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Purpose To evaluate the use of inframalleolar access for endovenous ablation when treating advanced venous disease with nonthermal nontumescent (NTNT) techniques. Methods This single-center retrospective study included 109 patients with advanced venous disease, treated using inframalleolar access between May 2018 and March 2020. NTNT techniques included ClariVein (Merit Medical Systems, South Jordan, Utah) and ScleroSafe (VVT Medical, Kefar Sava, Israel). Outcomes measured were postprocedure pain, leg edema, ulcer healing and recurrence rates, and venous insufficiency recurrence. Results Seventy-seven patients (70%) were treated with ClariVein and 32 (30%) with ScleroSafe. Postprocedure pain score (range, 0-10) after 1 week decreased from a preprocedure median of 5 (interquartile range, 3-6) to 1 ((interqartiel range, 0-2) (P = .0001). Complete wound healing was achieved in 38 patients (43.7%) after 30 days and in 71 patients (81.6%) after 90 days. One patient developed an ulcer recurrence and six developed venous insufficiency recurrence. There was no reported nerve or skin injuries. Conclusions NTNT ablation techniques using inframalleolar access are effective and safe without risk of nerve damage. Their use facilitates ulcer healing and limits pain in patients with advanced disease.

The purpose of this article is to assess the performance and safety of a novel, symmetric, side-hole–free tunneled cuffed catheter hypothesized to sustain adequate flow without the need for side holes. Between November 2016 and January 2019, Pristine hemodialysis catheters were placed de novo in 45 end-stage renal disease patients (27 males and 18 females) at a single investigational site. Forty-one catheters were placed in the right and four in the left internal jugular vein. There were no incidents of insertion failure. Patients had dialysis three times per week and were followed at four investigational sites. Nominal catheter flows, incidence of poor flow, and catheter-related infections were recorded at each dialysis session and analyzed. The average follow-up time was 161.69 days for a total of 7116 catheter days. Nine patients died from reasons unrelated to the catheter and one patient switched to fistula. Four patients had poor flows necessitating catheter replacement. Four patients had catheter-related bloodstream infections which resolved with antibiotics. These equate to 0.56 events per 1000 catheter days. Catheter survival was 100%, 97.6%, and 89.7% at 30, 90, and 180 days, respectively. The initial clinical assessment of the symmetric Pristine hemodialysis catheter featuring a Y-tip devoid of side holes revealed good catheter performance and survival and a low complication rate.

Background: Eighty percent of hemodialysis patients start their dialysis with a tunneled hemodialysis catheter. Catheter related bacteremia is the second most common cause of death in these patients. Side holes near the tips of the tunneled cuffed central venous catheters are associated with accumulation of thrombus, which can lead to catheter dysfunction and, possibly, also to catheter-related infection. To assess the hypothesis that a catheter without side holes would be associated with less bacterial growth, this study compared the susceptibility of a side-hole-free catheter to accumulation of pathogenic bacteria at the catheter tip with that of two catheters which have side holes. Methods: Eight tunneled cuffed double-lumen central venous catheters were inserted into both jugular veins of four sheep; one side-hole-free and one control catheter with side holes at the tip in each animal. Staphylococcus aureus bacteria were then infused intravenously to cause bacteremia. Six hours later, the catheters were removed, the clots that accumulated in their tips were collected and cultured, and the bacterial colonies were counted after additional 12 h of incubation. Results: Bacteria grew on culture plates seeded with the clot homogenate obtained from the tips of all catheters. The colony counts from the catheters with side holes at the tip exceeded the colony counts of bacteria accumulated in the tips of the side-hole-free hemodialysis catheters by one or more orders of magnitude, with a difference of at least two orders of magnitude observed in three of the four intra-animal comparisons. Conclusions: In paired intra-animal post-inoculation comparison made in this limited study, fewer colony forming units of pathogenic bacteria accumulated at the tip of the side-hole-free catheters than at the tips of the catheters which have side holes. This may translate to a decreased rate of catheter-related blood stream infections in the side-hole-free catheters.

