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Objective: Central aortic cannulation for aortic arch surgery has become more popular over the last decade; however, evidence comparing it with axillary artery cannulation remains equivocal. This study compares outcomes of patients who underwent axillary artery and central aortic cannulation for cardiopulmonary bypass during arch surgery. Methods: A retrospective review of 764 patients who underwent aortic arch surgery at our institution between 2005 and 2020 was performed. The primary outcome was failure to achieve uneventful recovery, defined as having experienced at least 1 of the following: in-hospital mortality, stroke, transient ischemic attack, bleeding requiring reoperation, prolonged ventilation, renal failure, mediastinitis, surgical site infection, and pacemaker or implantable cardiac defibrillator implantation. Propensity score matching was used to account for baseline differences across groups. A subgroup analysis of patients undergoing surgery for aneurysmal disease was performed. Results: Before matching, the aorta group had more urgent or emergency operations (P = .039), fewer root replacements (P

Abstract Purpose To examine the short-term complications of arterial cannulation for intraoperative monitoring and their related risk factors. Methods We included adult inpatients (≥ 18 years old) who underwent an initial transradial access (TRA) cannulation and were scheduled for general surgery between April 8 and November 30, 2020. We used 20G arterial puncture needles for puncturing and manual compression for hemostasis. Demographic, clinical, surgical, anesthetic, and laboratory data were extracted from electronic medical records. Vascular, neurologic, and infectious complications of TRA cannulation were recorded and analyzed. Logistic regression analyses were used to identify risk factors related to TRA cannulation for intraoperative monitoring. Results Among 509 included patients, 174 developed TRA cannulation-related complications. Puncture site bleeding/hematoma and median nerve injury were observed in 158 (31.0%) and 16 (3.1%) patients, respectively. No patient developed cannula-related infections. Logistic regression analysis revealed increased odds of puncture site bleeding/hematoma in women (odds ratio 4.49, 95% CI 2.73–7.36; P

Objective: To compare the frequency of first attempt successful ultrasound guided radial artery cannulation by modified short axis out-of-plane technique versus conventional long axis in-plane technique. Study Design: Quasi Experimental Study Setting: Jinnah Hospital, Lahore. Study Period: 1st January 2019 to 30th June 2019. Material & Methods: 180 patients fulfilling the selection criteria were divided in two groups using lottery method. Group modified SA-OOP (short axis out-of-plane) and group LA-IP (long axis in-plane). Modified Allen test was performed in all patients, if positive, procedure was carried out. In modified short axis out of plane approach, a suture was tied on the midpoint of ultrasound probe and perpendicular to the long axis as a guide and then radial artery was viewed by placing US probe on the wrist of patient transversely. The needle was inserted at 30O-45O angle into the skin. In long Axis In-Plane approach, radial artery was first viewed by placing US probe transversely on the wrist of patient and then probe was rotated to 90O in clockwise direction to see the artery in longitudinal plane. Then cannula was inserted at 30O-45O angle into the skin. Success of first attempt was recorded. Results: The age range was 18-70 years. Mean age of the patients was 46.69 ± 17.35 and 43.68 ± 17.99 years in group LA-IP and SA-OOP, respectively (4). In group LA-IP, 57 patients (63.3%) were male and in group SA-OOP 45 patients (50%) were male while 33 patients (36.7%) of group LA-IP and 45 patients (50%) of group SA-OOP were female. Frequency of first attempt was 64.4% (58 patients) in group LA-IP and in group SA-OOP frequency of first attempt was 53.3% (48 patients). Statistically significant difference was not seen between two groups as p-value is 0.172. Conclusion: There is no difference in frequency of first attempt success in modified short axis out-of-plane ultrasound versus conventional long axis in-plane ultrasound to guide radial artery cannulation. [ABSTRACT FROM AUTHOR]

Abstract Background The two most common methods for ultrasound-guided arterial cannulation are the long-axis in-plane (LA-IP) and short-axis out-of-plane (SA-OOP) approaches. However, it is uncertain which method is more advantageous. We conducted a meta-analysis of reported randomized clinical trials (RCTs) comparing the two techniques in terms of success rate, cannulation time, and complications. Methods We systematically searched PubMed, Embase, and the Cochrane Library database for RCTs comparing the LA-IP and SA-OOP techniques for ultrasound-guided arterial cannulation published from inception through April 31, 2022. The Cochrane Collaboration’s Risk of Bias Tool was used to evaluate the methodological quality of each RCT. Review Manager 5.4 and Stata/SE 17.0 were used to analyze the two primary outcome measures (first-attempt success rate and total success rate) and two secondary outcome measures (cannulation time and complications). Results A total of 13 RCTs with 1,377 patients were included. There were no significant differences in first-attempt success rate (risk ratio [RR], 0.93; 95% confidence interval [CI], 0.78–1.12; P = 0.45; I2 = 84%) and overall success rate (RR, 0.99; 95% CI, 0.95–1.02; P = 0.48; I2 = 57%). When compared with the LA-IP technique, the SA-OOP technique was associated with an increased incidence of posterior wall puncture (RR, 3.01; 95% CI, 1.27–7.14; P = 0.01; I2 = 79%) and hematoma (RR, 2.15; 95% CI, 1.05–4.37; P = 0.04; I2 = 63%). There was no significant difference in the incidence of vasospasm between techniques (RR, 1.26; 95% CI, 0.37–4.23; P = 0.07; I2 = 53%). Conclusions The present results suggest that the SA-OOP technique is associated with a higher incidence of posterior wall puncture and hematoma than the LA-IP technique, whereas success rates are similar for the two ultrasound-guided arterial cannulation techniques. These findings should be experimentally evaluated in a more rigorous manner due to high inter-RCT heterogeneity.

