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Objective To analyze and classify arterial supply and venous drainage of postcatheterization femoral arteriovenous fistulas (AVFs). Methods A review of extremity Doppler reports identified 77 femoral AVFs in 75 patients. Doppler exams were reviewed retrospectively. Fistulas were classified as above or below the common femoral artery bifurcation and subclassified based on the location of arterial inflow and venous outflow. Results Arterial inflow originated above the femoral bifurcation in 32 cases. The communication was between the common femoral artery and the superficial circumflex iliac vein in 25 of 32 cases and between a branch of the common femoral or external iliac artery and the common femoral or external iliac vein in 4 of 32 cases. In 3 of 32 cases, AVFs arose from the common femoral artery, but the venous outflow was not determined. Arterial inflow originated from the superficial femoral artery in 23 cases. Venous outflow originated from the common femoral vein in 10 of 23 cases, the femoral vein in 7 of 23 cases, and the lateral circumflex femoral vein in 6 of 23 cases. Arterial inflow originated from the deep femoral artery in 12 cases. Venous outflow originated from the common femoral vein in 6 of 12 cases and from the lateral circumflex femoral vein 6 of 12 cases. In 8 cases, the AVF originated below the bifurcation, but the arterial inflow was not classified. In 2 cases, it was impossible to determine if the AVF originated above or below the bifurcation. Conclusions Iatrogenic femoral AVFs arise above the femoral bifurcation more often than previously recognized. Classification based on the arterial inflow and venous outflow provides a straightforward means of describing these fistulas.

The performance of each veno-venous extracorporeal membrane oxygenation (vv-ECMO) configuration is determined by the anatomic context and cannula position. A mathematical model was built considering bicaval specificities to simulate femoro-jugular configuration. The main parameters to define were cardiac output (QC ), blood flow in the superior vena cava (QSVC ), extracorporeal pump flow (QEC ), and pulmonary shunt (kS-PULM ). The obtained variables were extracorporeal flow ratio in the superior vena cava (EFRSVC = QEC /[QEC + QSVC ]), recirculation coefficient (R), effective extracorporeal pump flow (Qeff-EC = [1 - R] × QEC ), Qeff-EC /QC ratio, and arterial blood oxygen saturation (SaO2 ). EFRSVC increased logarithmically when QEC increased. High QC or high QSVC /QC decreased EFRSVC (range, 68%-85% for QEC of 5 L/min). R also increased following a logarithmic shape when QEC increased. The R rise was earlier and higher for low QC and high QSVC /QC (range, 12%-49% for QEC of 5 L/min). The Qeff-EC /QC ratio (between 0 and 1) was equal to EFRSVC for moderate and high QEC . The Qeff-EC /QC ratio presented the same logarithmic profile when QEC increased, reaching a plateau (range, 0.67-0.91 for QEC /QC = 1; range, 0.75-0.94 for QEC /QC = 1.5). The Qeff-EC /QC ratio was linearly associated with SaO2 for a given pulmonary shunt. SaO2

BACKGROUND AND OBJECTIVES Vasospasm is a thorny problem often encountered in microvascular surgery that seriously threatens the survival of vascularized tissue transfers. This investigation is dedicated to establishing a model of vasospasm and to evaluating the antispasmodic efficacy of 10 pharmacologic agents. STUDY DESIGN/MATERIALS AND METHODS Eighty Sprague-Dawley rats were used. After anesthesia and depilation, the femoral neurovascular bundle was exposed, and a pair of microsurgical forceps were used to trigger vasospasm of the femoral vessels by blunt dissection. Then, 10 pharmacological agents, namely, prostaglandin E1, sodium nitroprusside, magnesium sulfate, papaverine, normal saline, phentolamine, verapamil, 2% lidocaine hydrochloride, amrinone, and 12% lidocaine hydrochloride, were dripped to the femoral vessels, after which laser speckle contrast imaging was used to collect perfusion images, acquiring the perfusion and the inner caliber of the femoral vessels at multiple timepoints. Furthermore, blood perfusion and the time consumed to escape vasospasm and reach hyperperfusion in each group were calculated. The difference of spasmolytic efficacy among the agents was statistically analyzed by one-way analysis of variance. RESULTS There was a significant difference in antispasmodic ability among the 10 agents (P

Repeat hepatectomy for recurrent colorectal liver metastases (CRLM) for the remnant hemiliver is sometimes challenging due to the insufficient future liver remnant (FLR) volume. We present an aggressive strategy for resection of the recurrent CRLM involving bisegmentectomy of the remnant right hemiliver with the aid of portal vein embolization (PVE) and venous reconstruction. The patient was a 50‐year‐old woman who had undergone left hemihepatectomy for a CRLM 10 months ago. Three metastatic tumors were found in the remnant segments 7 and 8 (S7&8) of the liver, and one of them involved the right hepatic vein (RHV). Conducting bisegmentectomy of S7&8 with resection of the RHV, the non‐congestive FLR volume was calculated as 34.9% of the remnant total liver volume, which was deemed insufficient considering the mild liver damage after repeated chemotherapy. After trans‐ileocecal PVE of the portal branches in S7&8 in a hybrid angio room, the non‐congestive FLR volume increased to 42.3%, which could be further advanced to 58.0% if the RHV was reconstructed. Segmentectomies of S7&8 with resection and reconstruction of the RHV using the right superficial femoral vein graft was performed. The patient was discharged without any complications, and the postoperative computed tomography (CT) scan showed the good patency of the reconstructed venous graft. Aggressive segmentectomies and venous reconstruction of the remnant hemiliver after PVE might be a new strategy to overcome the insufficient FLR volume., Bisegmentectomy for recurrent colorectal liver metastases (CRLM) is sometimes challenging due to the insufficient future liver remnant volume in patients undergoing hemihepatectomy for initial CRLM. Segmentectomy combined with venous reconstruction after portal vein embolization for the remnant hemiliver could be a new strategy.