Background: The issue of side holes in the tips of the tunneled cuffed central venous catheters is complex and has been subject to longstanding debate. This study sought to compare the clotting potential of the side-hole-free Pristine hemodialysis catheter with that of a symmetric catheter with side holes. Methods: Both jugular veins of five goats were catheterized with the two different catheters. The catheters were left in place for 4 weeks and were flushed and locked with heparin thrice weekly. The aspirated intraluminal clot length was assessed visually prior to each flushing. In addition, the size and weight of the clot were recorded upon catheter extraction at the end of the 4-week follow-up Results: The mean intraluminal clot length observed during the entire study follow-up measured up to a mean of 0.66 cm in the GlidePath (95% CI, 0.14–1.18) and 0.19 cm in the Pristine hemodialysis catheter (95% CI, −0.33 to 0.71), the difference being statistically significant ( p = 0.026). On average, 0.01 g and 0.07 g of intraluminal clot were retrieved from the Pristine and GlidePath catheters, respectively ( p = 0.052). Conclusion: The Pristine hemodialysis catheter was largely superior to a standard side hole catheter in impeding clot formation, and, contrary to the side hole catheter, allowed for complete aspiration of the intraluminal clot.

Purpose The VenaTrac™ is designed for exchange and primary placement of chronic tunneled hemodialysis catheters over a wire. It occludes both lumens of the catheter for the purpose of reducing the risk of air embolism and blood loss. The purpose of this paper is to report our experience with the use of this device. Methods A retrospective review of chronic hemodialysis dialysis catheters exchanges over a 30-month period was performed. Two hundred and ninety-seven over-the-wire catheter exchanges and 47 primary placements using the VenaTrac™ device were reviewed. In addition, 430 over-the-wire catheter exchanges without the use of the VenaTrac™ were reviewed. Results No insertional complications or air embolism occurred when using the VenaTrac™. Symptomatic air embolism was documented in 5 out of 430 catheter exchanges performed without the use of VenaTrac™ (1.2%). Conclusions VenaTrac™ over-the-wire insertion device demonstrated safe and reliable use with no incidence of air embolism.

Objective The use of foam and liquid sclerotherapy for the treatment of varicose veins and underlying venous reflux is widespread. A novel device, the ClariVein Occlusion Catheter (Vascular Insights LLC, Madison, Conn), has been the subject of several clinical trials in humans. We report the initial histologic results obtained with use of the device in a caprine vein model. Methods A total of 11 male goats (12 veins) underwent minimally invasive procedures. Unilateral mechanochemical ablation of the lateral saphenous vein by the ClariVein Occlusion Catheter with an E-140° tip was performed under fluoroscopic guidance in five veins with 5 mL of 1.5% sodium tetradecyl sulfate (STS) and in one vein with 5 mL of 0.9% saline. The remaining six received injection sclerotherapy with 5 mL of 1.5% STS or 0.9% saline. All subjects were assessed with ultrasound before the procedure and intermittently afterward during a period of 12 weeks. Subsequent termination was immediately followed by necropsy and histologic examination of the treated veins. Results Complete occlusion of the lateral saphenous vein was observed in all subjects treated with ClariVein and STS, whereas complete patency was noted in all other treatment modalities. Histologic staining with hematoxylin and eosin and Masson trichrome stain revealed total fibrotic sealing with extensive collagen production in all ClariVein/STS veins. A statistical significance was observed in the difference in the number of occluded veins between subjects treated with ClariVein/STS and those treated by injection sclerotherapy (Fisher exact test, P Conclusions The ClariVein Occlusion Catheter with 1.5% STS can be used to achieve complete mechanochemical ablation of the lateral saphenous vein in a caprine model. The evidence in this report can be used to justify the device's use for the treatment of the great saphenous vein in subsequent human clinical trials.

This report describes a 67-year-old trauma victim in whom a retrievable Günther Tulip (Cook, Bloomington, IN) inferior vena cava filter was placed. The filter migrated to the right atrium immediately after placement. Initial attempts to retrieve the filter with Amplatz Goose Neck snares (Microvena, White Bear Lake, MN) were unsuccessful. A second attempt performed a week later with the addition of the new EnSnare (MDTech, Gainesville, FL) was successful. Possible causes of the migration are discussed and the difficulties encountered while removing this retrievable filter are described.

