Umberto G. Rossi

Percutaneous ultrasound-guided central venous catheters: the lateral in-plane technique for internal jugular vein access

Purpose To describe the possible ultrasound guidance techniques for the insertion of central venous catheters (CVCs), with emphasis particularly to the lateral short axis in-plane technique. Methods Numerous articles have shown significant benefits of using ultrasound guidance for venous access. Two main approaches to vein puncture are available, when considering visualization of the needle during its entry into the vein under the ultrasound beam: in-plane and out-of-plane, which can be combined with two types of vein visualization, placing the ultrasound probe on the vein long axis or short axis. Results Advantages and limitations in internal jugular vein (IJV) cannulation for long-term dialysis CVCs are described for the above-mentioned approaches and visualizations. The lateral short axis in-plane technique has virtually no limitations, ensuring most benefits. Conclusions The lateral short axis in-plane technique should be considered the first-line technique for IJV cannulation.

Optimization of dialysis catheter function

Central venous catheters (CVCs) are essential in the management of hemodialysis patients, but they also carry unintended negative consequences and in particular thrombosis and infection, adversely affecting patient morbidity and mortality. This review will focus on the etiology, prevention, and management of CVC-related dysfunction, which is mainly associated with inadequate blood flow. CVC dysfunction is a major cause of inadequate depuration. Thrombus, intraluminal and extrinsic, as well as fibrous connective tissue sheath (traditionally indicated as fibrin sheath) formation play a central role in establishing CVC dysfunction. Thrombolysis with urokinase or recombinant tissue plasminogen activator (rTPA) can be undertaken in the dialysis unit, restoring adequate blood flow in most patients, preserving the existing catheter, and avoiding an interventional procedure. If thrombolytics fail, mainly because of the presence of fibrous connective tissue sheath, catheter exchange with fibrin sheath disruption may be successful and preserve the venous access site. Prevention of CVC dysfunction is important for containing costly pharmacologic and interventional treatments, which also affect patients’ quality of life. Prevention is based on the use of anticoagulant and/or thrombolytic CVC locks, which are only partially effective. Chronic oral anticoagulation with warfarin has also been proposed, but its use for this indication is controversial and its overall risk-benefit profile has not been clearly established.

Congenital anomalies of superior vena cava and their implications in central venous catheterization

Congenital anomalies of superior vena cava (SVC) are generally discovered incidentally during central venous catheter (CVC) insertion, pacemaker electrode placement, and cardiopulmonary bypass surgery. Persistent left SVC (PLSVC) is a rare (0.3%) anomaly in healthy subjects, usually asymptomatic, but when present and undiagnosed, it may be associated with difficulties and complications of CVC placement. In individuals with congenital heart anomalies, its prevalence may be up to 10 times higher than in the general population. In this perspective, awareness of the importance of the incidental finding of PLSV during CVC placement is crucial. To improve knowledge of this rare but potentially dangerous condition, we describe the embryological origin of SVC, its normal anatomy, and possible congenital anomalies of the venous system and of the heart, including the presence of a right to left cardiac shunt. Diagnosis of PLSVC as well as the clinical complications and technical impact of SVC congenital anomalies for CVC placement are emphasized.

Tunneled central venous catheter exchange: techniques to improve prevention of air embolism

Malfunctioning tunneled hemodialysis central venous catheters (CVCs), because of thrombotic or infectious complications, are frequently exchanged. During the CVC exchanging procedure, there are several possible technical complications, as in first insertion, including air embolism. Prevention remains the key to the management of air embolism. Herein, we emphasize the technical tricks capable of reducing the risk of air embolism in long-term CVC exchange. In particular, adoption of a 5 to 10 degrees Trendelenburg position, direct puncture of the previous CVC venous lumen for guide-wire insertion, as opposed to guide-wire introduction after cutting the CVC, a light manual compression of the internal jugular vein venotomy site after catheter removal. The Valsalva maneuvre in collaborating patients, valved introducers, and correction of hypovolemia are also useful precautions. Principles of air embolism diagnosis and treatment are also outlined in the article.

Role of interventional radiology in the management of complications after pancreatic surgery: a pictorial review.

AbstractPancreatic resections are surgical procedures associated with high incidence of complications, with relevant morbidity and mortality even at high volume centres. A multidisciplinary approach is essential in the management of these events and interventional radiology plays a crucial role in the treatment of patients developing post-surgical complications. This paper offers an overview on the interventional radiological procedures that can be performed to treat different type of complications after pancreatic resection. Procedures such as percutaneous drainage of fluid collections, percutaneous transhepatic biliary procedures, arterial embolisation, venous interventions and fistula embolisation are viable treatment options, with fewer complications compared with re-look surgery, shorter hospital stay and faster recovery. A selection of cases of complications following pancreatic surgery managed with interventional radiological procedure are presented and discussed. Teaching Points • Interventional radiology is crucial to treat complications after pancreatic surgery • Percutaneous drainage of collections can be performed under ultrasound or computed tomography guidance • Percutaneous biliary procedures can be used to treat biliary complications • Venous procedures can be performed effectively through transhepatic or transjugular access • Fistulas can be treated effectively by percutaneous embolisation