Purpose Point-of-care ultrasound (POCUS) has been demonstrated as one of the primary diagnostic tools for deep vein thrombosis (DVT) screening in the emergency department, but there are quite different results in the literature regarding its diagnostic value. The aim of this study is to assess the diagnostic value of POCUS in DVT diagnosis. Methods Patients with a clinical suspicion of DVT who underwent POCUS and were monitored by the radiology department via ultrasonography (US) or venography for DVT were retrospectively examined. POCUS examination for DVT was performed in the femoral and popliteal regions by a two-point compression technique. The inclusion criteria were age >18 years and patients with both a POCUS report and venography or US examinations performed by the radiology department (RUS) and reported by the radiology clinic. RUS and venography were considered as the gold standards. Results The study included 266 patients. POCUS had a sensitivity of 93% (95% CI: 84-98) and specificity of 93% (95% CI: 89-96). Its positive likelihood ratio (LR+ ) was 14 (95% CI: 8-24), and its negative likelihood ratio (LR- ) was 0.08 (95% CI: 0.03-0.19). POCUS also had a positive predictive value (PPV) of 83% (95% CI: 74-89) and a negative predictive value (NPV) of 97% (95% CI: 94-99). Conclusions Our study verifies that POCUS has high specificity and sensitivity for the examination of the popliteal and femoral veins by an emergency physician to evaluate patients with a preliminary diagnosis of DVT.

Femoral venous catheterization is a common procedure in critical care patients. Pregnant women and those in the postpartum period are at risk of various complications such as shock, acute kidney injury, and thrombotic microangiopathic syndromes requiring hemodialysis and plasma exchange, which may necessitate central venous catheterization. Femoral vein catheters may also sometimes be needed. These women may have underlying pelvic congestion and varicosities. Here we present a 24-year-old female patient, who has been treated for postpartum thrombotic microangiopathy with initial clinical improvements, became hemodynamically unstable with diffuse abdominal tenderness and a significant drop in the hemoglobin/hematocrit. Her abdominal ultrasound showed fluid in the peritoneal cavity with hemorrhagic diagnostic tap. The patient underwent exploratory laparotomy which unexpectedly revealed an erroneously introduced femoral vein catheter into a broad ligament varicose vein causing hemoperitoneum and evident ovarian injury. Puncturing of broad ligament varicosities causing hemoperitoneum in peripartum women has not been previously reported as a complication of femoral vein catheterization. This indicates that femoral catheterization in pregnant and peripartum women should be cautiously done and that development of acute abdominal issues, following insertion of femoral vein catheter should raise clinical suspicion and warrant evaluation of catheter misplacement.

Background Venous bleeding complication is often observed after catheter ablation of atrial fibrillation (AF), but the risk factors remain unclear. Methods We retrospectively evaluated 570 consecutive patients who underwent catheter ablation of AF from April 2012 to March 2017. After the procedure, the sheaths were removed, and hemostasis was obtained by manual compression followed by application of rolled gauze with elastic bandage and continuous pressure to the puncture site. We evaluated the risk factors for venous bleeding complications defined as hemorrhage from the puncture site that needed recompression after removal of the elastic bandage and rolled gauze. Results After excluding 11 patients because of missing data, 559 patients (395 [70.7%] men, mean age: 65.6 ± 8.7 years) were included for analysis. Venous bleeding complication was observed in 213 patients (38.1%). In the multivariate logistic regression analysis, low body mass index (BMI; odds ratio [OR] 0.95, 95% CI 0.90‐1.00, P = .04), short compression time (OR 0.77, 95% CI 0.68‐0.88, P, We retrospectively evaluated 570 consecutive patients who underwent catheter ablation of atrial fibrillation. The risk factors for venous bleeding complications were analyzed. Low BMI, short compression time, and antiplatelet therapy were found to be the significant risk factors.

Intermittent pneumatic compression is part of the current standard of care model for preventing venous thromboembolic events (VTE) after total joint arthroplasty. Pneumatic motors limit the rate of inflation resulting in bulky devices with uncomfortable sleeves that inhibited patient compliance and mobility. Nonpneumatic mechanical devices are an alternative for providing mobile, graded, intermittent, sequential, rapid, and monitorable compression posthospitalization. Fifteen healthy volunteers underwent mechanical compression using the Cirvo (Radial Medical, Mountain View, CA) as well as pneumatic compression with four commercially available systems (VenaFlow Elite, Kendall SCD Compression System, ActiveCare DVT, Vasculaire Compression System) and manual calf compression. Peak flow velocity (PFV) was measured by ultrasound of the femoral vein during compression and at baseline. Mechanical compression for 1 second resulted in a significant increase in femoral venous PFV to 107.8 ± 38.2 cm/s from 17.1 ± 4.7 cm/s at baseline (P < .001). The change in femoral venous PFV with mechanical compression for 1 second (90.7 ± 34.9 cm/s) was not statistically different from pneumatic compression from VenaFlow system (106.0 ± 35.6 cm/s, P = .124) and statistically lower than manual calf compression (115.5 ± 26.8 cm/s, P = .015). Pneumatic compression from the VenaFlow system produced the largest change in femoral venous PFV of all commercial pneumatic systems tested. Mechanical compression replicates or exceeds femoral venous PFV available from currently available intermittent pneumatic compression.

Temporary central venous catheters are commonly used for patients who require emergency hemodialysis (HD). An arteriovenous fistula (AVF) is a rare complication of this procedure. In this case report, we present a patient who was diagnosed with an iatrogenic femoral AVF after cannulation of the right femoral vein with a temporary HD catheter.

The aim of the study was to provide quantitative data and to look for new landmarks useful during transseptal puncture (TSP) using a fluoroscopy-guided approach. METHODS AND RESULTS: A total of 104 patients at mean age 57 ± 12 years, of whom 92% underwent pulmonary vein isolation, were analysed. Before TSP catheters were placed in the coronary sinus (CS) and His bundle region. A guidewire running from femoral vein through great veins was left loose in superior vena cava. Before TSP X-ray images were taken in right anterior oblique (RAO) 45° and RAO 53° projections. Locations posterior to TSP site in RAO were described with negative values and those anterior with positive values. The measured distances in millimeters were as follows: (a) between TSP site and posterior atrial wall (RAO 45 = -21 ± 7 mm; RAO 53 = -19 ± 6 mm (b) between TSP site and free guidewire (RAO 45 = -5 ± 4 mm, RAO 53 = -3 ± 4 mm (c) between TSP site and CS ostium (RAO 45 = 9 ± 6 mm; RAO 53 = 8 ± 5 mm (d) between TSP site and His region (RAO 45 = 29 ± 8 mm; RAO 53 = 30 ± 8 mm). We observed correlations between measured distances and age, body mass index and sizes of cardiac chambers. The distance between TSP site and the line projected by the guidewire running between great veins, measured in mid-RAO projections, was very small. CONCLUSION: The distances between TSP site and standard anatomical landmarks used during TSP vary with regard to age, physique and cardiac chamber dimensions. TSP site, as assessed in mid RAO, is in direct vicinity to the line projected by a guidewire running between the great veins.