Purpose End-stage renal disease patients with hemodialysis catheters in need of contrast enhanced imaging studies often have limited peripheral venous access. In this study we aimed to determine pressures generated in hemodialysis catheters during power injection of computed tomography (CT) contrast media. Methods Three different chronic hemodialysis catheters and two acute hemodialysis catheters were included in this study. All catheters were evaluated in vitro. A total volume of 120 cc of CT contrast material was injected at rate of 10 cc/s using a power injector. The catheters were connected to the power injector using a standard connecting tubing. Pressures were simultaneously measured in the power injector as well as in the hemodialysis catheters. Results The maximal measured pressures during injection in the power injector averaged 338 PSI (SD ± 8.7 PSI). The maximal measured pressure in the dialysis catheters ranged between 9.17 and 21.2 PSI. Pressures averaged 14.02 PSI (SD ± 3.34 PSI). The average pressure in the power injector was over 23 times higher than the pressure recorded at the hemodialysis catheter. None of the catheters ruptured or deformed during testing. Conclusions Pressures measured in hemodialysis catheters during power injection are lower than currently believed and markedly lower than the pressures recorded in the power injector. Standard hemodialysis catheters are likely to be amenable to power contrast injection in hemodialysis patients who have limited venous access. In vivo studies are necessary to confirm these findings.

To compare the rates of central venous stenosis in patients undergoing hemodialysis who underwent disruption of fibrin sheath with percutaneous transluminal angioplasty balloons and those who underwent over-the-wire catheter exchange. This study is a retrospective review of 209 percutaneous transluminal angioplasty balloon disruption and 1304 over-the-wire catheter exchange procedures performed in 753 patients. Approval from the Human Investigations Committee was obtained for this study. Up to 10-year follow-up was performed. A χ(2) test was used to compare the rates of central venous stenosis after balloon disruption versus catheter exchange. A t-test was used to compare time to central venous stenosis development. Of the 753 patients in the study, 127 patients underwent balloon disruption of fibrin sheath and 626 had catheter exchange. Within the balloon disruption group, 18 (14.2%) of 127 patients subsequently developed central venous stenosis, compared with 44 (7.0%) of 626 in the catheter exchange group (P 0.01, χ(2) test). Time to central venous stenosis development was approximately 3 years in both groups and not significantly different (1371 and 1010 days, P = 0.20). A total of 25.2% of patients in the balloon disruption group had four or more subsequent catheter exchanges, versus 12.6% in the catheter exchange group (P 0.01, χ(2) test). In conclusions, there is a possible association between percutaneous transluminal angioplasty balloon disruption of fibrin sheath and late-onset central venous stenosis. Because venography was not routinely performed in catheter exchange patients, future randomized studies are necessary to confirm these findings.

Catheter-related infections (CRIs) are a significant source of morbidity and mortality in hemodialysis patients. The identification of novel, modifiable risk factors for CRIs may lead to improved outcomes in this population. Peripherally inserted central catheters (PICCs) have been hypothesized to compromise vascular access due to vascular damage and venous thrombosis, whereas venous thrombosis has been linked to the development of CRIs. Here we examine the association between PICC placement and CRIs. A retrospective review was performed of all chronic hemodialysis catheter placements and exchanges performed at a large university hospital from September 2003 to September 2008. History of PICC line use was determined by examining hospital radiologic records from December 1993 to September 2008. Catheter-related complications were assessed and correlated with PICC line history. One hundred eighty-five patients with 713 chronic tunneled hemodialysis catheter placements were identified. Thirty-eight of those patients (20.5%) had a history of PICC placement; these patients were more likely to have CRIs (odds ratio = 2.46, 95% confidence interval = 1.71–3.53, p

Purpose To report the authors' clinical experience with the Tal Palindrome chronic dialysis catheter with a symmetric tip. Materials and Methods During a 39-month period, 126 Palindrome catheters were placed consecutively in 85 patients. Follow-up was available for 115 catheters. Insertion complications, patency, catheter-related bacteremia, exit site infections, and reasons for catheter removal were recorded. The patient's initial cause of end-stage renal disease, underlying diseases, and site of access were recorded as well. Results Patient ranged in age from 35 to 91 years (median, 69 years). Fifty percent of patients had diabetes. One hundred twenty-six Palindrome catheters were placed for a total of 12,046 catheter-days. The technical success rate of catheter placement was 100%. The average catheter indwell time was 105 days (range, 1–673 days). Catheters were inserted via the right ( n = 107) or left ( n = 19) jugular vein in all patients without insertional complication. Catheter-related infections occurred in 16 of the 115 catheters (13.9%) during the study period and culture-proved bacteremia occurred in four (3.5%). Seven exit site infections were recorded, and 10 catheters (8.7%) developed fibrin sheaths that necessitated catheter exchanges. Conclusions Clinical experience with the Tal Palindrome hemodialysis catheter demonstrated safe and reliable use with low infection rates.

