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Pulmonary angiography
Published in Debabrata Mukherjee, Eric R. Bates, Marco Roffi, Richard A. Lange, David J. Moliterno, Nadia M. Whitehead, Cardiovascular Catheterization and Intervention, 2017
Hong Jun Yun, Syed Sohail Ali, Paul Michael Grossman
At our institution, we use the EkoSonic Endovascular system with or without adjunctive thrombus fragmentation or aspiration for the treatment of massive and sub-massive PE confirmed by CT pulmonary angiography. The EkoSonic Endovascular System consists of three components: an Intelligent Drug Delivery Catheter (IDDC); a removable MicroSonic Device containing multiple small ultrasound transducers distributed over the treatment zone; and the EkoSonic control unit. Venous access is obtained via the right femoral vein or right internal jugular vein (if the femoral vein approach is not feasible) using the modified Seldinger technique under ultrasound guidance. A 7-Fr introducer sheath or 10-Fr double-lumen introducer sheath is inserted depending on the need for a unilateral or bilateral EkoSonic device placement. The embolic occlusion is crossed using a 0.035-in guidewire and standard diagnostic angiographic catheter (either a 7-Fr Van Aman APC or 7-Fr Montefiore MONT-1 catheter). With the guidewire tip in a safe position, the angiographic catheter is exchanged for the IDDC. The guidewire is then removed and the MicroSonic Device inserted into the IDDC. A fixed-dose regimen of tissue-plasminogen activator (t-PA) of 24 mg is administered at 1 mg/h with saline coolant at 35 mL/h for both unilateral and bilateral PEs for 12-24 hours. Baseline right heart pressures are measured before and following infusion of fibrinolytic therapy. This procedure may be preceded by use of a mechanical thrombectomy device to debulk clot in patients with massive PE.
Endovascular reconstruction of inferior vena cava obstructions
Published in Peter Gloviczki, Michael C. Dalsing, Bo Eklöf, Fedor Lurie, Thomas W. Wakefield, Monika L. Gloviczki, Handbook of Venous and Lymphatic Disorders, 2017
Young Erben, Haraldur Bjarnason
For the procedure, an introducer sheath needs to be used. Coming from the jugular vein, a 45-cm long introducer sheath will habitually extend to the level of the IVC bifurcation. Having the introducer sheath at that level will, in addition to the support, allow simultaneous pressure measurement in the open IVC above the obstructed segment, through the introducer sheath, and from the catheter which has been advanced distally into the open distal “inflow” vein. This gives the pressure gradient across the obstructed segment before the procedure and following angioplasty and stent placement. If access has been gained from the CFV, FV, or popliteal vein, an introducer of a sufficient length to extend to the distal landing zone should be selected. The long introducer will ease repeat exchange of balloons and catheters when an extended segment of partially recanalized FV is crossed on the way to the distal landing zone (CFV).
Venous anatomy and pathophysiology
Published in Helane S Fronek, The Fundamentals of Phlebology: Venous Disease for Clinicians, 2007
The patient is placed in a supine position on an adjustable table for the procedure. Some practitioners elect to provide oral or intravenous sedation. The course of the GSV, from the SFJ to near the knee, is mapped and marked with indelible ink. A patch of nitroglycerin paste on paper tape may be applied to the opposed insertion site prior to the sterile surgical prep to help dilate the vein and prevent venospasm (which can make percutaneous access difficult). The leg is circumferentially cleansed, groin-to-ankle, with antiseptic. Sterile Stockinet may be used to cover the foot, ankle, and distal calf. A split-sheet drape is used to isolate the leg. After infiltration of local anesthetic at the insertion site, under ultrasound guidance, the GSV is accessed with a 19- or 21-gauge needle. Using the Seldinger technique, the introducer sheath is advanced into the vein. A radiofrequency Closure® catheter is advanced, under ultrasound guidance, up to just below the entrance of the superficial epigastric vein into and 2 cm distal to the SFJ. This position is confirmed by ultrasound. Approximately 200 cm3 of 0.1-0.2% lidocaine or another dilute local anesthetic is then injected directly, under ultrasound guidance, into the saphenous compartment from the insertion site up to 2 cm below the SFJ. This solution provides the local anesthetic, protects the surrounding tissues from heat-related damage, and compresses the vein around the catheter electrodes, ensuring complete vein wall treatment. The patient is placed in a moderate Trendelenberg
