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  • ISSN: 2378-9344
    Volume 4, Issue 7
    Research Article
    Mathis Planert, Erik Stahlberg*, Susanne Anton, Fabian Jacob, Martin Nitschke, Jorg Barkhausen, and Jan Peter Goltz
    Objectives: To evaluate a method for determination of the catheter length and identification of the target-zone (TZ) in order to position the catheter-tip (CT) during percutaneous implantation of antegradely tunneled-hemodialysis-catheters (THC). To evaluate the influence of obesity on CT-migration.
    Materials and methods: In 20 consecutive patients (11 males, age 69, IQR 56 to 77 years) THC were implanted percutaneously using sonographic and fluoroscopic guidance. Using fluoroscopy the center of the right atrium was marked extra-corporally. By this the optimal catheter-and tunnel-lengths were estimated. After implantation CT-position was documented after inspiration and expiration in a supine position on the angiography-table. Distances of the CT to the carina, cavo-atrial-junction and atrial-bottom were measured for inspiration and expiration. These were compared to those measured on post-interventional x-ray-images in upright position after expiration. Data from obese (OB, n=13) and non-obese patients (NOB, n=7) were compared.
    Results: All CTs were located within the right atrium. Median CT-movement between inspiration and expiration was 9mm (IQR: 6 to 21mm). Median distance from CT to cavo-atrial junction after inspiration was 46mm (IQR: 39 to 60mm) and to the atrium bottom after expiration 18mm (IQR: 13 to 26mm). The median difference between expiration in supine and expiration in upright position was 9mm (IQR:-3 to 17) (p=0.04). Median movement of 15mm (IQR: 5 to 23mm) was measured for the OB group, and 9mm (IQR: 6 to 18mm) in the NOB group (p<0.001).
    Conclusions: Fluoroscopically aided identification of the center of the right atrium can be used as a target-zone for adequate determination of the catheter length with correct positioning of CT during percutaneous implantation of THCs. Obesity has a small but relevant influence on the catheter-migration.
    Raffaele De Lucia*, Zucchelli G, Segreti L, Di Cori A, Soldati E, Viani S, Paperini L, and Bongiorni MG
    Background: Long-term use of Port-a-Caths (PACs) is related to device-related delayed complications. The aim of this study is to describe the high success rate and safety of cardiac pacing lead extraction techniques used to manage PACs complicated by infection or migration and not removed by manual traction.
    Methods: During a 19-year period (1997-2016), 39 consecutive PAC recipients (54.6 ± 14.5 years, 23 females) were referred to our hospital for PAC-related delayed complications and not removable by manual traction (mean dwelling time 45.7 ± 44.1 months).
    Results: PAC implantation indications included gastrointestinal cancer (15.3%), breast cancer (12.8%), neuroendocrine cancer (7.6%), other malignant diseases (61.5%), and non-malignant diseases (2.5%). PAC removal indications were breakdown due to subclavian crush (53.8%), breakdown due to unsuccessful previous removal attempt (10.3%), sepsis (15.4%), or malfunction (20.5%). Removal of fractured free-floating catheters (25) migrated toward the venous blood course was attempted by tool-guided traction in all cases except 1 in whom mechanical dilation was necessary.
    For the 14 intact ones (6 infected and 8 malfunctioning) we used tool-guided traction and single-sheath mechanical dilation, depending on the vascular/cardiac-catheter setting. By using multiple venous approaches we removed 37 catheters completely and 1 partially, achieving clinical success in all of these patients. We had only 1 patient referred to cardiothoracic surgeon for very tight convolutions and adherences along the subclavian course of an intact and malfunctioning PAC. The most commonly used venous approach was transfemoral (TFA; 56.4%), followed by the original venous entry site approach (VEA; 35.9%) and internal transjugular approach (ITA; 5.1%). No major or minor complications were observed.
    Conclusions: In experienced centers, cardiac pacing lead extraction techniques may be considered as an additional, efficacious, and safe option for extraction of otherwise non removable entrapped PACs before surgery.
    Minal Bhagwat, Vidyasagar Casikar,* and Karkenahalli Srinivas
    There are many published reports of studies of blood flow in an Arterio-Venous Malformation. One such is the experiments by Casikar and Ramaswamy which has clearly demonstrated the unexpected relationship among vessel diameter, blood pressure and steal phenomenon.
    The present research was designed to create a computational model to critically analyse the experimental findings. In addition, due to the difficulty of measuring any values in vivo, a computational model is the most feasible response to enhance the current understanding of this vascular malformation in the medical and engineering communities.
    To initiate this examination of the factors leading to arteriovenous malfunction development and progression, a Buckingham Pi analysis was conducted in order to identify some dimensionless value connected with the specific blood flow found in the AVM network. Various assumptions were incorporated into the calculations. Critical variables (based on the assumptions made in this analysis) were identified.