Background: Transvenous lead extraction (TLE) may be performed by superior approach using the original implant vein or via a femoral approach; however, limited comparative data exists. We compare outcomes between femoral versus nonfemoral TLE approaches and determine predictors of bailout transfemoral lead extraction in patients undergoing initial TLE via the original implant vein by a superior approach. Methods: All consecutive TLEs between October 2000 and March 2018 were prospectively collected (n = 1052). Patients were dichotomized into femoral (n = 118) and nonfemoral (n = 934) groups. Results: Demographics were balanced between femoral vs nonfemoral groups. Patients in the femoral group had significantly higher mean lead dwell times (11.6 ± 9.7 vs 6.6 ± 6.6 years, P

Background How to maximally improve the drainage of intracranial and upper body venous and to reduce neurological complications during thoracic tumor‐causedsuperior vena cava replacement are still clinical problems to be solved. Methods We have innovatively used the bilateral jugular vein‐left femoral vein ECMO shunting to perform mediastinal tumor resection and superior vena cava replacement in a 50‐year‐old woman. Results During the operation, this technique maintained the patient's hemodynamic stability, improved the cerebral oxygen saturation and reduced the cerebral ischemia, hypoxia as well as the neurological complications. Conclusion It is indicated for patients with superior vena cava replacement who are unable to perform venous bypass (such as innominate vein to right atrial bypass) or venous shunting (such as differential pressure drainage from internal jugular vein to femoral vein).

Background Since the femoral artery frequently overlaps the femoral vein, femoral central venous catheterization carries the risk of arterial puncture in pediatric patients. Aims We evaluated the angle range of leg abduction with external hip rotation to minimize the overlap between the femoral artery and vein in pediatric patients undergoing general anesthesia. Methods Eighty-two pediatric patients who underwent elective surgery with general anesthesia were enrolled in this study. Using ultrasonography, patients were divided into groups N (patients with non-overlap) and O (patients with continuing overlap) based on the presence of non-overlap range between the femoral artery and vein. The range minimizing the overlap was defined as the range without overlap in group N and as the range presenting the overlap that was less-than-half of the radius of the femoral vein in group O. By increasing the angle of leg abduction with external hip rotation, the starting and ending angles minimizing the overlap were found using ultrasonographic images. Results The angle range of leg abduction with external hip rotation minimizing the overlap between the femoral artery and vein was defined as the range from the maximum 99% confidence interval of starting angles to the minimum 99% confidence interval of ending angles, which was between 45° and 65° in group N and between 48° and 58° in group O, respectively. Conclusion Positioning patients in a range of 48° and 58° leg abduction with external hip rotation can minimize the overlap between the femoral artery and vein. However, the clinical usefulness of this positioning for femoral venous catheterization remains to be seen.

Air insufflation has been used for various surgical procedures such as during laparoscopy. We hypothesized that the use of pressurized air might enable cadaveric dissection to differentiate smaller veins better than traditional dissection techniques. In three fresh-frozen cadavers, the inferior vena cava (IVC) and right or left femoral veins were exposed just distal to the inguinal ligament and a needle placed into one of them. Pressurized air was then placed into the cannulated femoral vein using an air compressor. In all specimens, the IVC and most of its tributaries, both left and right sides, were clearly insufflated. When the IVC was traced superiorly by resecting the diaphragm through the caval foramen, the right atrium and ventricle were also found to be dilated. Additionally, venous variants that would have not been obvious without dilatation of the IVC were identified. Air dissection of the venous system in fresh-frozen cadavers aids in anatomical dissection. Such a model might also serve as a surgical training model and teaching tool as it better mimics life-like anatomy and physiology. We term this technique "cadaveric air dissection." Clin. Anat. 32:566-572, 2019. © 2019 Wiley Periodicals, Inc.

This study aims to validate whether bone marrow stromal cells (BMSCs) transplantation could promote the resolution and recanalization of deep vein thrombosis (DVT) and to explore the underlying mechanism. The right hind femoral vein was embolized to establish the DVT rabbit model. BMSCs from New Zealand white rabbits were isolated and identified, and then injected into DVT rabbits. After that, the extent of angiogenesis was determined by the amount of capillaries that were positive for antibody against vWF. Macrophage infiltration was measured by immunohistochemistry with F4/80 antibody. M1 or M2 macrophages were identified as F4/80 + CD11c + or F4/80 + CD206 + cells by using flow cytometry analysis, respectively. BMSCs were successfully isolated and identified. BMSCs transplantation promotes macrophage infiltration and angiogenesis in DVT rabbits. BMSCs transplantation causes M1/M2 polarization, altered cytokine production and increased monocyte chemotactic protein 1 (MCP-1) protein expression in DVT rabbits. However, injection of MCP-1 protein not only reversed the effects of BMSCs transplantation on macrophage infiltration and angiogenesis, but also reversed the effects of BMSCs transplantation on M1/M2 polarization and cytokine production in DVT rabbits. BMSCs transplantation promotes the resolution and recanalization of DVT in rabbits through regulating macrophage infiltration and angiogenesis, the underlying mechanism is associated with MCP-1 expression.

In patients with challenging femoral vein anatomy, transcatheter patent foramen ovale (PFO) closure can be safely and effectively be done through the jugular veins guided by ICE from the arm. This novel technique can potentially save resources (anesthesia and TEE) and provide an option for patients without a femoral option.