A 39-year-old gravida 2 para 2 woman presented to our Hospital's Emergency Department with complaints of difficulty voiding. She had an enlarged leiomyomatous uterus, for which she was not receiving any current treatment. A Foley catheter placed yielded 1,500 cc of clear yellow urine; however, the patient remained Foley-dependent for 2 weeks until she underwent uterine artery embolization (UAE). Twenty-four hours afterwards, the Foley catheter was removed and the patient spontaneously voided with negligible post-void residual. There was no recurrence of urinary retention or development of any other urinary symptoms during the outpatient follow-up period. Repeat pelvic magnetic resonance imaging (MRI) 1 week after UAE showed negligible reduction in the size of the fibroids and uterus in comparison with a pre-procedure MRI. The Vascular Steal Theory, first presented in this paper, discusses this improvement in symptoms without significant change in size.

Current literature suggests that side holes may be detrimental to dialysis catheter performance. Today, these catheters are primarily available with side holes. The purpose of this study was to compare flow rates, infection rate, and survival of side hole vs. non side hole hemodialysis catheters. Over a 16-month period patients were arbitrarily assigned to either a 14.5 F MAHURKAR MAXID cuffed dual lumen tunneled catheter with side holes or a 14.5 F MAHURKAR MAXID cuffed dual lumen tunneled catheter without side holes ("non side hole catheters"). We performed a retrospective analysis of catheter flow rates, patency, catheter survival, and catheter-related infections. Information was gathered for the life of the catheter or up to 28 weeks. A total of 54 patients were enrolled in the study. Thirty-seven of 54 (68%) patients received a catheter with side holes for a total of 3,930 catheter days and 17/54 (32%) received a similar catheter without side holes for a total of 2,188 catheter days. Catheter infection necessitating removal of the catheter occurred in 10/37 catheters with side holes and 1/17 without side holes. Infection rates per 1,000 catheter days were 2.545 with side holes and 0.254 without side holes (p

PURPOSE The purpose of this study was to evaluate in vivo recirculation of a new bi-directional dialysis catheter with a symmetric tip design and compare it to currently marketed staggered and split tip catheters. MATERIALS AND METHODS Twelve catheters were placed in three 70-kg male swine. The catheters were connected to a roller type peristaltic pump. Blood flow and recirculation rates were measured with ultrasound (US) dilution. Recirculation was measured in blood flow rates of 300 mL/min, 400 mL/min, and 500 mL/min. The dialysis lines were then reversed and recirculation was measured in flow rate of 400 mL/min. Measurements were conducted with the catheter tip in the right atrium (RA) and repeated with the catheter tip in the superior vena cava (SVC). RESULTS Recirculation rates measured with the Palindrome catheter tip (Tyco Healthcare Group LP, Mansfield, MA) in the SVC and in the RA were 0%. When the dialysis lines were reversed, the Palindrome catheter average recirculation was 0% with the tip in the SVC and 1% (0%–3%) with the tip in the RA. The average recirculation rates measured with the split tip catheter were 1% (0%–10%) in the SVC and 0% when the catheter tip was in the RA. When the dialysis lines were reversed split tip catheter recirculation was 11% (9%–16%) with the tip in the SVC and 13% (7%–18%) with the tip in the RA. With the staggered tip catheter, 1% (0%–5%) recirculation was measured. When the dialysis lines were reversed, the average recirculation in the staggered tip catheter measured 23% (18%–30%). Recirculation rate with reversal of dialysis lines was significantly lower with the Palindrome catheter when compared to the split tip and staggered tip designs ( P CONCLUSIONS Preliminary results in vivo indicate that the Palindrome catheter demonstrates minimal recirculation with reversal of the dialysis lines compared to currently marketed split tip and staggered tip catheters.

In seven of 255 consecutive patients (2.7%) who underwent pulmonary arteriovenous malformation (PAVM) embolization at our center between July 1, 1996, and July 1, 2000, the feeding artery was considered too short for safe occlusion with use of standard stainless-steel coils or detachable balloons. These patients were successfully treated with use of a modified vein of Galen technique similar to the one used for managing intracranial vein of Galen aneurysms. In this article, the authors report their experience with this technique in safely occluding the aneurysmal sacs of PAVMs in patients with short (