Vascular hemostasis after venous and arterial access in cardiovascular procedures remains a challenge. As sheath size gets larger for structural heart and vascular procedures, no dedicated closure devices exist that can overcome all the challenges of achieving vascular hemostasis, in particular on the venous side. Efficiently and reliably ensuring hemostasis at the access point is crucial for enhancing the safety of a procedure. Historically, hemostasis relied on manually compressing venous access sites. However, the shift towards larger sheaths and the more frequent use of continuous anticoagulation has strained this approach. Achieving hemostasis solely through compression in these scenarios demands heightened vigilance and prolonged application, resulting in increased patient discomfort and extended immobility. Consequently, manual compression may consume more time for healthcare providers and contribute to bed occupancy in hospitals. This review article summarizes the development of the SiteSeal® Vascular Closure Device, a novel leave-nothing-behind approach to achieve hemostasis. The introduction of this technology has provided clinicians with a safer and more effective way to achieve immediate hemostasis, facilitate early ambulation, and enable earlier discharges with fewer access site complications compared with traditional manual compression.

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BACKGROUND: Peripherally inserted central catheters (PICCs) and new type of arm-port, the PICC-port, are currently used for neoadjuvant chemotherapy treatment in patients with breast cancer. We aimed to compare Quality of Life (QoL) of patients receiving one of these two devices investigating overall satisfaction, psychological impact, as well as the impact on professional, social and sport activities, and local discomfort.
METHODS: We did a prospective observational before-after study of PICCs versus PICC-ports. Adult (aged ≥ 18 years) females with breast cancer candidate to neoadjuvant chemotherapy were included. The primary outcome was QoL according to the Quality-of-Life Assessment Venous Device Catheters (QLAVD) questionnaire assessed 12 months after device implantation.
RESULTS: Between May 2019 and November 2020, of 278 individuals screened for eligibility, 210 were enrolled. PICC-ports were preferred over PICCs with a QLAVD score of 29 [25; 32] vs 31 [26; 36.5] (p = 0.014). Specifically, most QLAVD constructs related to psychological impact, social aspects, and discomfort were in favor of PICC-ports vs PICC, especially in women under the age of 60. Overall, pain scores at insertion and during therapy administration were not significantly different between the two groups, as well as infection, secondary malpositioning, thrombosis, or obstruction of the device.
CONCLUSIONS: In women with breast cancer undergoing neoadjuvant chemotherapy, PICC-ports were overall better accepted than PICCs in terms of QoL, especially in those who were younger. Device-related complications were similar.

OBJECTIVE: Dual-lumen cannulas for veno-venous (VV) extracorporeal membrane oxygenation (ECMO) support are typically inserted in the right internal jugular vein (RIJV); however, some scenarios can make this venous route inaccessible. This multicentre case series aims to evaluate if single-site cannulation using an alternative venous access is safe and feasible in patients with an inaccessible RIJV.
METHODS: We performed a multi-institutional retrospective analysis including high-volume ECMO centres with substantial experience in dual-lumen cannulation (DLC) (defined as >10 DLC per year). Three centres [Freiburg (Germany), Toronto (Canada) and Vienna (Austria)] agreed to share their data, including baseline characteristics, technical ECMO and cannulation data as well as complications related to ECMO cannulation and outcome.
RESULTS: A total of 20 patients received alternative DLC for respiratory failure. Cannula insertion sites included the left internal jugular vein (n = 5), the right (n = 7) or left (n = 3) subclavian vein and the right (n = 4) or left (n = 1) femoral vein. The median cannula size was 26 (19-28) French. The median initial target ECMO flow was 2.9 (1.8-3.1) l/min and corresponded with used cannula size and estimated cardiac output. No procedural complications were reported during cannulation and median ECMO runtime was 15 (9-22) days. Ten patients were successfully bridged to lung transplantation (n = 5) or lung recovery (n = 5). Ten patients died during or after ECMO support.
CONCLUSIONS: Alternative venous access sites for single-site dual-lumen catheters are a safe and feasible option to provide veno-venous ECMO support to patients with inaccessible RIJV.

