High incidence of large bore temporary hemodialysis catheter malfunction in patients with COVID-19 related kidney injury

Purpose: To evaluate the incidence of large bore hemodialysis catheter malfunction in the setting of COVID-19. Materials and methods: A retrospective review was performed of all patients who underwent placement of a temporary hemodialysis catheter after developing kidney injury after COVID-19 infection at our institution. Data collected included demographic information, procedure related information, and incidence of replacement due to lumen thrombosis. Groups were compared using students t-test for continuous variables and Fisher’s exact test for nominal variables. Results: Sixty-four patients (43M, mean age 63.2 ± 13.3) underwent placement of temporary hemodialysis catheter placement for kidney injury related to COVID 19 infection. Thirty-one (48.4%) of catheters were placed via an internal jugular vein (IJV) access and 33 (52.6%) of catheters were placed via a common femoral vein (CFV) access. Overall, 15 (23.4%) catheters required replacement due to catheter dysfunction. There were no differences in demographics in patients who required replacement to those who did not ( p > 0.05). Of the replacements, 5/31 (16%) were placed via an IJV access and 10/33 (30.3%) were placed via a CFV access ( p = 0.18). The average time to malfunction/replacement was 7.8 ± 4.8 days for catheters placed via an IJ access versus 3.4 ± 3.3 days for catheters placed via a CFV access ( p = 0.055). Conclusion: A high incidence of temporary dialysis catheter lumen dysfunction was present in patients with COVID-19 infection. Catheters placed via a femoral vein access had more frequent dysfunction with shorter indwelling time.

Single-Centre Retrospective Study Using Propensity Score Matching Comparing Left Versus Right Internal Jugular Vein Access for Transjugular Intrahepatic Portosystemic Shunt (TIPS) Creation

Purpose To compare the safety and efficacy of left versus right internal jugular vein access for portal vein puncture during transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with a small liver and short vertical puncture distance. Materials and Methods The vertical distance from the hepatic vein orifice to the puncture point of the portal vein was measured by CT and DSA. A distance ≤ 30 mm is defined as a short vertical puncture distance. After 1:1 propensity score matching (PSM), 29 patients of left internal jugular vein-TIPS (LIJ-TIPS) and 29 patients of right internal jugular vein-TIPS (RIJ-TIPS) were included. The number of needle punctures, fluoroscopy time, and radiation dose during the puncture process were statistically analyzed. Results There was no significant difference in the average vertical puncture distances on CT or DSA between LIJ-TIPS and RIJ-TIPS (19.10 ± 0.60 mm vs. 19.30 ± 0.60 mm, P = 0.840; 22.02 ± 0.69 mm vs. 22.23 ± 0.64 mm, P = 0.822, respectively). The average number of needle punctures, fluoroscopy time, and radiation dose in LIJ-TIPS were significantly lower than those in RIJ-TIPS (2.07 ± 0.20 vs. 4.10 ± 0.24, P < 0.001; 78.45 ± 12.80 s vs. 201.16 ± 23.71 s, P < 0.001; 31.55 ± 7.04 mGy vs. 136.69 ± 16.38 mGy, P < 0.001, respectively). Within three punctures, the technical success rate in LIJ-TIPS was significantly higher than that in RIJ-TIPS (86.2 vs. 27.6%, P < 0.001). The incidence of hemoperitoneum in LIJ-TIPS was significantly lower than that in RIJ-TIPS (0% vs. 13.8%, P = 0.038). Conclusion The left internal jugular vein could be used as primary access for TIPS creation in patients with a small liver and short vertical puncture distance.