Percutaneous Transaxillary versus Surgically-Assisted Transsubclavian TAVR: A Single Center Experience
Published in Structural Heart, 2021
Ben Wilkins, Gintautas Bielauskas, Giulia Costa, Motoki Fukutomi, Lars Søndergaard, Ole De Backer
Details of the surgical access technique used for transsubclavian TAVR have been previously reported.7 To summarize, a 5–7 cm long incision just below and parallel to the clavicle was made from the mid-clavicular line to the axillary line. The subclavian artery was isolated by use of two rubber vascular loops passed around its proximal and distal portions and clamped at both ends. Heparin was administered to an activated clotting time (ACT) of <250 sec. A large 18–20 Fr Cook introducer sheath was amputated (10–12 cm length) and connected with the subclavian artery by means of a 15 cm x 8 mm GelweaveTM polyester vascular prosthesis (Vascutek-Terumo, UK) using a so-called “chimney” approach, i.e., the vascular graft was anastomosed (end-to-side) onto a lateral incision on the subclavian artery (at the distal end) and the 10–12 cm long introducer sheath was inserted into the vascular prosthesis and sealed to it by a 2–0 silk suture (at the proximal end). In this way, the introducer sheath did not extend into the subclavian artery and the TAVR device could be inserted and advanced “sheathless” through the subclavian artery. Once the TAVR device was implanted, the graft was clamped with vascular staple clips just above the anastomosis with the subclavian artery, avoiding additional manipulation of the vessel. Following hemostasis, routine surgical wound closure was obtained with an intradermic suture.
Complications of Bioprosthetic Valve Fracture as an Adjunct to Valve-in-Valve TAVR
Published in Structural Heart, 2019
John T. Saxon, Keith B. Allen, David J. Cohen, Brian Whisenant, Jason Ricci, Ilie Barb, Sameer Gafoor, James Harvey, Danny Dvir, Adnan K. Chhatriwalla
The True dilatation balloon is the most common valvuloplasty balloon selected to perform BVF5 due to its rapid inflation and deflation performance as well as its noncompliant design. The Kevlar balloon material is bulky, and has a tendency to deflate unpredictably after valvuloplasty, with residual folding resulting in a high crossing profile. Most commonly, this poses a challenge when withdrawing the True balloon into the introducer sheath, as the residual folds can catch on the edges of the sheath. Importantly, a poorly wrapped balloon can interact with a newly placed THV by catching the edge of the THV. Therefore, any resistance to withdrawal of the balloon or migration of the THV should be addressed by advancing the balloon and performing an additional inflation and deflation, which may improve the rewrapping of the true balloon and facilitate withdrawal. Although THV embolization is less common than during the initial experience with VIV TAVR, this complication can be avoided by careful technique. Furthermore, this complication may be avoided altogether if BVF is performed prior to implantation of the THV.
The Evolut R and Evolut PRO transcatheter aortic valve systems
Published in Expert Review of Medical Devices, 2019
Tawfiq Choudhury, Amir Solomonica, Rodrigo Bagur
The addition of the external wrap results in an increased profile of the device leading to a larger (16-French) EnVeo PRO delivery system, as compared to the 14-French for the EnVeo R (Figure 2). The 16-French (equivalent) EnVeo™ InLine™ sheath requires a minimal vessel diameter of ≥5.5 mm [1] and can be inserted ‘sheathless’, yet, the delivery system including the InLine™ sheath can be used through i.e. a 20-French introducer sheath when access site vessel diameter is not an issue. The EnVeo™ sheath has a significantly smaller outer diameter compared to the sheaths used with the CoreValve; thus, the 14-French (18-French outer diameter) EnVeo™ Inline™ sheathless results in 4-French profile reduction [2]. The EnVeo PRO delivery system also has a 1:1 response allowing for a better control during valve positioning and deployment. Importantly, should balloon-aortic valvuloplasty (BAV) be required and a decision to use the InLine™ sheath has been made, a 12- or 14-French sheath is first needed to perform BAV, then further exchanged for the InLine™ sheath.