Surgical intervention for HB with tumor thrombi extending into the IVC and the RA might requires careful planning of the surgical procedures, including vascular reconstruction and extracorporeal circulation. We herein report a successful case of LDLT for HB with atrial extension of a tumor thrombus by extracorporeal circulation with a transdiaphragmatic approach. The patient was a 5-year-old boy with PRETEXT IV HB with a tumor thrombus that extended into the IVC and the RA. After 4 cycles of chemotherapy and resection of bilateral lung metastases, the size of the primary HB tumor decreased. As the tumor extension from the LHV to the RA had decreased but was still present, we performed LDLT with tumor thrombectomy. The central part of the diaphragm was sagittally incised to expose the suprahepatic IVC and the RA. Venovenous bypass was achieved from the right femoral vein and IMV to the RA En bloc resection of the native liver with the tumor thrombus was then performed. HV anastomosis was made between the newly created orifice on the IVC and the graft LHV. The duration of LDLT was 10 hours and 44 minutes (extracorporeal circulation time: 78 minutes). Pediatric LT for HB with the extension of tumor thrombi into the RA under extracorporeal circulation is a feasible option and allows for the expansion of the indications for transplantation for children with unresectable liver tumors.

Introduction Although the precise cause of obstructive sleep apnea (OSA) remains unknown, various anatomical or structural factors are thought to influence upper airway patency. Recent clinical studies show that OSA is frequently observed among patients with fluid‐retaining states, such as heart/renal failure and postsurgery. It is important to note that a cause–effect relationship is not yet established, and our understanding of the effects of fluid overload is limited. The goal of this study was to investigate an animal model that can characterize the physiological changes that occur in response to fluid overload. Method Acute nonsurvival experiments were conducted in 16 Sprague–Dawley rats. Rats were initially anesthetized by inhaled isoflurane, while the femoral vein was cannulated and urethane (1.2–1.5 g/Kg body weight) was gradually delivered intravenously to induce anesthesia. Additional doses of urethane were delivered as necessary to maintain a surgical plane of anesthesia. A surgical incision was made on the cervical area to catheterize carotid artery to measure blood pressure. A pair of stainless‐steel wires was injected into the tongue to measure genioglossus muscle activity (GGEMG). All physiological measurements were recorded as intravenous infusion of saline was provided to the rat (infusion rate = 22 ml/kg over 30 min). Results Acute saline overloading resulted in a 33% decrease in GGEMG, when compared to baseline. There was also a gradual drop in the respiratory rate (13% decrease) that reached statistical significance at 10 min after infusion was stopped. The blood pressure exhibited a 14% increase which subsequently returned to baseline within 40 min stopping infusion. There were no significant changes in the heart rate. Conclusion The results of this study indicate that systemic fluid overload can affect significant changes in different physiological systems including reduction in genioglossus muscle activity, increase in blood pressure, and change autonomic nervous system function., In this study, the effects of acute intravenous saline infusion on multiple physiological parameters—such as respiratory, cardiovascular, and autonomic nervous system—which was conducted in urethane anesthetized rodents were evaluated. Our results showed that “fluid overloading” causes a significant decrease in upper airway dilator muscle activity, which is a characteristic biomarker observed in obstructive sleep apnea patients.

Background Inserting an electrophysiological (EP) catheter into the coronary sinus (CS) via the femoral vein can be difficult and time‐consuming in patients with variants of the CS orifice or lumen curve. Our experience with such patients inspired us to develop two new techniques: the Asclepius and Yellow Ribbon techniques. Methods Data from a 4‐year period were retrieved from records of patients undergoing radiofrequency ablation for paroxysmal supraventricular tachycardia (PSVT) or Wolff–Parkinson–White (WPW) syndrome. Data were analyzed to determine the success and complication rates of conventional and alternative techniques for catheter placement. Results The success rate of the Asclepius technique was 96.7% (30/31) and that of the Yellow Ribbon technique was 100.0% (7/7). The overall success rate of these two techniques was 97.3% (37/38). Conclusions With a high success rate, shorter procedure time, and no complications, the Asclepius and Yellow ribbon techniques may be safe, inexpensive, and effective alternative strategies for EP catheter placement in patients with difficult coronary sinus orifice access.

Objective This single-center, retrospective analysis investigated the clinical outcomes of a novel vascular closure device (VASCADE, Cardiva Medical, Santa Clara, CA) for closure of 7F femoral venotomies. Background The VASCADE closure device has been widely used to close arteriotomy sites following femoral procedures; however, little data have been published regarding the device's utility in closure of venotomy sites after procedures such as right-heart catheterization. Methods This was a retrospective analysis of outcomes in 102 consecutive patients who underwent venous closure using the VASCADE device following diagnostic right and left-heart catheterization between April 2016 to May 2018. Patients' age, gender, valvular disease status, comorbidities, and periprocedural use of antiplatelet/anticoagulant therapy were analyzed. Results Closure was successful in 99% (101/102) of patients with respect to achieving the primary outcome of rapid hemostasis in ≤3 min. There was one device failure requiring manual compression, with no further complications. There were no other related adverse events or complications through 30 days of follow-up. Conclusions The VASCADE device achieved venous hemostasis in nearly all our patients. We believe devices for venous closure can aid in improving patient experience, safety, and efficiency during these procedures.

INTRODUCTION As the number of elderly end-stage renal disease patients lacking suitable vessels for arteriovenous fistula (AVF) is increasing, indications for tunnel cuffed catheters (TCCs) may be expanding. This study aimed to clarify changes over time in the number of patients with TCC and indications for TCCs. METHODS This single-center retrospective study analyzed 143 catheters for 95 patients who inserted TCCs between July 2005 and July 2017. Patients were divided into two groups (early- and late-phase groups) based on the median observational period. Demographic data and clinical information were then compared. FINDINGS Fifty TCCs were inserted in the early phase group, and 93 TCCs were inserted in the late-phase group. The late-phase group was older (77 vs. 70 years; P = 0.003) and showed a higher frequency of hypertensive nephropathy (29% vs. 14%; P < 0.05) and a lower frequency of a history of cardiovascular disease (52.7% vs. 70.0%; P = 0.045). In the late-phase group, indications for bridge vascular access (0% vs. 11.8%; P < 0.05) or severe cardiac dysfunction (8.0% vs. 20.5%; P < 0.05) were increased. In addition, the late-phase group showed increases in percentage of patients with the catheter inserted in the femoral vein (10.0% vs. 23.7%; P = 0.047), nephrologists performing catheter insertion (56.0% vs. 87.1%; P < 0.001), and the patients who underwent superficialization of the brachial artery (28.0% vs. 46.2%; P = 0.034). Significant differences in catheter survival, incidence of complications, reasons for catheter removal, or incidence of catheter-related infection were not observed between groups. DISCUSSION Patients with indications for TCC may be increasing due to an increase in elderly end-stage renal disease patients whose activities of daily living have decreased. In addition, indications for bridge vascular access were widely accepted in the late-phase group.