UNASSIGNED: Education and training is core to improving peripheral intravenous access outcomes. This study aimed to show that a vascular access training program (Operation STICK) in the emergency department (ED) improves the outcomes of traditionally placed peripheral intravenous catheters (PIVC).
UNASSIGNED: This was a pre-post quasi-experimental study of traditionally placed PIVCs at a large ED in southeastern Michigan, United States. A control group (non-OSTICK) was compared to an experimental group (OSTICK) using a 3:1 propensity score matched analysis. Groups were comprised of ED patients with traditional PIVC placements in two separate six-month periods: non-OSTICK PIVCs from April to September 2021 and OSTICK PIVCs (placed by an OSTICK graduate) from October 2022 to March 2023. The primary outcome was PIVC functionality. The secondary outcome was adherence to best practices.
UNASSIGNED: A total of 6512 PIVCs were included in the study; 4884 (75.0%) were in the non-OSTICK group, while 1628 (25.0%) were in the OSTICK group. 68.1% of OSTICK PIVCs and 59.7% of non-OSTICK PIVCs were placed by ED technicians (p < 0.001). 91.3% of OSTICK PIVCs were placed on the first attempt, and 98.5% were placed within two attempts. A subgroup analysis of admitted patients (2540 PIVCs; 553 (21.8%) OSTICK-trained and 1987 (78.2%) non-OSTICK-trained) revealed 87.6% of OSTICK PIVCs and 80.3% of non-OSTICK PIVCs were 20 gauge (p < 0.001). The median proportion of dwell time to hospital length of stay was 94% for OSTICK PIVCs, compared to 88% for non-OSTICK PIVCs (p < 0.001).
UNASSIGNED: This study underscores the value of education and training in enhancing vascular access outcomes. Implementing Operation STICK, a comprehensive vascular access training program, at a large ED has led to high first-stick success, adherence to best practice recommendations for site and device selection, and improved PIVC functionality for traditionally placed catheters.

BACKGROUND: Venous access devices commonly used in clinical practice for long-term chemotherapy of breast cancer include central venous catheters (CVCs), peripherally inserted central venous catheters (PICCs), and implantable venous access ports (IVAPs). CVCs and PICCs are less costly to place but have a higher complication rate than IVAPs. However, there is a lack of cost-utility comparisons among the three devices. The aim of this study was to assess the cost-effectiveness of three catheters for long-term chemotherapy in breast cancer patients.
METHODS: This study used propensity score matching (PSM) to establish a retrospective cohort. Decision tree models were used to compare the cost-effectiveness of three different intravenous lines in breast cancer chemotherapy patients. Cost parameters were derived from data extracted from the outpatient and inpatient charging systems, and total costs included costs of placement, maintenance, extraction, and handling of complications; utility parameters were derived from previous cross-sectional survey results of the research group; and complication rates were derived from breast cancer catheterization patient information as well as follow-up information. Quality-adjusted life years (QALYs) were measured for efficacy outcomes. Incremental cost-effectiveness ratios (ICERs) were used to compare the three strategies. To assess uncertainty in model parameters, sensitivity analyses (univariate sensitivity analysis and probabilistic sensitivity analysis) were performed.
RESULTS: A total of 10,718 patients (3780 after propensity score matching) were included. IVAPs had the smallest cost-utility ratio, and PICCs had the largest cost-utility ratio when left in place for more than 12 months. The incremental cost-utility ratio of PICC to CVC was $2375.08/QALY, IVAP to PICC was $522.01/QALY, and IVAP to CVC was $612.98/QALY. Incremental cost-effectiveness ratios showed that IVAPs were more effective than CVCs and PICCs. Model regression analysis showed that the IVAP was recommended as the best regimen regardless of the catheter indwelling time (6 months, 12 months or more than 12 months). The reliability and stability of the model were verified by single-factor sensitivity analysis and Monte Carlo simulation (probabilistic sensitivity analysis).
CONCLUSIONS: This study provides economic evidence for the selection of vascular access in breast cancer chemotherapy patients. In the case of limited resources in China, establishing a decision tree model comparing the cost-effectiveness of three vascular access devices for breast cancer chemotherapy patients determined that the IVAP was the most cost-effective regimen.

UNASSIGNED: Teaching ultrasound (US) guidance for placement of peripheral intravenous (PIV) catheters requires significant time for synchronous didactic and hands-on training. The investigators assessed the feasibility of an asynchronous model for critical care nurses to learn the novel skill of US-guided PIV placement. Secondary outcomes included the percentage of successful attempts and number of sticks per attempt for anatomy versus US-guided approaches.
UNASSIGNED: The investigators built a self-contained training cart for learners to practice and record their performance. Training occurred asynchronously. The learners recorded data from PIV attempts. Participants completed pre- and post-training surveys. Data from this prospective observational cohort was analyzed for descriptive and comparative statistics, using Kirkpatrick\'s Model for evaluation of this educational intervention.
UNASSIGNED: During a 6 month period, 21 nurses completed the asynchronous training, with eight recording their PIV placements. 81.0% of the training occurred outside of a Monday to Friday 9AM-5PM period. There were 64 attempts by anatomy approach and 84 with US-guidance. The anatomic approach was successful in 35.9% of attempts with a mean of 1.5 sticks (SD 1.0, Range 1-5). The US-guided approach had a statistically significant greater rate of success (77.4%; p < 0.001) with a mean of 1.2 sticks (SD 1.2, range 1-2, p < 0.01). Participants reported increased confidence in US-guided PIV placement and enjoyment with this method of learning.
UNASSIGNED: Asynchronous learning model with cart-based instruction and practice is a feasible means for nurses to learn US-guided PIV placement. Significant outcomes were seen across Kirkpatrick levels I-IV for educational outcome assessment.