Ultrasound Guided Brachiocephalic Vein Cannulation using Supraclavicular Approach

The need of central vein cannulation has been increased since the increased case of critical patients and patients underwent high-risk patients. Supraclavicular approach of central vein cannulation is an alternative approach to central vein cannulation due to fewer anatomical variance, good longitudinal vein view, better visualization of needle during procedure, clear demarcation of landmarks, larger target area, better patient comfort, and fewer complications. This case study presents an ultrasound guided central vein cannulation using supraclavicular approach in 30 year old male patient diagnosed with septic shock, anemia, trombcytopenia, and electrolyte imbalance post laparotomy. The indication of central vein cannulation in the patient was to deliver volume resuscitation, to provide emergency vein access, to provide nutritional support, to deliver chemically caustic agents, and central vein pressure monitoring.

26 Procedural planning and tip-to-base lampoon to succeed in a complex valve-in-valve TMVR procedure

Aims Left ventricle outflow tract (LVOT) obstruction is a feared complication of transcatheter mitral valve replacement (TMVR) procedures. Multimodal imaging evaluation is the key to identify at-risk patient and select the best management. Methods and results An 83-year-old woman with a history of mitral valve replacement with a 27-mm Carpentier-Edwards bioprosthesis (Edwards Lifesciences, Irvine, CA) for rheumatic heart disease was admitted to our department complaining worsening effort dyspnoea. Clinical evaluation revealed a grade 3/6 holosystolic murmur. She underwent combined transthoracic and transesophageal echocardiography (TEE) which demonstrated mitral bioprosthesis degeneration leading to severe stenosis (mean gradient = 13 mmHg, PHT-derived area = 0.9 cm2) and moderate regurgitation, with preserved biventricular function, and severe pulmonary hypertension (pulmonary artery systolic pression = 65 mmHg). The patient presented a high estimated risk for redo-surgery (Society of Thoracic Surgeons score estimated mortality: 6%) due to her complex medical history, including advanced chronic kidney disease and permanent atrial fibrillation; therefore, she underwent evaluation for valve-in-valve TMVR. Cardiac computed tomography (CT) revealed bioprosthetic anterior leaflet in tight contact with the septum in systole; predicted neo-LVOT using virtual 26-mm Sapien S3 (Edwards Lifesciences, Irvine, CA) valve was 150 mm2, conferring a high risk of fixed LVOTO. A 26-mm Sapien S3 valve was selected based on CT derived surgical valve ID of 24 mm. After Heart Team discussion, we performed a modified LAMPOON technique to achieve tip-to-base laceration of the bioprosthetic leaflet beside the LVOT, in order to prevent LVOT obstruction. Briefly, after transseptal puncture through right femoral vein access (16 Fr), we crossed the mitral prosthesis using a balloon wedge end-hole catheter, through which we advanced a 300 cm 0.014-inch wire into the ascending aorta, where it was snared from left arterial femoral access (8 Fr) and covered by a micro-catheter. The wire was previously kinked mid-shaft to form a ‘flying-V’ that was focally denuded and positioned at the target bioprosthetic leaflet’s tip using TEE and fluoroscopy. The guidewire was pulled toward the valve ring and electrified at 70 W with continuous 5% dextrose flush until adequate tip-to-base leaflet laceration. Thereafter, we successfully implant a 26-mm Sapien S3 valve. Maximal LVOT gradient post implant was 5 mmHg. The patient was discharged on post-operative day two and she recovered well, reporting functional and symptomatic improvement at 6-month follow-up. Conclusions our case highlights the importance of multimodality imaging and careful procedural planning to succeed even in complex valve-in-valve TMVR procedures. Transcatheter electrosurgery is an emerging tool for percutaneous structural heart interventions.