Background Iatrogenic hemorrhagic pericardial tamponade (IHPT) represents a life-threating condition requiring emergency pericardiocentesis. In this clinical context, reinfusion of pericardial blood can stabilize the patient and sustain hemodynamic conditions. Aims and methods We reviewed all cases of IHPT occurred at our hospital over a 10 years span. In all patient autologous blood reinfusion through a femoral vein was performed. Results In our clinical experience of 30 consecutive patients with hemorrhagic cardiac tamponade, this technique was successful to limit blood transfusions, to prevent further clinical worsening and bridge patients with intractable bleeding, to cardiac surgery. No major adverse reactions were directly related to blood autotransfusion. Conclusion In the complex clinical scenario of acute tamponade occurring during catheter-based cardiac procedures, autotransfusion of pericardial blood through a femoral vein is safe and effective. It can be a useful trick up the sleeve of the interventional cardiologist.

The femoral vein (FV) is a clinically important vessel. Failure of its valves can lead to chronic venous insufficiency (CVI) with severe manifestations such as painful ulcers. Although they are crucial for identifying suitable implant sites for therapeutic valves, studies on the topography of FV tributaries and valves are rare. Moreover, the femoral vein diameter (FVD) must be known to assess the morphometric requirements for valve implants. To reassess the anatomical requirements for valve implants, 155 FVs from 82 human corpses were examined. FVDs and tributary and valve topographies were assessed using a laboratory straightedge. The FVD increased from 6 mm in the distal femoropopliteal vein to 11 mm in the iliofemoral vein proximal to the saphenofemoral junction (SFJ). Diameters were significantly bigger in males than females. Height correlated positively with FVD. Distal to the SFJ, within a distance of 38 cm, one to eight valves were present. Up to two valves were present within 10 cm proximal to the SFJ. Individual tributary and valve topography must be considered to ensure appropriate design and successful implantation of a venous valve for CVI therapy in the FV. A suitable implant site would be proximal to the SFJ via an infrainguinal transfemoral access. Clin. Anat. 31:1065-1076, 2018. © 2018 Wiley Periodicals, Inc.

Item does not contain fulltext OBJECTIVE: We sought to evaluate the feasibility, technical aspects, and outcome of transcatheter perimembranous ventricular septal defect (pmVSD) closure using duct occluder devices with a single retention disc. BACKGROUND: Use of duct occluder devices to close pmVSD seems a promising alternative therapy. However, limited data exist on this technique. METHODS: From 2010 to 2016, 222 patients (female 47.7%) were identified from databases of five participating institutions in whom pmVSD closure was attempted using an Amplatzer Duct Occluder I or Lifetech duct occluder device. RESULTS: Patients ranged in age from 0.7 to 52 years (median, 7.0 years) and in weight from 4.0 to 70 kg (median, 18.0 kg). The mean size of the VSD was 6.8 +/- 2.2 mm. A large defect (> 6 mm) was present in 137 patients (61.7%). Device closure was successful in 218 patients (98.2%). The 10/8 mm device was used in most patients (n = 85, 38.3%), and the vascular approach was from the femoral vein in 169 patients (76.1%). There were 18 early complications in 17/218 patients (7.8%). Three patients (1.4%) developed complete heart block (transient n = 2; requiring permanent pacing n = 1). Median follow-up was 6 months (6 months-6 years). A mild residual shunt was seen in 10 patients at 6 months follow-up. CONCLUSIONS: The immediate results of transcatheter pmVSD closure using a duct occluder device with a single retention disc are promising. It is an effective technique with a lower rate of complications than for other currently available devices.

We aimed to investigate the effects of blood purification and cold saline injection sites on the transpulmonary thermodilution values. We measured the cardiac output of eight pigs in every combination of cold saline injection (left jugular and femoral veins) and blood purification sites (right jugular and femoral veins), with or without blood purification. We examined the influence of the difference between the presence and absence of blood purification, vascular sites for blood purification, and sites for cold saline injection on the transpulmonary thermodilution values. Cardiac output measured during blood purification using transpulmonary thermodilution was underestimated; however, there was no difference between vascular sites. Cardiac output measured via injection of cold saline into the femoral vein was higher than that obtained through injection of cold saline into the jugular vein, with or without blood purification.

To date, several techniques for transseptal left ventricular (LV) endocardial pacing for cardiac resynchronization therapy (CRT) have been proposed in patients for whom routine transvenous LV pacing is infeasible. These techniques are of varying difficulty and complexity, and some requires devices not easily accessible. We herein report a simple, safe and effective approach of atrial transseptal LV lead implantation using arteriovenous loop technique in a patient for whom transvenous LV implantation lead had failed.

Nephrotic syndrome is a well-known risk factor of deep vein thrombosis (DVT). Catheter-related DVT under the setting of nephrotic syndrome may be presented as a more fulminant form, phlegmasia cerulea dolens. Phlegmasia cerulea dolens may lead to severe obstruction of venous drainage of the extremities and presents with compartment syndrome that impairs arterial perfusion. Aggressive management with thrombolysis and/or thrombectomy are considered with simultaneous anticoagulant treatment.

A 32-year-old woman collapsed following an intravenous injection of material that included crushed pharmaceutical tablets. Resuscitation was attempted but was unsuccessful. She had an extensive past medical history of complications resulting from intravenous drug use. Death was due to mixed drug toxicity. The major findings at autopsy included a 10 mm deep skin sinus over the right femoral vein that was used as an injection site. Polarizable foreign material was present at the injection site and also within the lungs with a granulomatous reaction. Of note, a probe-patent foramen ovale had permitted paradoxical embolization of this material into the systemic circulation with lodgement within the liver, portal lymph nodes, myocardium, spleen, kidneys, and pancreas. This case highlights the importance of checking for any intracardiac shunts, which may be quite small, and systemic dissemination of foreign material to multiple organs in intravenous drug users who present for medicolegal assessment.