Arterial cannulation is an essential procedure for invasive blood pressure measurement as well as repeated arterial blood gas sampling in intensive care unit setting. Common sites for placing an arterial cannula are the radial artery, femoral artery, brachial artery, and dorsalispedis artery. In certain situations such as in the case of prone ventilation, arterial cannula from common peripheral sites may get accidentally disconnected and it becomes very difficult for even a senior anesthesiologist to place an arterial cannula in the prone position. In those circumstances, an alternate site such as the popliteal artery may serve as a site for arterial cannulation. Therefore, here we present three cases of severe acute respiratory distress syndrome, whose arterial cannula was accidentally dislodged during prone ventilation maneuver and were successfully managed by ultrasound-guided popliteal artery cannulation.

Arterial cannulation is an essential procedure for invasive blood pressure measurement as well as repeated arterial blood gas sampling in intensive care unit setting. Common sites for placing an arterial cannula are the radial artery, femoral artery, brachial artery, and dorsalispedis artery. In certain situations such as in the case of prone ventilation, arterial cannula from common peripheral sites may get accidentally disconnected and it becomes very difficult for even a senior anesthesiologist to place an arterial cannula in the prone position. In those circumstances, an alternate site such as the popliteal artery may serve as a site for arterial cannulation. Therefore, here we present three cases of severe acute respiratory distress syndrome, whose arterial cannula was accidentally dislodged during prone ventilation maneuver and were successfully managed by ultrasound‑guided popliteal artery cannulation. [ABSTRACT FROM AUTHOR]

Purpose: To examine the short-term complications of arterial cannulation for intraoperative monitoring and their related risk factors. Methods: We included adult inpatients (≥ 18 years old) who underwent an initial transradial access (TRA) cannulation and were scheduled for general surgery between April 8 and November 30, 2020. We used 20G arterial puncture needles for puncturing and manual compression for hemostasis. Demographic, clinical, surgical, anesthetic, and laboratory data were extracted from electronic medical records. Vascular, neurologic, and infectious complications of TRA cannulation were recorded and analyzed. Logistic regression analyses were used to identify risk factors related to TRA cannulation for intraoperative monitoring. Results: Among 509 included patients, 174 developed TRA cannulation-related complications. Puncture site bleeding/hematoma and median nerve injury were observed in 158 (31.0%) and 16 (3.1%) patients, respectively. No patient developed cannula-related infections. Logistic regression analysis revealed increased odds of puncture site bleeding/hematoma in women (odds ratio 4.49, 95% CI 2.73–7.36; P < 0.001) and patients who received intraoperative red blood cell (RBC) suspension transfusion ≥ 4U (odds ratio 5.26, 95% CI 1.41–19.57; P = 0.01). No risk factors for nerve injury were identified. Conclusion: Bleeding/hematoma were a common complication of TRA cannulation for intraoperative hemodynamic monitoring during general surgery. Median nerve injury may be an under recognized complication. Female sex and extensive intraoperative RBC transfusion are associated with an increased risk of bleeding/hematoma; however, the risk factors for nerve injury remain unclear. Trial registration: The study protocol was registered at https://www.chictr.org.cn (ChiCTR1900025140). [ABSTRACT FROM AUTHOR]

Abstract Background High bifurcation of the deep femoral artery (DFA) is rare in clinical practice, and patients with this variation are less likely to receive venoarterial extracorporeal membrane oxygenation (V-A ECMO) treatment. Therefore, the method by which V-A ECMO is introduced in patients with vascular variation is very important. Case presentation A 52-year-old male patient had ST elevation myocardial infarction due to coronary heart disease. Angiography showed tripartite coronary artery lesions, and coronary artery stenting supported by V-A ECMO was needed. Vascular evaluation before ECMO catheterization revealed high bifurcation of the bilateral DFA located at the inguinal ligament. After discussion, the perfusion cannula was placed in the left superficial femoral artery (SFA) towards the heart, and the distal perfusion catheter (DPC) was placed in the left SFA towards the distal end. Nevertheless, after the patient's heart recovered, necrosis of the toe of the left lower limb still occurred. Conclusion Common femoral artery assessment must be performed before V-A ECMO for patients with high bifurcation of the DFA. Incision catheterization and DPC placement are recommended. After decannulation, arterial repair under direct visualisation is recommended, and rigorous distal vascular assessment and management are needed.