Parenteral nutrition administered via central venous catheter is an established treatment option for people with intestinal failure. A serious complication of central venous catheters is the high risk of catheter-related bloodstream infections (CRBSIs). Catheter-locking solutions are one strategy for CRBSI prevention, with the solution taurolidine showing beneficial effects. The aim of this meta-analysis was to identify and synthesize evidence to assess taurolidine efficacy against comparators for the prevention of CRBSI for people with intestinal failure receiving parenteral nutrition.
Six health literature databases were searched for efficacy data of rate of CRBSI for taurolidine vs control among our study population; no study design limits were applied. Individual study data were presented for the number of CRBSIs and catheter days, and rate ratio. Overall data were synthesized as a pooled risk ratio, with subgroup analyses by study design, control type, and taurolidine solution.
Thirty-four studies were included in the final analysis. At the individual level, all studies showed superior efficacy of taurolidine vs control for prevention of CRBSIs. When the data were synthesized, the pooled risk ratio was 0.49 (95% CI, 0.46-0.53; P ≤ 0.0001), indicating a 51% decreased risk of CRBSI through the use of taurolidine. Subgroup analysis showed no difference depending on study design (P = 0.23) or control type (P = 0.37) and a significant difference for taurolidine type (P = 0.0005).
Taurolidine showed superior efficacy over controls regardless of study design or comparator group. The results show that taurolidine provides effective CRBSI reduction for people with intestinal failure receiving parenteral nutrition.

OBJECTIVE: The cephalic vein cutdown (CVC) and the subclavian puncture (SP) is the most common access for pacemaker implantation. The purpose of this study was to compare the peri-/postoperative complications of these approaches.
METHODS: A retrospective analysis of the quality assurance data of the state of North Rhine-Westphalia was performed to evaluate the peri-/postoperative complications of first pacemaker implantation according to the venous access. The primary endpoint was defined as the occurrence of one of the following: asystole, ventricular fibrillation, pneumothorax, hemothorax, pericardial effusion, pocket hematoma, lead dislocation, lead dysfunction, postoperative wound infection or other complication requiring intervention. Descriptive analysis was done via absolute, relative frequencies and Odds Ratio. Fisher\'s exact test was used for comparison of the both study groups.
RESULTS: From 139,176 pacemaker implantations from 2010 to 2014, 15,483 cases were excluded due to other/double access. The median age was 78 years and the access used was CVC for 75,251 cases (60.8%) and SP for 48,442 cases (39.2%). The implanted devices were mainly dual-chamber pacemakers (73.9% in the CVC group and 78.4% in the SP group), followed by single-chamber pacemakers VVI (24.9% and 19.9% in the CVC and SP group respectively). There were significantly fewer peri/postoperative complications in the CVC group compared to the SP group (2.49% vs. 3.64%, p = 0.0001, OR 1.47; 95% CI 1.38-1.57).
CONCLUSIONS: CVC as venous access for pacemaker implantation has significantly fewer peri/postoperative complications than SP and appears to be an advantageous technique.

OBJECTIVE: Osteogenesis imperfecta (OI) is a genetic disorder that causes skeletal fragility. For the most fragile infants and young children with OI, intravenous (IV) bisphosphonate administration is essential, but IV access attempts often cause fractures. Port-a-caths help prevent these events, but some surgeons are hesitant to insert these devices in these infants due to lack of data on their safety.
METHODS: Retrospective study of pediatric patients with OI who underwent port-a-cath placement from 1999 to 2018; incidence of complications such as infection and thrombosis and need for reoperation or replacement are described.
RESULTS: Port-a-caths were placed in 17 patients with OI (median age, 8 mos [5-23 mos]; median weight, 5.8 kg [3.96-9.08 kg]) and remained in place for a median of 53.5 mos (10-127 mos). One port-a-cath was replaced because of thrombosis. Two port-a-caths were removed because of malfunction, one for skin erosion, and one for infection. In these five cases, replacement was not needed because patients could safely tolerate IV access. Two patients have their port-a-cath in place and the remaining ten patients had theirs removed electively as it was no longer needed.
CONCLUSIONS: Port-a-cath placement in pediatric patients with OI is safe and efficacious for durable central access, enabling reliable IV bisphosphonate delivery and reducing iatrogenic trauma.