BACKGROUND Since FDA approval of the Melody valve, transcatheter pulmonary valve replacement (TPVR) has been offered to an expanding population. Limited data exist regarding the safety and feasibility of TPVR in smaller patients. METHODS All patients weighing

PURPOSE To detect and characterize changes in stiffness of thrombus in patients with acute and subacute deep venous thrombosis (DVT) by using real-time elastography (RTE). METHODS Fifty-eight patients with acute or subacute DVT were prospectively evaluated by B-mode sonography (US), color Doppler US (CDUS), and RTE. Two radiologists evaluated the thrombus echogenicity, compressibility, and recanalization of the affected vein, and thrombus stiffness in consensus. The thrombi were classified into 3 groups as soft, intermediate, and hard on RTE images. RESULTS The final study group consisted of 30 patients with acute DVT, among whom 10 were women (33%), and 19 patients with subacute DVT, among whom 6 were women (32%). The presence of hypoechoic thrombus, incompressible vein, and absence of recanalization on US and CDUS were significantly associated with acute DVT (P

PURPOSE:To investigate the feasibility of estimating calibration constants (K and T2o ) in vivo for converting whole-blood T2 to blood hemoglobin oxygen saturation (HbO2 ) according to the Luz-Meiboom model, 1/T2=1/T2o+K(1-HbO2)2, where K and T2o are relaxivity and transverse relaxation time of fully saturated blood, respectively. METHODS:A range of HbO2 values was achieved in the superficial femoral vein with intermittent cuff occlusion in seven healthy adults (four males) to establish a calibration curve between blood T2 and HbO2 at 1.5T. HbO2 was derived via MR susceptometry, a technique previously validated, and the transverse relaxation time was quantified with an optimized T2 -prepared balanced steady-state free precession pulse sequence. To evaluate the accuracy of the in vivo calibration method, T2 and HbO2 were quantified in the superior sagittal sinus in six additional subjects and compared with susceptometry. RESULTS:Two sets of gender-specific calibration constants were derived, one for each gender corresponding to hematocrits of 0.47 ± 0.02 for males and 0.38 ± 0.01 for females, yielding K/T2o = 41 Hz/260 ms and 26 Hz/280 ms, respectively. The in vivo calibration returned physiologically plausible superior sagittal sinus SvO2 values (65 ± 5% HbO2 ), and there was no significant difference between the results from the two methods (average difference -0.3% HbO2 ). CONCLUSION:The results show feasibility of performing in vivo calibration for converting whole-blood T2 to HbO2 . The proposed approach bypasses the involved and cumbersome processes associated with in vitro calibration. Magn Reson Med 79:2290-2296, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

BACKGROUND Adenosine administration after pulmonary vein (PV) isolation is effective for identifying dormant conduction (DC). We aimed to compare the efficacy and safety of local injection of adenosine into the PV with systemic intravenous injection. METHODS After complete PV isolation was performed, adenosine was injected directly into the PV (local method, 6-18 mg) and the femoral vein (systemic method, 12-30 mg) sequentially. We compared the incidence of DC and the hemodynamic effect of adenosine between the methods. RESULTS We analyzed 150 PVs in 40 patients who underwent atrial fibrillation ablation. A total of 16 DCs were seen in 14 patients with either the local or systemic method. Among them, two DCs were detected only by the local method (detection rate: local 10.7% vs systemic 9.3%). The effective doses of adenosine required to induce atrioventricular (AV) block or detect DC were 7.7 ± 3.1 mg (local) and 13.1 ± 3.4 mg (systemic), respectively (P < 0.001). The time interval between adenosine injection and AV block was shorter with the local than systemic method (5.8 seconds vs 11.7 seconds, P < 0.001). Six DCs (four with local and two with systemic method) were detected without manifested AV block. Additionally, there were fewer decrements in blood pressure with the local than systemic method. CONCLUSION Local adenosine injection via the PV was comparable to systemic administration for detecting DC after PV isolation. Furthermore, the local method required a smaller dose of adenosine, took less time to induce AV block, and resulted in less systemic hemodynamic compromise than did the systemic method.

Background Thromboembolic complications can be life-threatening during atrial fibrillation (AF) catheter ablation. The aim of our study was to evaluate the safety and efficacy of continuous treatment using direct oral anticoagulants (DOACs) as an alternative to uninterrupted acenocoumarol for periprocedural anticoagulation. Hypothesis Continuous treatment with DOACs has similar safety and efficacy compared to acenocoumarol. Methods We enrolled 474 patients (mean age, 58 years; 68.4% male) undergoing AF catheter ablation between June 2013 and December 2016. All patients were equally assigned to take acenocoumarol (group 1, 136 patients) or DOACs (group 2, 338 patients) for ≥2 months before the procedure. We compared thromboembolic and bleeding complications between the 2 groups. Results Our analysis showed no significant difference in major and minor complications between the 2 patient groups. Specifically, 3 of 136 patients (2.2%) using uninterrupted acenocoumarol had a major complication (1 patient [0.7%] had transient ischemic attack resolved 8 hours later, 1 [0.7%] had pericardial tamponade, and 1 [0.7%] had a subcapsular renal hematoma) and 2 patients (1.4%) had minor complications (1 [0.7%] pseudoaneurysm and 1 [0.7%] groin hematoma). In group 2, 1 of 338 patients (0.3%) had a major complication (transient ischemic attack). In the same group, 7 patients (2.1%) had a minor complication (1 patient [0.3%] presented with pseudoaneurysm, 4 [1.2%] with pericardial effusion

Recently, we demonstrated that in human intravascular papillary endothelial hyperplasia (IPEH), vein wall vascularization occurs in association with myriad papillae, a large part of which formed in the vascularized vein wall. Previously, using an animal model, we observed that PGE2 and glycerol administration around the femoral vein originates intense vascularization of the vein wall from its intimal endothelial cells (ECs). This vascularization is similar to that in IPEH. The aim of this study is to assess the mechanism of papillary formation, using this model after demonstrating papillary development in neo-vascularized femoral vein walls. In semithin and ultrathin sections, the sequential vascular and papillary development was as follows: (a) activation of vein intimal ECs, (b) sprouting of intimal ECs towards the vein media layer and microvessel development, (c) interconnection between neighboring microvessels originated elementary loops, which encircled vein wall components and formed papillae. The encircling ECs formed the papillary cover, and the encircled component formed the core. The papillae showed a similar structure to that of folds and pillars in intussusceptive angiogenesis, and (d) origin of secondary and complex loop systems by interconnection of neighboring elementary loops and by splitting of papillae by new loops, with abundant papillary development. In conclusion, the results support a piecemeal angiogenic mechanism in papillary formation, with association of sprouting and intussusceptive types of angiogenesis. Further studies are needed to assess whether the intravascular papillae described in several pathologic processes, including vessel tumors, such as Dabska's tumor, retiform hemangioendothelioma, and angiosarcoma, follow a similar mechanism. Anat Rec, 2017. © 2017 Wiley Periodicals, Inc. Anat Rec, 300:1781-1792, 2017. © 2017 Wiley Periodicals, Inc.