Background: The two most common methods for ultrasound-guided arterial cannulation are the long-axis in-plane (LA-IP) and short-axis out-of-plane (SA-OOP) approaches. However, it is uncertain which method is more advantageous. We conducted a meta-analysis of reported randomized clinical trials (RCTs) comparing the two techniques in terms of success rate, cannulation time, and complications. Methods: We systematically searched PubMed, Embase, and the Cochrane Library database for RCTs comparing the LA-IP and SA-OOP techniques for ultrasound-guided arterial cannulation published from inception through April 31, 2022. The Cochrane Collaboration's Risk of Bias Tool was used to evaluate the methodological quality of each RCT. Review Manager 5.4 and Stata/SE 17.0 were used to analyze the two primary outcome measures (first-attempt success rate and total success rate) and two secondary outcome measures (cannulation time and complications). Results: A total of 13 RCTs with 1,377 patients were included. There were no significant differences in first-attempt success rate (risk ratio [RR], 0.93; 95% confidence interval [CI], 0.78–1.12; P = 0.45; I2 = 84%) and overall success rate (RR, 0.99; 95% CI, 0.95–1.02; P = 0.48; I2 = 57%). When compared with the LA-IP technique, the SA-OOP technique was associated with an increased incidence of posterior wall puncture (RR, 3.01; 95% CI, 1.27–7.14; P = 0.01; I2 = 79%) and hematoma (RR, 2.15; 95% CI, 1.05–4.37; P = 0.04; I2 = 63%). There was no significant difference in the incidence of vasospasm between techniques (RR, 1.26; 95% CI, 0.37–4.23; P = 0.07; I2 = 53%). Conclusions: The present results suggest that the SA-OOP technique is associated with a higher incidence of posterior wall puncture and hematoma than the LA-IP technique, whereas success rates are similar for the two ultrasound-guided arterial cannulation techniques. These findings should be experimentally evaluated in a more rigorous manner due to high inter-RCT heterogeneity. [ABSTRACT FROM AUTHOR]

Objective: The dorsalis pedis artery and posterior tibial artery are recognised sites for arterial cannulation. This study aimed to compare the first-attempt success rates of cannulation along with other cannulation characteristics of these 2 arteries in adult patients undergoing surgery under general anaesthesia using the conventional palpatory method. Methods: Two hundred twenty adults were allocated randomly into 2 groups. The dorsalis pedis artery and posterior tibial artery were attempted for cannulation in the dorsalis pedis artery and posterior tibial artery group, respectively. First-attempt success rates, cannulation times, number of attempts, ease of cannulation, and complications were recorded. Results: Demographic characteristics, pulse characteristics, single-attempt success rates, ease of cannulation, reasons for failure, and complications were similar. Single-attempt success rates were similar (64.5% and 61.8%, P = .675) with equal median attempt. Easy cannulation (Visual Analogue Scale score =4) was the same in both groups, whereas percentages of difficult cannulation (Visual Analogue Scale scores =4) were 16.4% and 19.1% in the dorsalis pedis artery and posterior tibial artery groups, respectively. Cannulation time was lower in the dorsalis pedis artery group [median time in seconds: 37 (28, 63) seconds vs. 44 (29, 75) seconds, P = .027]. Single-attempt success rates were lower in the feeble pulse group as compared to the strong pulse group (48.61% vs. 70.27%, P = .002). Likewise, a higher Visual Analogue Scale of ease of cannulation (>4 score) was seen in the feeble pulse group compared to the strong pulse group (26.39% vs. 13.51%, P = .019). Conclusions: The single-attempt success rate was similar for both dorsalis pedis artery and posterior tibial artery. However, the time taken for cannulating the posterior tibial artery is significantly higher than that for dorsalis pedis artery. [ABSTRACT FROM AUTHOR]

The radial artery is the most common choice for arterial cannulation, coronary interventions, and various interventional radiological procedures. Here, we describe a case of unilateral duplication of the radial artery detected during radial artery cannulation using point-of-care ultrasonography (POCUS). The duplication of the radial artery in the forearm can hinder trans-radial access secondary to variations in the diameter. An actual duplication also carries a high risk of accidental injury to the arterial wall during routine invasive procedures and other forearm procedures such as free flap construction. POCUS is invaluable for detecting arterial anomalies before proceeding with any interventional procedures.

Abstract Background Continuous invasive arterial monitoring is necessary in sick neonates needing hemodynamic and ventilatory support. The primary objective of our study was to describe clinical experience with percutaneous peripheral arterial cannulation (PAC) in sick neonates. Methods Neonates needing PAC were prospectively enrolled in the study. Inclusion criteria were: neonates needing respiratory support (invasive or non-invasive), neonates requiring vasoactive medications or neonate likely to need more than 5 sampling pricks in 24 h. Results One hundred eight neonates (93.1%) needed cannulation of one arterial site while 8 (6.9%) needed cannulation of 2 arterial sites, thus giving a total of 124 cannulations. Out of the 124 cannulations, 102 (82%) were performed in first attempt, while 22 (18%) cannulations needed 2 or more attempts. Serious complications like discolouration of digits, blanching of skin or bleeding were seen in 6 (4.9%) cannulations. These resolved after removal of arterial line and no long term consequences were noted. On comparing neonates having radial arterial cannulation(n = 108) with posterior tibial arterial cannulation (n = 16) there was no difference in duration of arterial line between radial artery group (mean, SD 53.30 ± 22.56) and posterior tibial artery group (mean, SD 48.25 ± 27.39). However, more attempts were needed to cannulate post tibial artery (mean, SD 2.25 ± 1.32) as compared to radial artery (mean 1.22 ± 0.789) and this difference was statistically significant (MD -1.02, 95% CI − 1.75 to − 0.30). There was no difference in incidence of serious complications between the radial artery group (3.7%, n = 4) as compared to posterior tibial group (5.5%, n = 1, OR 0.57, 95% CI 0.06–5.51, p = 0.63). Conclusions Peripheral arterial cannulation is a safe method for hemodynamic monitoring and blood sampling in sick neonates. Complications can be minimized by diligent monitoring and proactive removal of line if there is damping of tracing.