Endovascular Treatment of a Symptomatic Thoracoabdominal Aortic Aneurysm by Chimney and Periscope Techniques for Total Visceral and Renal Artery Revascularization

We appreciated the comments about the saccular pseudoaneurysm originating from the fusiform abdominal aneurysm in the Letter to the Editor from Canyigit et al. [1]. We agree with the comment of Canyigit et al. [1] that this kind of pathology is extremely rare and that penetrating atherosclerotic ulcer is the most likely underlying mechanism of its formation [1]. Contrast-enhanced multidetector computed tomography (MDCT) has become the technique of choice to evaluate aortic disease for its specificity, sensibility, and availability [2]. To our knowledge, the total number of described saccular pseudoaneurysms originating from the fusiform abdominal aneurysm has increased to six cases in total [1, 3, 4]. In our previous paper, we have not emphasized this pathological aspect, because the focus of the case report was on revascularization [3]. However, on MDCT followup after endovascular treatment the pseudoaneurysmatic sac showed a considerable reduction in volume [3]. Conflict of interest None.

Response to: Central venous catheterization in fragile patients: which is the best approach?

1. Pescatori LC, Carrafiello G. Central venous catheterization in fragile patients: which is the best approach? J Vasc Access. 2017;18(2):e24. 2. Rossi UG, Rigamonti P, Tichà V, et al. Percutaneous ultrasoundguided central venous catheters: the lateral in-plane technique for internal jugular vein access. J Vasc Access. 2014;15(1):56-60. 3. Rossi UG, Rigamonti P, Torcia P, et al. Congenital anomalies of superior vena cava and their implications in central venous catheterization. J Vasc Access. 2015;16(4):265-268. 4. Gallieni M, Giordano A, Rossi U, Cariati M. Optimization of dialysis catheter function. J Vasc Access. 2016;17(Suppl 1):S42-S46. 5. Rossi UG, Torcia P, Rigamonti P, et al. Tunneled central venous catheter exchange: techniques to improve prevention of air embolism. J Vasc Access. 2016;17(2):200-203.

Endovascular manual aspiration thrombectomy of acute superior mesenteric artery thromboembolic occlusion: the good, the bad, and the ugly.

The outcome of endovascular treatment in acute superior mesenteric artery (SMA) thromboembolic occlusion is variable at best. We describe three patients who underwent urgent endovascular manual aspiration thrombectomy of the SMA, illustrating the good, the bad, and the ugly. The good: a 63-year-old male patient was admitted to our hospital for acute abdominal pain. Contrast-enhanced multidetector computed tomography (MDCT) showed total occlusion of the SMA with just air distension of the bowel. From the right femoral artery, he underwent emergency angiography that confirmed the diagnosis of total occlusion of the SMA (Fig. 1a). A manual aspiration thrombectomy was performed into the SMA, using a Luer-lock 60-mL syringe, connected to a 7 F catheter (Mach-1, Boston Scientific, Natick, Massachusetts, USA) to generate a vacuum effect (Fig. 1b). The clots were aspirated and removed from the SMA; six passes of the guiding catheter were made. The final control demonstrated patency of the SMA, distal arcades, and vasa rectae (Fig. 1c). Intravenous heparin (1000 IU/hour) was administered for 48 hours. The patient did not need a bowel resection. The bad: a 76-year-old female patient was admitted to our hospital after two days of acute and progressive abdominal pain. MDCT showed total occlusion of the SMA with signs of mesenteric ischemia (pneumatosis intestinalis). From the right femoral artery, she underwent emergency angiography, confirming the diagnosis of total occlusion of the SMA (Fig. 2a). A manual aspiration thrombectomy was performed into the SMA, using a Luer-lock 60-mL syringe, connected to a 7 F catheter (Mach1, Boston Scientific; Fig. 2b). Some clots were removed, but no patency of the SMA was noted; three passes of the guiding catheter were made. During these maneuvers and a SMA postorigin dissection, the distal ileal vascular arcade was accidentally perforated. So, an angioplasty and stenting of the postorigin segment of the SMA, and consequent distal ileal vascular arcade metallic-coil embolization, were performed. The final control demonstrated partial patency of the SMA and continued occlusion of the distal arcades and vasa rectae (Fig. 2c). Due to the vascular perforation, catheter-directed thrombolysis was not performed, and intravenous heparin was given at dose of 1000 IU/hour. The patient underwent urgent abdominal bowel resection surgery and SMA thrombectomy, but she died 72 hours later. The ugly: a 71-year-old male patient was admitted to our hospital with progressive abdominal pain. MDCT showed

Spontaneous Hematoma of the Rectus Sheath: Urgent Embolization with Squidperi Liquid Embolic Device

We treated a 78-year-old female affected by nontraumatic spontaneous rectus sheath hematoma. We decided to perform the embolization with the new liquid agent Squidperi. Complete exclusion of the bleeding vessel was obtained without complications. Its use should be considered for treatment of nontraumatic rectus sheath hematoma.

Aortic dissection: The flood tide sign

Aortic dissection is a challenging medical and surgical problem. Its evolution depends on size and location of its intimal tears. We describe a case of contrast enhanced MD-CT with low out flow of the false lumen for an unbalanced between the entry and the reentry tears. This determined a delayed filling up of the false lumen on the arterial phase that was complete on the venous one.