731 Single centre experience tricuspid valve transcatheter edge to edge repair

Aims Severe tricuspid valve regurgitation (TVR) is critically associated with an increased risk of morbidity and mortality, surgical treatment is limited by high perioperative risk. In these patients, transcatheter edge to edge valve repair (TEER) is progressively recognized as an effective treatment strategy. The aim of this work is to report the single centre experience procedural results and clinical outcomes in ‘real-world’ patients suffering TVR treated with the TriClip™ device (Abbott Vascular, Santa Clara, California). Methods From January up to July 2021, we screened 30 patients with severe TR, among which 8 were treated with TEER. All patients underwent cardiac computerized tomography and both transesophageal and transthoracic echocardiography, with the purpose to identify a dedicated grasping strategy. TEER was performed through right common femoral vein access, advancing a 24 F steerable guiding catheter (SGC) in the right atrium. Following, the TriClip delivery system was advanced and positioned over the valve centroid and, once oriented, the clip was opened. Under fluoroscopic and transesophageal monitoring, the clip was advanced in the right ventricle and pulled back to grasp the target leaflets. Following echocardiographic control, the clip was released. Results Procedural success, defined as a significative reduction of the regurgitation’s severity, was achieved in all patients. No procedural or in-hospital adverse events were reported. At 30 days follow-up, all patients were alive and no further hospitalizations occurred. Conclusions In our single centre experience, TEER appeared to be a valid and feasible therapeutic option in patients with severe TVR. Multicentre prospective studies are mostly needed to assess the long terms outcomes of TEER in these patients, with the purpose to introduce in the clinical practice a valid alternative to the highly risk surgical option.

298 Domiciliary periodic Levosimendan infusions in advanced heart failure: a single centre experience

Aims There are several studies that describes a possible use of periodical infusions of Levosimendan in patients with advance heart failure (AHF). In these studies, Levosimendan was administered in ambulatory settings (LevoRep, LION-HEART) or during 24 h of hospital stay (LAICA) and for a maximum of 12 months. Currently there is no strong evidence about the feasibility and safety of performing the infusions in an out of hospital setting. Aim of our study was to analyse the feasibility and safety of periodical Levosimendan infusions in AHF patients, in an out of hospital setting for palliative use. Methods and results Aretrospective study was conducted from June 2016 to September 2021 on AHF patients, followed by our centre for periodic infusion of Levosimendan. All patients were previously implanted with an ICD, were ineligible for heart transplant or for ventricular assist devices. All patients on each cycle underwent a cardiological evaluation, a blood sample (complete blood count, biochemical profile, coagulation profile, and NTproBNP), and Levosimendan was administrated with a wearable infusion pump (CADD-Legacy®; Smiths Medical). The patient went home and came back the day after, to return the pump and for reassessment. We collected data on the different infusion regimen, adapted for every patient, and on adverse events during infusions. We enrolled 11 patients with AHF, 9 (82%) of which of ischaemic origin, 2 (18%) were female, median age 72 years (IQR: 64–75), 10 with NYHA class III, 1 with a NYHA class IV, for a total of 231 infusions, with a median Follow-up of 459 days (IQR 132; 783). A total dose of 6.25 mg was administered at 0.05 μg/kg/min in 24 h. In five patients the infusion was of 12.5 mg at 0.1 μg/kg/min rate in 24 h and in other three patients at 0.05 μg/kg/min in 48 h. The median interval between administrations was 21 days (IQR: 14–24.5). Mild adverse events (i.e. that did not contraindicate successive cycles) were 7 on 231 infusions (3.0%): symptomatic hypotension (four cases, 1.7%), loss of consciousness (two cases 0.9%), bleeding for vein access misplacement (one case, 0.4%). No serious adverse event such as sustained or malignant arrhythmia, allergic reaction, or need for hospital admission were recorded. Conclusions The administration of Levosimendan at home with a wearable iv pump is safe and well tolerated. This practice allows to reduce infusion costs of day hospital regime and to lengthen the time available for drug infusion, thus reducing the events caused by a too rapid infusion.