Background: Early intraoperative hypotension is associated with acute kidney and myocardial injury in patients undergoing noncardiac surgery. Precise arterial blood pressure measurement before and during the induction of general anaesthesia may avert early intraoperative hypotension. However, rapid arterial cannulation in anxious, conscious patients can be challenging. We describe the protocol for a randomised controlled trial designed to test the hypothesis that readily available, handheld ultrasound-guided arterial cannulation is the optimal method in conscious patients undergoing noncardiac surgery. Methods: Participants >45 yr undergoing noncardiac surgery expected to last >120 min and requiring an overnight hospital stay will be eligible. We will randomly allocate participants to undergo cannulation of the radial artery in the non-dominant arm before the induction of general or regional anaesthesia using either handheld ultrasound-guided dynamic needle position technique or palpation. The primary outcome is first-pass successful arterial cannulation, analysed by intention-to-treat. Secondary outcomes include adequacy/characteristics of the arterial waveform and complications within 24 h of cannulation. We will require 118 patients to demonstrate a doubling of successful first-pass arterial cannulation, from ∼30% using the palpation approach (α=0.05; 1–β=0.1). Results: This study has been approved by the NHS Health Research Authority and Health Care Research Wales (21/WA/0403) and commenced recruitment in May 2022. Conclusions: This study will establish whether handheld ultrasound-guided arterial cannulation before the induction of anaesthesia should be the standard of care in patients at risk of developing perioperative organ injury after noncardiac surgery. Clinical trial registration: NCT05249036.

Objectives: Serious acute vascular complications may occur during ECMO support. In our study, acute vascular complications that developed in patients followed up with ECMO support were evaluated. Methods: Patients older than 18 years of age who received ECMO support were included in this study. Acute vascular complications, risk factors, and results were analyzed by evaluating the data retrospectively. Results: Nineteen patients were included in the study. It was observed that V-A ECMO support was performed in 17 patients and V-V ECMO support was performed in two patients. Acute vascular complications developed in 7 patients (36.8%). A significant correlation was found between the ECMO cannulation type and the development of vascular complications (p=0.032). It was determined that the using of distal perfusion cannula or femoral artery graft to prevent the development of vascular complications did not reduce the development of vascular complications (including digital ischemia). Conclusion: We think that peripheral ECMO cannulation is associated with vascular complications and prospective studies are needed to prevent these complications. [ABSTRACT FROM AUTHOR]

BACKGROUND: Arterial cannulation is an important procedure for hemodynamic monitoring and blood sampling. Traditional radial artery cannulation is performed by using anatomical knowledge and pulse palpation as a guide. Arterial cannulation using ultrasound (US) requires specific training, especially for new US users. We hypothesized that even for new US users, US guidance would facilitate the successful puncture by lower attempts before successful intraluminal cannulation of a simulation model of the radial artery. METHODS: A prospective randomized controlled crossover study was conducted with new US users on a gelatin phantom wrist. Three sessions of training were proposed: US-guided technique with low blood pressure (BP), palpation-guided technique with high BP, and one secondary comparison with low BP. For the 2 first sessions, all volunteers performed each technique but not in the same order. The main criterion was the number of attempts before successful catheterization of the model artery. A secondary criterion was the number of needle movements (the number of attempts plus the number of needle directional changes). RESULTS: Twenty new US users participated in the study. Numbers of attempts before successful catheterization were significantly lower when using the US technique: 1.1 (± 0.4) for US versus 1.6 (± 0.8) for palpation high BP (P = .02) versus 2.5 (± 1.4) for the secondary comparison, palpation low BP (P < .001). All of the participants achieved success after the 12th needle movement for US technique, after the 19th needle movement for palpation high BP, and after the 25th needle movement for the secondary comparison, palpation low BP. The total time before success was not significantly different between the 2 first sequences (US vs palpation high BP). CONCLUSIONS: US technique was more successful than traditional palpation technique for novice US users performing arterial cannulations for the first time. A study in the clinical practice is needed to confirm these results. [ABSTRACT FROM AUTHOR]

Background: High bifurcation of the deep femoral artery (DFA) is rare in clinical practice, and patients with this variation are less likely to receive venoarterial extracorporeal membrane oxygenation (V-A ECMO) treatment. Therefore, the method by which V-A ECMO is introduced in patients with vascular variation is very important.Case Presentation: A 52-year-old male patient had ST elevation myocardial infarction due to coronary heart disease. Angiography showed tripartite coronary artery lesions, and coronary artery stenting supported by V-A ECMO was needed. Vascular evaluation before ECMO catheterization revealed high bifurcation of the bilateral DFA located at the inguinal ligament. After discussion, the perfusion cannula was placed in the left superficial femoral artery (SFA) towards the heart, and the distal perfusion catheter (DPC) was placed in the left SFA towards the distal end. Nevertheless, after the patient's heart recovered, necrosis of the toe of the left lower limb still occurred.Conclusion: Common femoral artery assessment must be performed before V-A ECMO for patients with high bifurcation of the DFA. Incision catheterization and DPC placement are recommended. After decannulation, arterial repair under direct visualisation is recommended, and rigorous distal vascular assessment and management are needed. [ABSTRACT FROM AUTHOR]

