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OBJECTIVE: In patients with a need for frequent but intermittent apheresis, vascular access can prove challenging. We describe the migration of the use of a Vortex LP dual lumen port (Angiodynamics, Latham, NY) to one Powerflow and one ClearVUE power injectable port (Becton Dickinson, Franklin Lakes, NJ) in a series of patients undergoing intermittent apheresis.
METHODS: All patients had a need for long-term intermittent apheresis. Eight had double lumen Vortex port (pre) and were exchanged for one Powerflow port and one conventional subcutaneous venous port with 90° needle entry (post) while 12 did not have any port in place and received the same configuration. IRB approval was granted. We recorded the treatment time, flow rate, and tissue plasminogen activator (tPA) use for five treatment sessions after placement. When available, we compared five treatments with the Vortex port and the new configuration.
RESULTS: The mean treatment time is reduced with the new configuration (P = 0.0033). The predicted mean treatment time, adjusting for gender, race, BMI and age and accounting for correlations within a patient is 91.18 min pre and 77.96 min post. The flow rate is higher with the new configuration (P < 0.0001). The predicted mean flow rate in mL/min is 61.59 for the Vortex port and 71.89 for the new configuration. tPA use was eliminated in the population converted from Vortex ports and had a 48% reduction when compared to all other configurations in the study.
CONCLUSIONS: The introduction of a novel device configuration of venous access ports for intermittent apheresis resulted in higher flow rates and less total time for treatment. Use of tPA was greatly reduced. These results suggest that the new configuration could result in less expense for the hospital and better throughput in a busy pheresis practice. Clinical trial registration with ClinicalTrials.gov: NCT04846374.

OBJECTIVE: Right heart catheterization (RHC) is a common diagnostic tool and of special importance in the diagnosis of pulmonary hypertension (PH). Until today, there have been no clear instructions or guidelines on which venous access to prefer. This meta-analysis assessed whether the choice of the venous access site for elective RHC has an impact on procedural or clinical outcomes.
METHODS: A structured literature search was performed. Single-arm reports and controlled trials reporting event data were eligible. The primary endpoint was a composite of access-related and overall complications.
RESULTS: Nineteen studies, including 6509 RHC procedures, were eligible. The results were analyzed in two groups. The first group compared central venous access (CVA; n = 2072) with peripheral venous access (PVA; n = 2680) and included only multi-arm studies (n = 12, C/P comparison). In the second group, all studies (n = 19, threeway comparison) were assessed to compare the three individual access ways. The overall complication rate was low at 1.0% (n = 68). The primary endpoint in the C/P comparison occurred significantly less for PVA than for CVA (0.1% vs. 1.2%; p = 0.004). In the threeway comparison, PVA had a significantly lower complication rate than femoral access (0.3% vs. 1.1%; p = 0.04). Jugular access had the numerically highest complication rate (2.0%), but the difference was not significant compared to peripheral (0.3%; p = 0.29) or femoral access (1.1%; p = 0.32).
CONCLUSIONS: This meta-analysis showed that PVA for RHC has a significantly lower complication rate than CVA. There was a low level of certainty and high heterogeneity. This pooled data analysis indicated PVA as the primary venous access for RHC.

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.

In pediatric patients, the choice of the venous access device currently relies upon the operator\'s experience and preference and on the local availability of specific resources and technologies. Though, considering the limited options for venous access in children if compared to adults, such clinical choice has a great critical relevance and should preferably be based on the best available evidence. Though some algorithms have been published over the last 5 years, none of them seems fully satisfactory and useful in clinical practice. Thus, the GAVePed-which is the pediatric interest group of the most important Italian group on venous access, GAVeCeLT-has developed a national consensus about the choice of the venous access device in children. After a systematic review of the available evidence, the panel of the consensus (which included Italian experts with documented competence in this area) has provided structured recommendations answering 10 key questions regarding the choice of venous access both in emergency and in elective situations, both in the hospitalized and in the non-hospitalized child. Only statements reaching a complete agreement were included in the final recommendations. All recommendations were also structured as a simple visual algorithm, so as to be easily translated into clinical practice.