Background Tricuspid valve surgery has been the de facto standard treatment for tricuspid valve endocarditis (TVE) refractory to medical therapy. It is now possible to remove right-sided vegetations percutaneously using a venous drainage cannula with an extracorporeal bypass circuit. Objectives The purpose of our study is to describe our single-center experience of percutaneous tricuspid valve vegetation removal. Methods We reviewed the perioperative course of 33 consecutive patients with large tricuspid valve vegetations who carried high surgical risk. Results The cohort included 12 males and 21 females over a 40-month period with an average age of 37 years. A preponderance of patients carried an admitted or confirmed diagnosis of injection drug use (72.7%). Average vegetation size was 2.1 +/– 0.7 cm prior to the procedure with a 61% reduction in size after the procedure. All patients survived the procedure and 90.9% survived the index hospitalization. Three patients proceeded to elective tricuspid valve replacement due to worsening severity of tricuspid regurgitation. Conclusion Percutaneous removal of large tricuspid valve vegetations is a safe and effective alternative for patients with TVE who carry high-surgical risk. © 2017 Wiley Periodicals, Inc.

Background Treatment of left ventricular electrode dislocation and phrenic nerve stimulation remains an issue in the era of new electrode designs. Methods Safety and efficacy of minimal invasive lead repositioning and pocket opening reposition procedures were evaluated between December 2005 and December 2012 at our center. Minimal invasive method was developed and widely utilized at our center to treat phrenic nerve stimulation. The distally positioned left ventricular lead is looped around by a deflectable catheter in the right atrium introduced from the femoral vein access and then pulled back. Coronary stent implantation was used afterwards for lead stabilization in some patients. Results 42 minimal invasive and 48 electrode repositions with pacemaker pocket opening were performed at 77 patients for left ventricular lead problems. Minimal invasive reposition could be carried out successfully in 69% of (29 patients) cases. Note that in 14.3% of the cases (six patients) minimal invasive procedures were acutely unsuccessful and crossover was necessary. In 16.6% of the cases (seven patients) lead issues were noted later during follow-up. Opening of the pocket could be carried out successfully in 81.2% (39 patients) and was unsuccessful acutely in 6.25% (three patients). Repeated dislocation was noticed, 12.5%, in this group (six patients). Complication during minimal invasive procedures was electrode injury in one case. Pocket openings were associated with several complications: atrial fibrillation, pericardial effusion, fever, hematoma, and right ventricular electrode dislodgement. Conclusion Minimal invasive procedure-as the first line approach-is safe and feasible for left ventricular electrode repositioning in selected cases.

The use of balloon aortic valvuloplasty (BAV) has increased with the development of transcatheter aortic valve implantation (TAVI) to medically optimize patients prior to procedure. It has been traditionally done by a retrograde approach via the femoral artery or an antegrade approach via the femoral vein. Large sheaths have been required with traditional balloons which require large vessel access. Use of a low profile compliant valvuloplasty balloon has been demonstrated to have adequate BAV results with smaller sheath sizes. We review the literature and report two cases where low profile compliant valvuloplasty balloons were used to perform BAV via the radial artery in patients without adequate femoral arterial access. © 2017 Wiley Periodicals, Inc.

Objective To report a case of successful surgical removal of a guide wire lost during central venous catheterization. Case Summary A 28 kg, 4-year-old female neutered mixed breed dog presented to the primary care veterinarian with diabetic ketosis. During the process of central venous catheterization, the guide wire was accidently released and the entire length of the guide wire slipped into the jugular vein. Due to the absence of nearby interventional radiology facilities, surgical intervention was proposed. An ultrasound was used to determine that the guide wire was located in the caudal vena cava extending caudally into the right internal iliac vein. Rommel tourniquets were placed around the iliac vein cranial to the bifurcation of the common iliac vein into the external and internal iliac veins. A venotomy was performed in the right common iliac vein and the guide wire was grasped with hemostats and gently removed while alternately relaxing the cranial then caudal tourniquets. During anesthesia, ventricular premature contractions were noted that varied in frequency with the dog's positioning. Postoperative color flow Doppler ultrasound evaluation of the caudal vena cava, right common, internal and external iliac veins, and right femoral vein was normal with no evidence of thrombosis. Several days postoperative the dog's diabetic ketosis and ventricular premature contractions had resolved and color flow Doppler ultrasound evaluation was normal with no evidence of thrombosis. New or Unique information provided To the authors’ knowledge, this is the first reported veterinary case of loss and subsequent surgical retrieval of a central venous catheter guide wire.

Central venous catheterization is a commonly used and important intervention. Despite its regular use it is still associated with a high incidence of complications especially infection and catheter tip embolization. Addition of ultrasound guidance to the technique has shown great improvement to the time and number of attempts for successful catheterization. The preference of vein depends greatly on the situation; subclavian vein is the preferred method overall but internal jugular vein is preferred in patients undergoing cardiac or thoracic surgery. This is especially true for pediatric patients in whom femoral vein catheterization is still preferred despite it carrying a higher risk than other locales. Addition of ultrasound guidance greatly reduces the incidence of arterial puncture and subsequent hematoma formation regardless of location. This is because it allows for visualization of anatomical variation prior to intervention and continual visualization of the needle during the placement. It is noteworthy however, that addition of ultrasound does not prevent complications such as catheter tip embolization as this may occur even with perfect placement. The value of ultrasound usage is undisputable since all studies assessing the difference between it and landmark based methods showed preferable outcome. Reduction of time and number of attempts is sufficient argument to make ultrasound guidance standard practice. Clin. Anat. 30:237-250, 2017. © 2017 Wiley Periodicals, Inc.