Objectives: To compare the success and complication rates of radial artery catheterization using ultrasound guidance versus the conventional palpation technique in obese patients by anesthesia residents with similar levels of experience in both methods, and to measure the skin-to-artery distance of radial, brachial, and dorsalis pedis arteries using ultrasound with standardized anatomic landmarks., Design: Prospective, randomized controlled trial SETTING: Single tertiary center PARTICIPANTS: Eighty adults with a body mass index (BMI) ≥30 kg/m 2 INTERVENTIONS: Ultrasound guidance or conventional palpation method MEASUREMENTS AND MAIN RESULTS: The primary outcome was the first-attempt success rate of arterial catheterization. The skin-to-artery distance of the radial artery was significantly greater in the BMI groups of 40 to 49 kg/m 2 and ≥50 kg/m 2 compared to the BMI group of 30 to 39 kg/m 2 (mean difference, 1.0 mm; 95% confidence interval [CI], 0.4-1.7; p = 0.0029) for BMI 40-49 kg/m 2 vs 30-39 kg/m 2 and 1.5 mm (95% CI, 0.6-2.4 mm; p = 0.0015) for ≥50 kg/m 2 vs 30-39 kg/m 2 . Similar findings were observed for the brachial artery. BMI was inversely associated with first-attempt success rates (p = 0.0145) and positively with time to successful catheterization (p = 0.0271). The first-attempt success and vascular complication rates of catheterization did not differ significantly between the ultrasound guidance group (65.0% and 52.5%, respectively) and the conventional palpation group (70.0% [p = 0.6331] and 57.5% [p = 0.6531], respectively)., Conclusion: The results of this study do not support the routine use of ultrasonography during radial arterial catheterizations for obese adults when junior practitioners perform the procedure., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The radial artery is the most common choice for arterial cannulation, coronary interventions, and various interventional radiological procedures. Here, we describe a case of unilateral duplication of the radial artery detected during radial artery cannulation using point-of-care ultrasonography (POCUS). The duplication of the radial artery in the forearm can hinder trans-radial access secondary to variations in the diameter. An actual duplication also carries a high risk of accidental injury to the arterial wall during routine invasive procedures and other forearm procedures such as free flap construction. POCUS is invaluable for detecting arterial anomalies before proceeding with any interventional procedures. [ABSTRACT FROM AUTHOR]

Abstract Objectives Determine if shortening the covered section of a self-expanding bidirectional arterial cannula, can enhance retrograde flow and thus reduce the risk of lower limb ischemia. Methods Outlet pressure vs flow rate was determined for three cannulas types: a 15F self-expanding bidirectional cannula having a covered section of 90 mm, the same cannula but with a shorter covered section of 60 mm, and a Biomedicus cannula as control. The performances of all the cannulas were compared using a computerized flow-bench with calibrated sensors and a centrifugal pump. Water retrograde flow was determined using a tank timer technique. Anterograde and retrograde flow rate versus outlet pressure were determined at six different pump speed. Results For each of the six pump speed, both bidirectional cannulas, 60-mm covered and 90-mm covered respectively, showed higher performance than Biomedicus cannula control, as demonstrated by higher flow rate and lower pressure. We also observed that for the bidirectional cannula with shorter covered section, i.e. 60 mm coverage, provides enhanced performance as compared to a 90-mm coverage. Finally, the flow rate and the corresponding pressure can be consistently measured by our experimental set-up with low variability. Conclusions The new configuration of a shorter covered section in a bidirectional self-expanding cannula design, may present an opportunity to overcome lower leg ischemia during extra-corporal life support with long term peripheral cannulation.

Arterial cannulation for cardiopulmonary bypass (CPB) is an important determinant of outcome in aortic surgery. Unlike traditional cardiac operations, aortic pathology may preclude the cannulation of the distal ascending aorta. In other cases, special need of the pathology/operation may demand an alternative cannulation site. Choosing the right cannulation site, especially in type A aortic dissection, is the most crucial initial step. The decision about cannulation sites should be individualized and patient-specific. Various cannulation techniques include femoral, right axillary, innominate, carotid, central aortic, direct true lumen, transapical, and trans-atrial left ventricle cannulation. The ideal cannulation should be easy, quick, and suitable for all clinical scenarios. It should allow smooth conduct of CPB without malperfusion or cerebral embolization. The cannulation strategy should also provide an option for selective antegrade cerebral perfusion and it should be free from neurovascular and local site complications. There is no ideal cannulation technique. Each technique has its pros and cons. Excellent results and drawbacks have been reported with each technique. Final selection of the cannulation site is dependent upon several factors. However, a surgeon's familiarity with a particular technique plays a major role in selection. Despite this, there is a definite shift in surgeons' preference from femoral to central cannulation (axillary, carotid, innominate, aortic) over the last few decades. The aim of this review is to give a brief overview of the cannulation techniques in aortic surgery and discuss the decision-making process. [ABSTRACT FROM AUTHOR]