«One prick and then it´s done»: a mixed-methods exploratory study on intramuscular injection in heroin-assisted treatment

Background Intramuscular (IM) injection of drugs is associated with high rates of injecting-related injuries and diseases. However, little is known about the role of this route of administration in heroin-assisted treatment. The aim of this study was to determine the prevalence of IM diacetylmorphine administration and associated complications as well as to explore patients’ views and opinions on the topic and the underlying reasons for this practice. Methods The research site was a Swiss outpatient treatment centre specialised in heroin-assisted treatment. We conducted in-depth interviews with two patients who intramuscularly inject diacetylmorphine. Interviews were analysed qualitatively, and emerging themes were used to develop a 38-item questionnaire on IM injections. We then offered this questionnaire to all patients in the treatment centre. Results Five main themes emerged from the in-depth interviews: poor venous access, side effects, subjective effects, procedure for IM injection, and consideration of alternatives to IM. These themes covered the rationale for using this route of administration, complications, subjective effects of IM diacetylmorphine, hygiene and safety measures as well as alternative routes of administration. Fifty-three patients filled in the questionnaire. The lifetime prevalence of IM injections was 60.4% (n = 32) and 34.4% (n = 11) of the patients stated that IM injection was their primary route of administration. No participant reported using the IM route for street drugs. The main reason for IM injections was poor vein access. Other reasons given were time saving and less risk of injuries. Complications included induration of muscle tissue and pain, whereas more severe complications like thrombosis and infections of the injection site were reported much less often. Conclusion As the population of opioid-dependent individuals is aging and the deterioration of access veins is likely to increase, the frequency of IM injecting will equally increase. Even though our data show that the IM injection of diacetylmorphine in a clinical setting is a common practice and appears to be relatively safe, research on alternative routes of administration is needed to provide potentially less harmful alternative routes of administration in heroin-assisted treatment.

Abstract 1122‐000229: Simultaneous Transarterial‐Transvenous Contrast Injection to Reveal Connection Point for Treatment of Carotid Cavernous Fistula

Introduction : Cavernous sinus (CS) via inferior petrosal sinus (IPS) access can present a challenge in the treatment of carotid‐cavernous fistulas (CCF) due to anatomical variations, tortuosity, and/or difficult visualization of IPS given high retrograde flow through the fistulous connection. Methods : A 58‐year‐old male was referred to our academic medical center for three weeks of right eye pain, now complicated by redness, diplopia and blurry vision. Magnetic Resonance Imaging (MRI) brain at the outside hospital revealed hemorrhagic lesion in right parietotemporal region. Computerized tomography‐angiogram (CTA) of the head revealed filling of cavernous sinus during an arterial phase suspicious for CCF. Under general anesthesia, after accessing right common femoral artery, 4 French (F) cook catheter (Cook Medical LLC, Bloomington, IN) was advanced over 0.035 angled glide wire to the proximal right internal carotid artery. Contrast injected through the ICA showed the CS but not the IPS (Fig. 1A). Through the left common femoral vein, access was obtained using an Infinity guide catheter (Stryker Neurovascular, Fremont, CA) and Catalyst 5 (Stryker Neurovascular, Fremont, CA) distal access catheter. A Synchro 2 soft microwire (Stryker Neurovascular, Fremont, CA) was advanced through Echelon 10 (Medtronic, Minneapolis, MN) microcatheter. The venous guide catheter was advanced into right internal jugular vein (IJV) and the distal access catheter was placed into sigmoid jugular junction. Injection of contrast revealed the IPS, but not the CS (Fig. 1B). A subsequent simultaneous hand injection with the microcatheter within the IPS and the diagnostic catheter in the left ICA elucidated the venous‐venous connection (Fig. 1C,) allowing for subsequent navigation and complete treatment of the fistula through IPS using target coils (Fig. 1D). Results : Given the arterial system is a high‐pressure system and the usual direction of flow of contrast would be from the high‐pressure ICA to the low‐pressure CS, injecting a simultaneous contrast bolus from the venous end would oppose the arterial contrast flow. As a result, the fistulous connection that was previously obscured became visible allowing roadmap imaging guiding navigation into the CS. Conclusions : Use of simultaneous trans‐arterial/trans‐venous contrast injection is relatively simple compared to other reported techniques to reveal an obscure connection point. It also shortens the duration of endovascular tools in the bloodstream and thus, reduces the potential complication rate. Further use of this technique on larger study samples is important to validate its general use.