Background The upper thigh has provided multiple new soft tissue free flaps in recent decades, including the anterolateral thigh, anteromedial thigh, transverse upper gracilis, the profunda artery perforator, and superficial circumflex iliac perforator flaps. The purpose of this study is to describe a new, reliable free flap option in the upper thigh: the proximal superficial femoral artery perforator (p-SFAP) flap. Methods A cadaveric dissection study was performed to confirm clinical landmarks and evaluate pedicle characteristics. A retrospective review of patients who have received a p-SFAP free flap and surgical technique are described in detail. Eight patients (aged 27–85 years) underwent reconstruction with the p-SFAP flap involving six upper and two lower extremity defects. Results A consistent pedicle 6 to 8 cm in length was identified in all cadaveric and clinical limbs, emerging from under the lateral aspect of the sartorius muscle and entering the flap approximately 10 cm inferior and 4 cm medial to the anterior superior iliac spine. The perforator took origin off of the superficial femoral artery and femoral vein in all clinical cases. Arterial and venous diameters were 1.2–1.5 mm and 2.0–2.5 mm, respectively. There was one occurrence of partial flap necrosis and one case of complete flap loss. Conclusions The p-SFAP flap represents a new, clinically relevant addition to the armamentarium of the reconstructive microsurgeon for use in small to medium sized defects. It can be harvested as a free flap and may have utility as a pedicled flap for groin and perineal reconstruction.

Sampling site, technique, and time influence postmortem drug concentrations. In 57 cases, we studied drug concentration differences as follows: subclavian vein-dissection/clamping versus blind stick, femoral vein-dissection/clamping versus blind stick, right cardiac chamber, and popliteal vein-dissection and clamping only. Cases were distributed in group #1 (all cases with both techniques), group #2 (dissection/clamping), and group #3 (blind stick). Sampled drugs were diazepam, methadone, morphine, and their metabolites. To assess PMR, mean concentrations and ratios were calculated for each group. Time-dependent variations of blood concentrations and ratios were also assessed. Results indicate that site, method, and time may influence postmortem distribution interpretation in different ways. Popliteal blood seems less subject to PMR. In conclusion, our study is the first to evaluate concurrently three main aspects of PMR and confirms that the popliteal vein may represent a site that is more resistant to the changes seen as a result of PMR.

The objective of this study is to establish a novel method for continuously monitoring thrombus progression with various outcome measures and to assess the efficacy of antithrombotic drugs in murine thrombosis model in mice. In the study, thrombus was induced in the femoral vein of mice by FeCl3 and monitored over time by spectral-domain optical coherence tomography (OCT). Three-dimensional images of thrombi with or without heparin as an antithrombotic agent were obtained from OCT angiography. In addition, several parameters of thrombi were analyzed and compared between control and anticoagulant groups. By using OCT, we were able to trace thrombus generation in the same mouse in real time. We found that in our model heparin reduced thrombus size by ~60% and thrombus cross-sectional area by 50%. OCT results also show that both time to thrombus size (>0.02mm3 ) and time to occlusion (>30%) were significantly reduced after heparin addition. This study demonstrates that OCT reliably monitors thrombus generation and progression from various aspects including thrombus size. This enables us to measure the kinetic of thrombosis more accurately, and effectively evaluate the efficacy and activities of antithrombotic drugs. This model may represent a useful tool in antithrombotic drug discoveries in preclinical studies.

PURPOSE: To evaluate the performance of acceleration-dependent vascular anatomy for non-contrast-enhanced MR venography (ADVANCE-MRV) in femoral veins and to investigate whether venous signal uniformity can be improved by applying multiple acquisitions with different flow suppressions or multiple flow suppressions in 1 acquisition. METHODS: The ADVANCE-MRV method uses flow-sensitized modules to acquire a dark-artery image set and a dark-artery vein set, which are subsequently subtracted. Ten healthy volunteers were imaged using the ADVANCE-MRV sequence with improved venous suppression uniformity in the dark-artery vein images achieved by applying multiple flow suppressions in the same acquisition or by combining multiple images acquired with different flow suppressions. The performance of the improved technique was also evaluated in 13 patients with lower-limb deep venous thrombosis. RESULTS: Multiple-preparation and multiple-acquisition approaches all improved venous signal uniformity and reduced the signal void artifacts observed in the original ADVANCE-MRV images. The multiple-acquisition approaches achieved excellent blood signal uniformity and intensity, albeit at the cost of an increase in the total acquisition time. The double-preparation approach demonstrated good performance in all measurements, providing a good compromise between signal uniformity and acquisition time. The blood signal spatial variation and its variation using different gradient amplitudes were reduced by 20% and 29%. All patient images showed uniform and bright venous signal in nonoccluded sections of vein. CONCLUSION: The enhanced ADVANCE-MRV methods substantially improved signal uniformity in healthy volunteers and patients with known deep venous thrombosis. The double-preparation approach gave good-quality femoral vein images, providing improved venous signal uniformity without increasing acquisition time in comparison to the original sequence.

BACKGROUND Temporary pace maker is necessary because of transient block or bradycardia during the intracoronary acetylcholine spasm provocation tests based on the Japanese Circulation Society guidelines. OBJECTIVES We examined the feasibility and safety of the acetylcholine spasm provocation test via the radial artery and brachial vein approach. METHODS We tried to perform the acetylcholine spasm provocation tests in 252 patients via the radial artery and brachial vein approach procedures during 5 years. Acetylcholine was injected in incremental doses of 20/50/80 μg into the right coronary artery (RCA) and 20/50/100/200 μg into the left coronary artery (LCA). Back-up pacing rate was set at 40 beats/min. Positive spasm was defined as transient ≥90% luminal narrowing and ischemic electrocardiographic change or usual chest pain. RESULTS The procedure success of radial artery and brachial vein access was 94.4% (238/252) and 93.3% (235/252), respectively. We performed 221 patients (87.7%) with acetylcholine tests by radial artery and brachial vein approach. We changed to the brachial approach due to the failures of radial artery access in 14 patients. We also changed to the femoral vein in 11 patients and internal jugular vein in two patients. Back-up pace maker rhythm was observed in 92.1% (232/252) of all study patients, while it was significantly higher in the RCA testing than that in the LCA tests (84.9% (191/225) vs. 52.2% (131/251), P < 0.001). No irreversible complication was found. CONCLUSIONS We recommend the radial artery and brachial vein approach for safety and convenience when performing the acetylcholine spasm provocation tests.