insertion program.

Modified Seldinger technique for internal jugular open central venous line insertion in neonates: merging two different manoeuvers

Background Central venous line insertion in neonates is an important and lifesaving procedure. It can carry significant risks and complications, including death, at the time of insertion or later. We aimed to retrospectively assess the modified Seldinger technique for open placement of a central venous catheter in neonates, regarding its safety, feasibility, operative time, and preservation of the patency of the internal jugular vein. This study was conducted on 120 neonates from March 2018 to March 2020. We closely monitored the pulse for the detection of arrhythmia or bradycardia, which might be caused during the insertion of the guide wire or the tip of the catheter. Post-operative X-ray was done immediately after the end of the procedure for all cases, to determine the site of the central venous catheter and to detect the presence of pneumothorax. Results Arrhythmia was observed in 9 cases (7.5%), and blood oozing in 5 cases (4.1%). There were 3 cases of pneumothorax (2.5%), 2 cases of neck hematoma in two cases (1.6%), 6 cases of internal jugular vein thrombosis (5%), and dislodging of the catheter in 3 cases (2.5%). There were no cases of arterial puncture, failure of cannulation, or haemothorax in our study. Conclusions The modified Seldinger technique insertion for open central venous line in neonates is a safe, accessible, and feasible method, especially in centers that lack the experience of ultrasound-guided insertion in neonates.

Long peripheral catheters in neonates: filling the gap between short peripheral catheters and epicutaneous-caval catheters?

Introduction: Non-critically ill neonates at times require venous access to provide peripherally compatible infusions for a limited period (more than 3 days). In such a situation, short peripheral cannulas are not appropriate as their average duration is about 2 days, while—on the other hand—epicutaneous-caval catheters may be too invasive. In these patients, insertion of long peripheral cannulas may be an effective option. Methods: In this observational retrospective study, we revised all “long” peripheral catheters (4 and 6 cm long) inserted by direct Seldinger technique in our neonatal intensive care unit when peripheral venous access was required for more than 3 days. Results: We inserted 52 2Fr polyurethane catheters, either 4 cm long ( n = 25) or 6 cm long ( n = 27) in 52 patients. Mean dwelling time was 4.17 days (range 1–12). Most devices were inserted in the cephalic vein ( n = 18, 35%), and the rest in the saphenous vein ( n = 11, 21%) and other superficial veins. There was no significant correlation between the duration of the device and type of infusion ( p = 0.40). The main complications were infiltration ( n = 16, 31%) and phlebitis ( n = 8, 15%). The rate of removal due to complications was significantly higher ( p < 0.01) in neonates with bodyweight <2000 g at the time of insertion. Conclusion: In our experience, 2 Fr 4–6 cm long peripheral catheters may be a valid option for neonates requiring peripherally compatible infusions for more than 3 days. The limits of this study are the necessity of training in the technique of insertion and the small size of our sample. The longest dwell was observed in neonates weighing >2000 g at the time of LPC insertion.

Modified Seldinger technique for neonatal epicutaneo-caval catheter insertion: A non-randomised retrospective study

Background: Epicutaneo-Caval Catheters (ECCs) are critical for good neonatal care. No previous studies have evaluated which insertion method provides the highest likelihood of success. Methods: This study aimed to compare the success rates and cost of modified Seldinger technique (MST) and split needle technique (SNT). MST was introduced to St Michael’s Neonatal Unit, SNT was already in use. Routinely documented data on ECC insertion was retrospectively collected from the clinical notes. Practitioners were able to use their preferred insertion method. A sub-group analysis of success rates in patients born at ⩾35-weeks GA was performed. Results: There was a significantly higher first pass (53% vs 26%; p = 0.014) and overall (72% vs 40%; p = 0.0046) successful ECC insertion rate with fewer venipunctures per successful ECC with MST (2.5 vs 6.5; p = 0.002). Logrank test demonstrated a significantly higher successful ECC insertion with MST for patients of all GA ( p = 0.003) and for neonates born at ⩾35 weeks ( p = 0.015). The cost per successful MST ECC was £156.41 versus £152.51 for SNT. Conclusion: In this uncontrolled retrospective study, there was a higher chance of successful ECC insertion with MST, with a reduced number of venipunctures and similar costs per successful ECC. Further work in randomised studies is needed to verify this finding and should focus on other clinical outcomes, including rates in central line associated blood stream infections.

Echo-Guided Seldinger Technique Facilitates Ascending Aorta Cannulation in Type A Aortic Dissection

Ascending aortic cannulation was successfully performed in 64 consecutive patients, using the Seldinger technique, with the hands-free continuous-echo monitoring, utilizing a new stabilizer. This stabilizer-assisted method can safely provide a rapid and reliable route for antegrade central perfusion during in type A dissections repair.

How We Perform a David Procedure With an Upper Hemisternotomy Approach

Objective Valve-sparing aortic root replacement (David procedure) is the technique of choice in appropriately selected patients with aortic root aneurysms. These procedures are seldom performed in a minimally invasive fashion. We describe our systematic approach to the David procedure using an upper hemisternotomy (UHS). Methods: Our method involves a J-type UHS exiting the right third or fourth intercostal space. Ascending aortic and femoral venous cannulation are performed using the Seldinger technique under transesophageal echocardiographic guidance. Between August 2005 and August 2014, 27 patients underwent an isolated elective David procedure using a full sternotomy (FS). Sixteen underwent an isolated elective UHS David procedure from May 2015 to February 2019. Perioperative safety outcomes were compared between the 2 cohorts. Results: The UHS and FS David cohorts were primarily male (87.5% and 85.2%, respectively) and 51 and 50 years old on average, respectively. Custodiol-histidine-tryptophan-ketoglutarate cardioplegia (93.8% vs 37.0%, P < 0.001) and Cor-Knot (100% vs 0%, P < 0.001) were used significantly more in the UHS David cohort. There were no significant differences in cardiopulmonary bypass (200 [183–208] vs 212 [183–223] min, P = 0.309) and aortic cross-clamp (169 [155–179] vs 188 [155–199] min, P = 0.128) times in the UHS and FS cohorts. There were no instances of hospital or 30-day mortality in either cohort. Intensive care unit and hospital stays were comparable between the 2 cohorts. Conclusions: The David procedure via UHS is a safe and reproducible technique for aortic root replacement.

Covid-19 and a lost guidewire: A misty tale of misery!

Central venous catheterization (CVC) is a routine procedure in patients admitted in Intensive Care Units (ICU) worldwide. Most commonly, seldinger technique is being practiced irrespective of the site of insertion. Though considered very safe, guide wire related complications have been reported in the literature and incidence has increased in the COVID era where intensivists have to work in personal protective equipment (PPE). We are reporting about a patient of severe COVID-19, admitted in ICU. His right femoral venous catheterization was done to start vasopressors. The guide wire accidentally slipped inside the femoral vein during the procedure. It was immediately detected and managed with the assistance of interventional radiologist under fluoroscopic guidance. Complications like misplacement of guide wire can be catastrophic during CVC. We have discussed the measures that can prevent or reduce such complications while working in PPE in COVID ICUs.