Background: Absorbable sutures, commonly used in general surgery, are not routinely used as purse strings for arterial and venous cannulation for cardiopulmonary bypass in pediatric heart surgery. The general concern is absorbable sutures could predispose to immediate postoperative bleeding; this safety concern has been evaluated in this retrospective study. Materials and Methods: A single center, retrospective study, was conducted with criteria for inclusion patient <18 years of age, operation on with cardiopulmonary bypass for heart surgery from July 1, 2018 to June 30, 2020, with purse strings for cannulation performed with absorbable sutures. Data collection included demographics at the time of surgery, site of arterial and venous cannulation with absorbable purse strings, bleeding, required reoperation, related hospital mortality, and complications. Results: One hundred and ninety‐eight patients, mean ± standard deviation (SD) age of 1597 ± 3021 days, mean ± SD body weight of 15.9 ± 18.8 kg, were operated on using absorbable sutures for purse strings for arterial and venous cannulation: No bleeding was reported, either intraoperative or in the immediate postoperative period, related to the type of sutures used for purse strings for cannulation. No hospital deaths or complications related to the type of sutures were observed. Conclusions: Based on the results of our analysis, we can conclude that the utilization of purse strings absorbable sutures for arterial and venous cannulation for cardio‐pulmonary bypass in children is safe in relationship to the intraoperative and immediate postoperative period. No complications related to the use of absorbable sutures have been observed in a large pediatric patient population. [ABSTRACT FROM AUTHOR]

Background: Continuous invasive arterial monitoring is necessary in sick neonates needing hemodynamic and ventilatory support. The primary objective of our study was to describe clinical experience with percutaneous peripheral arterial cannulation (PAC) in sick neonates.Methods: Neonates needing PAC were prospectively enrolled in the study. Inclusion criteria were: neonates needing respiratory support (invasive or non-invasive), neonates requiring vasoactive medications or neonate likely to need more than 5 sampling pricks in 24 h.Results: One hundred eight neonates (93.1%) needed cannulation of one arterial site while 8 (6.9%) needed cannulation of 2 arterial sites, thus giving a total of 124 cannulations. Out of the 124 cannulations, 102 (82%) were performed in first attempt, while 22 (18%) cannulations needed 2 or more attempts. Serious complications like discolouration of digits, blanching of skin or bleeding were seen in 6 (4.9%) cannulations. These resolved after removal of arterial line and no long term consequences were noted. On comparing neonates having radial arterial cannulation(n = 108) with posterior tibial arterial cannulation (n = 16) there was no difference in duration of arterial line between radial artery group (mean, SD 53.30 ± 22.56) and posterior tibial artery group (mean, SD 48.25 ± 27.39). However, more attempts were needed to cannulate post tibial artery (mean, SD 2.25 ± 1.32) as compared to radial artery (mean 1.22 ± 0.789) and this difference was statistically significant (MD -1.02, 95% CI - 1.75 to - 0.30). There was no difference in incidence of serious complications between the radial artery group (3.7%, n = 4) as compared to posterior tibial group (5.5%, n = 1, OR 0.57, 95% CI 0.06-5.51, p = 0.63).Conclusions: Peripheral arterial cannulation is a safe method for hemodynamic monitoring and blood sampling in sick neonates. Complications can be minimized by diligent monitoring and proactive removal of line if there is damping of tracing. [ABSTRACT FROM AUTHOR]

Aim and Background: Ultrasound-guided arterial catheterization is a frequently performed procedure. Additional techniques such as acoustic shadowing-assisted ultrasound may be useful in improving success rate. This systematic review aimed to assess the efficacy of acoustic shadowing assisted ultrasound for arterial catheterization., Materials and Methods: PubMed, Medline, EMBASE, Cochrane Library, EMCARE, and MedNar were searched in January 2024. Randomized controlled trials comparing the first attempt success rate of arterial catheterization using acoustic shadowing ultrasound vs unassisted ultrasound were included. Data were pooled for risk ratios (RRs) using the random-effects model. Subgroup analysis was conducted based on a single or double acoustic line. Sensitivity analysis was undertaken after excluding pediatric data. The certainty of evidence (COE) was assessed using the GRADE framework., Results: Six randomized controlled trials ( n = 777) were included. A meta-analysis found the first attempt success rate is significantly higher in the acoustic ultrasound group ( n = 6, RR: 0.47, 95% CI: 0.34-0.66, p ≤ 0.00001). Hematoma formation was significantly less in the acoustic ultrasound group ( n = 6, RR: 0.52, 95% CI: 0.34-0.80, p = 0.003). First attempt success was significantly higher in the single acoustic line ultrasound (USG) group compared to the unassisted ultrasound group ( n = 3, RR: 0.41, 95% CI: 0.28-0.59, p ≤ 0.00001). Sensitivity analysis after excluding pediatric data was similar to the primary analysis ( n = 5, RR: 0.50, 95% CI: 0.33-0.70, p ≤ 0.00001). Certainty of evidence was "Moderate" for the first attempt cannulation., Conclusions: Acoustic shadowing-assisted ultrasound improved first-attempt arterial catheterization success rate and was associated with reduced hematoma formation., How to Cite This Article: Mishra L, Rath C, Wibrow B, Anstey M, Ho K. Acoustic Shadowing to Facilitate Ultrasound Guided Arterial Cannulation: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2024;28(7):677-685., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2024; The Author(s).)