    Overall the tests conducted pertained a high level of reliability, owing to the repeated testing procedures within this examination. Each CFD analysis was tested thrice over, to identify errors and ensure reliable testing procedure and results obtained. Each test yielded the same, or highly similar, data sets, identifying conclusively the overall reliability of the data obtained. These results can be reproduced.
    The paper explores additional mechanisms of vessel wall remodelling resulting from changes in wall shear stress experienced by the vessels. The article finds that increasing wall shear stress in the region results in an increase in wall thickness and vessel diameter in order to normalise the values.
    The model shows that when AVM fistula diameter increases, with all other variables constant, the pressure and velocity across the entire system shows significant changes. The computational evidence suggests that the critical change for both pressure and velocity are directly related steal phenomenon in the system. This further solidifies the various hypotheses relating to the critical nature of both diameter and the effect of the onset of steal phenomenon. The sudden alteration in pressure and velocity of blood in the AVM after during and after the onset of vascular steal may present further explanation for the dormant nature of the symptoms of the disorder where the symptoms are found to largely present only after steal occurs.
    The results obtained in this study highlight relationship between mass flow rate, fistula diameter, and amount of flow shunting upon the overall progression of an AVM.
    This study postulates that the combination of vessel dilation and diminished capacity of auto-regulation of the vessels may render the AVM incapable of approaching a point of equilibrium. This study has found evidence to explain the onset of symptomology of AVMs as a result of steal phenomenon and create highly volatile clinical conditions.
    All AVMs are due to a fistula between the artery and the vein. There is a specific connection between the arteries and veins as in other extra cranial situations. In this paper AVM refers collectively to all the fistulae. The word fistula is used when a single example is cited.
    The model does not explain “pial AVM”. The concept of pial AVM is influenced by early embryologists, before Padget. There is no evidence to support this based on principles embryology
    This study offers many potential avenues for future research. Much of the future work should focus on incorporating biological processes, such as auto regulation and cell renewal, into the computational model.
    Hassan N, Hammodi A, Alhubail R*, and Rayyan N
    Context: Femoral, jugular and subclavian catheterization are performed during critically ill patient care which may lead to additional morbidity, mortality, and infectious complications.
    Objectives: To determine the Subclavian, Jugular or Femoral central venous catheters (CVC) risk of central line associated blood stream infection (CLABSI), the CVC sites related complications and patients mortality.
    Methods: Retrospective observational study in medical-surgical ICU of a tertiary care hospital on adult patients admitted from January 2010 till December 2013. We enrolled 840 patients divided into 283 internal jugular (IJC), 270 subclavian (SCC) and 287 femoral (FC) in which lines were inserted by experienced physicians, using CVC bundle checklist. Patient characteristics and catheter duration were chosen similar in all groups. CLABSI rate, Complications, and patient’s mortality were the outcomes of the study.
    Results: Rate of CLABSI in IJC, SCC and FC groups was 5.8 vs 7.2 vs 3.45 per 1000 catheter-days respectively with p-value of 0.35. Mortality in 134 (47%) cases of IJC, 108 (39%) of cases SCC and 113 (39%) cases of FC with p value 0.14, with no significant difference between the 3 groups in CLABSI rate and mortality. Pneumothorax in 6 (2.2%) cases of SCC and 11 (3.8%) of IJC with no significant difference between the 2 groups as the p value was 0.3.
    Conclusion: Site of insertion of CVC does not appear to affect the rate of CLABSI among critically ill patients with no statistical difference in mortality. Pneumothorax was recorded in SCC and IJC groups with no preference to either group.
    Editorial
    Irina Iuliana Costache*, Cristiana Vlad, Alexandru Dan Costache, Victor Cristian Aursulesei, and Viviana Aursulesei
    The most common cause of Lower extremity artery disease (LEAD) is atherosclerotic vascular disease. LEAD due to atherosclerosis is relatively highly prevalent and is a significant public health problem that impairs quality of life, as well as a major cause of cardiovascular morbidity and mortality [1,3]. The low level of high-density lipoprotein cholesterol (HDL-c) is a major risk factor for atherosclerotic cardiovascular disease including LEAD [3]. Genetic investigation of LEAD is an evolving concept useful for understanding its pathogenesis and for identification of new therapeutic targets [2,3].
    Aursulesei Viviana*, Aursulesei Victor Cristian, Costache Alexandru Dan, Al Namat Razan, and Costache Irina Iuliana
    Over the recent decades, the prevalence of obesity has increased dramatically, leading to a high rate of cardiovascular complications and mortality. On the other hand, despite the improvement of medical awareness and diagnosis, venous thromboembolism remains the third most common cause of cardiac death.
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