Abstract Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is an increasingly adopted life-saving mechanical circulatory support for a number of potentially reversible or treatable cardiac diseases. It is also started as a bridge-to-transplantation/ventricular assist device in the case of unrecoverable cardiac or cardio-respiratory illness. In recent years, principally for non-post-cardiotomy shock, peripheral cannulation using the femoral vessels has been the approach of choice because it does not need the chest opening, can be quickly established, can be applied percutaneously, and is less likely to cause bleeding and infections than central cannulation. Peripheral ECMO, however, is characterized by a higher rate of vascular complications. The mechanisms of such adverse events are often multifactorial, including suboptimal arterial perfusion and hemodynamic instability due to the underlying disease, peripheral vascular disease, and placement of cannulas that nearly occlude the vessel. The effect of femoral artery damage and/or significant reduced limb perfusion can be devastating because limb ischemia can lead to compartment syndrome, requiring fasciotomy and, occasionally, even limb amputation, thereby negatively impacting hospital stay, long-term functional outcomes, and survival. Data on this topic are highly fragmentary, and there are no clear-cut recommendations. Accordingly, the strategies adopted to cope with this complication vary a great deal, ranging from preventive placement of antegrade distal perfusion cannulas to rescue interventions and vascular surgery after the complication has manifested. This review aims to provide a comprehensive overview of limb ischemia during femoral cannulation for VA-ECMO in adults, focusing on incidence, tools for early diagnosis, risk factors, and preventive and treating strategies.

Objectives: Determine if shortening the covered section of a self-expanding bidirectional arterial cannula, can enhance retrograde flow and thus reduce the risk of lower limb ischemia.Methods: Outlet pressure vs flow rate was determined for three cannulas types: a 15F self-expanding bidirectional cannula having a covered section of 90 mm, the same cannula but with a shorter covered section of 60 mm, and a Biomedicus cannula as control. The performances of all the cannulas were compared using a computerized flow-bench with calibrated sensors and a centrifugal pump. Water retrograde flow was determined using a tank timer technique. Anterograde and retrograde flow rate versus outlet pressure were determined at six different pump speed.Results: For each of the six pump speed, both bidirectional cannulas, 60-mm covered and 90-mm covered respectively, showed higher performance than Biomedicus cannula control, as demonstrated by higher flow rate and lower pressure. We also observed that for the bidirectional cannula with shorter covered section, i.e. 60 mm coverage, provides enhanced performance as compared to a 90-mm coverage. Finally, the flow rate and the corresponding pressure can be consistently measured by our experimental set-up with low variability.Conclusions: The new configuration of a shorter covered section in a bidirectional self-expanding cannula design, may present an opportunity to overcome lower leg ischemia during extra-corporal life support with long term peripheral cannulation. [ABSTRACT FROM AUTHOR]

Purpose: Safety and feasibility of distal radial artery cannulation at the anatomic snuffbox in the perioperative settings in adult patients have been assessed in this study. Methods: Adult patients undergoing elective surgery requiring arterial cannulation were recruited in this retrospective cohort study. Results: Data of 55 patients have been reviewed here; among which in 21 patients, arterial puncture was performed ultrasound guidance and in 34 patients puncture was guided by the pulsation of the distal radial artery at the anatomical snuffbox. First attempt success rate of distal radial arterial cannulation was 76.3% (42 of 55 patients) and it was similar between ultrasound guided (USG) and palpation technique (P = 0.53, Chi-square test). Overall, cannulation success rate was 87.3% (48 of 55 patients) and it was also similar between USG and palpation technique (P = 0.79, Chi-square test). Conclusion: Distal radial artery cannulation is technically feasible in patients undergoing elective surgery. However, further randomized controlled trials are required to establish its clinical utility and safety profile in comparison to conventional radial artery cannulation.

Introduction: Superficial arteries, such as radial and dorsalis pedis arteries, are commonly cannulated for invasive blood pressure monitoring. Failure to cannulate these arteries necessitates alternate arteries, such as the posterior tibial artery (PTA). The deep-seated anatomy of PTA makes arterial cannulation precarious by the palpatory technique. Ultrasound guidance during PTA cannulation may overcome this problem. With this background, we evaluated the ultrasound-guided (USG) versus palpatory method for PTA cannulation with respect to the first attempt's success and number of attempts., Methods: A total of 240 American Society of Anesthesiology (ASA) physical status I-IV adult patients undergoing major surgeries requiring arterial cannulation were randomly allocated (1:1) to group A (USG-guided cannulation, n = 120) and Group B (cannulation by palpatory technique, n =120). PTA was cannulated by either of the techniques according to randomization. Data were analyzed and compared in both groups for first-attempt success, number of attempts, assessment time, cannulation time, and complications., Result: The successful cannulation in the first attempt in Group A was 25.8% (n = 31), and in Group B, it was 12.5% (n = 15) (p = 0.009). In Group A, 78.3% of patients (n = 94) had successful cannulation, and in group B, 65% of patients (n =78) had successful cannulation (p = 0.022). Both groups had similar assessment time (p = 0.348) and cannulation time (p = 0.864)., Conclusion: USG-guided PTA cannulation offers a greater chance of success without any added increase in procedure time., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Eda et al.)

Background: Distal radial artery cannulation at the "anatomical snuffbox" carries several theoretical advantages over conventional radial arterial cannulation at the wrist. However, these two techniques have not been evaluated in perioperative settings., Methods: In this randomized controlled trial, n  = 200 patients requiring arterial cannulation for perioperative monitoring were recruited. Patients were randomized to either ultrasound guided distal radial artery cannulation group (group D) or ultrasound guided conventional radial artery cannulation group (group W). Primary outcome of this study was first attempt cannulation success rate., Results: First attempt cannulation success rate was significantly lower in distal radial artery cannulation (57% in group D and 77% in group W; p  = 0.003). Use of alternative cannulation site was significantly higher in group D when compared to group W ( p  = 0.015) and number of attempts for successful cannulation was significantly higher in group D when compared to group W ( p  = 0.015). None of the patients in any group developed thrombosis and related complications and intraoperative catheter dislodgement. Time to puncture the artery ( p  < 0.0001), total cannulation time ( p  < 0.0001), and actual catheter insertion time ( p  < 0.0001) were significantly higher in group D in comparison to group W., Conclusion: Distal radial artery cannulation was associated with lower first attempt cannulation success rate and requires longer time to perform. As distal radial artery is a new technique, further studies are required in different clinical settings., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: The purpose of the study is to study and classify the superficial palmar arch and its variation based upon the gross dissection and to check the bilateral symmetry of the arches. Specifically, we checked for the presence of the superficial palmar arch as described in the standard textbooks. Methods: We dissected 55 hands from 28 cadavers of both sexes that include 18 males and 10 females. The superficial palmar arch was carefully dissected and the arteries contributing its formation were traced. It was classified into complete, incomplete arches. Bilateral symmetry of the arches was also studied. Results: The most common pattern of superficial palmar arch observed is complete. And it is further classified into radio-ulnar and predominantly ulnar types. A consistent proportion of radio-ulnar type arch is completed around first web space. None of the dissected hand meets the definition of the classical superficial palmar arch as described in the standard anatomical textbooks. We also encountered few rare variants of the incomplete superficial palmar arch. Conclusions: Type 1–4 superficial palmar arch is complete and can be utilized for radial artery or ulnar artery cannulation and radial artery harvesting procedure. In type 5 arch, ulnar artery occlusion could lead to severe hand ischemia and at the same time the radial artery in this type can be harvested without ischemic complication. We suggest that the definition of the complete superficial palmar arch should be rechecked and modified as complete superficial palmar or complete superficial first web space arch. [ABSTRACT FROM AUTHOR]

Surgery on thoracic aorta is complex with a number of approaches being required depending on the pathology and anatomy that is specific to each patient and therefore, careful planning is required to ensure successful outcomes. Among the key factors that determine a satisfactory and safe operation is the choice of arterial cannulation site to establish cardiopulmonary bypass and deliver brain protection adequately. Direct proximal aortic cannulation is the gold-standard method for elective aortic root surgery and traditionally femoral arterial cannulation has been used in complex aortic surgeries such as redo or acute pathologies; however, axillary and innominate artery (IA) cannulation has evolved dramatically and several centers are currently using proximal cannulation sites as the default cannulation choice in elective and emergency settings of complex thoracic aortic surgeries. The evidence behind cannulating the IA is growing; however, it is yet to be well established through large studies or trial to confirm its superiority to other methods of central cannulation techniques. [ABSTRACT FROM AUTHOR]

The article focuses on the best site and process for the arterial access during surgery of the aortic arch and in front of hostile aortas during emergencies. It discusses the technique of cannulation of the right axillary artery as well as other few modes of cannulation through a peripheral artery. Information about femoral arteries and the use of a common carotid artery is presented.

Purpose: Safety and feasibility of distal radial artery cannulation at the anatomic snuffbox in the perioperative settings in adult patients have been assessed in this study. Methods: Adult patients undergoing elective surgery requiring arterial cannulation were recruited in this retrospective cohort study. Results: Data of 55 patients have been reviewed here; among which in 21 patients, arterial puncture was performed ultrasound guidance and in 34 patients puncture was guided by the pulsation of the distal radial artery at the anatomical snuffbox. First attempt success rate of distal radial arterial cannulation was 76.3% (42 of 55 patients) and it was similar between ultrasound guided (USG) and palpation technique (P = 0.53, Chi-square test). Overall, cannulation success rate was 87.3% (48 of 55 patients) and it was also similar between USG and palpation technique (P = 0.79, Chi-square test). Conclusion: Distal radial artery cannulation is technically feasible in patients undergoing elective surgery. However, further randomized controlled trials are required to establish its clinical utility and safety profile in comparison to conventional radial artery cannulation. [ABSTRACT FROM AUTHOR]