BACKGROUND: Establishing peripheral vein access is challenging for pediatric residents and a painful procedure for neonates. We assessed the efficacy of a red light-emitting diode transilluminator during peripheral vein catheter insertion performed by pediatric residents.
METHODS: Patients were stratified by current weight (≤1,500 g, >1,500 g) and randomized to the transillumination or the control group. The first three attempts were performed by pediatric residents, followed by three attempts by a neonatologist. The primary outcome was success at first attempt. Secondary comparisons included time to successful insertion and overall success rates of residents and neonatologists.
RESULTS: A total of 559 procedures were analyzed. The success rate at resident\'s first attempt was 44/93 (47%) with transillumination versus 44/90 (49%) without transillumination (p = 0.88) in the strata ≤1,500 g and 103/188 (55%) with transillumination versus 64/188 (34%) without transillumination in the strata >1,500 g (p < 0.001). The overall success rate for residents was 86% in the transillumination versus 73% in the control group in the strata >1,500 g (p = 0.003) but not different in the strata ≤1,500 g (78/93 [84%] vs. 72/90 [80%], p = 0.57). There was no effect when the experience level of residents exceeded 6 months. Neonatologists\' overall success rate and time to successful cannulation did not differ significantly in both weight strata.
CONCLUSIONS: Transillumination improves the first-attempt success rate of peripheral vein cannulation performed by pediatric residents in neonates >1,500 g, while no benefit was found in infants ≤1,500 g.

OBJECTIVE: In the trans-radial era, arm venous access for right heart catheterization (RHC) is rising. Procedural success is affected by many factors, including subclavian/innominate vein stenosis (SVS) and pre-existing wires or catheters. In a study published previously by the same authors, 2% of cases had unsuccessful RHC through the arm, predominantly due to SVS. Since that study, techniques to improve RHC success rates have been developed, including crossing the stenosis with a coronary guidewire, followed by balloon dilatation. We aimed to determine whether subclavian/innominate venoplasty allows successful RHC in patients with SVS.
METHODS: Our retrospective study included patients who had RHC from the arm between November 1, 2019, and December 31, 2022 that was unsuccessful due to the inability to pass a catheter through the SVS, and then underwent balloon venoplasty. The success rate of completed RHC was then assessed.
RESULTS: Out of 2506 RHCs via arm access, 2488 were successful with a catheter alone or over a guidewire. In 18 patients, venoplasty was needed for catheter passage over a guidewire. Post-dilatation, all 18 cases (100%) had successful RHC with a mean procedural time of 35.2 (SD = 15.5) minutes. The most common stenosis site was the subclavian vein in 13 patients (72.2%), and 12 patients (66.7%) had pacemaker/ implantable cardioverter defibrillator wires present.
CONCLUSIONS: Balloon dilatation of SVS is an efficacious method to improve the success rate of RHC from the arm. It is a safe technique that may prevent cross-over to a different access site, thereby improving patient satisfaction and reducing the possibility of alternate site complications.

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.

BACKGROUND: Obtaining vascular access is crucial in critically ill patients. The EZ-IO® device is easy to use and has a high insertion success rate. Therefore, the use of intraosseous vascular access (IOVA) has gradually increased.
OBJECTIVE: We aim to determine how IOVA was integrated into management of vascular access during out-of-hospital cardiac arrest (OHCA) resuscitation.
METHODS: Analysing the data from the OHCA French registry for events occurring between 1 January 2013 and 15 March 2021, we studied: demography, circumstances of occurrence and management including vascular access, delays and evolution. The primary outcome was the rate of IOVA implantation.
RESULTS: Among the 7156 OHCA included in the registry, we analysed the 3964 (55%) who received cardiopulmonary resuscitation. The vascular access was peripheral in 3122 (79%) cases, intraosseous in 775 (20%) cases and central in 12 (<1%) cases. The use of IOVA has increased linearly (R2  = 0.61) during the 33 successive trimesters studied representing 7% of all vascular access in 2013 and 33% in 2021 (p = 0.001). It was significantly more frequent in traumatic cardiac arrest: 12% versus 5%; p < 0.0001. The first epinephrine bolus occurred significantly later in the IOVA group, at 6 (4-10) versus 5 (3-8) min; p < 0.0001. Survival rate in the IOVA group was significantly lower, at 1% versus 7%; p < 0.0001.
CONCLUSIONS: The insertion rate of IOVA significantly increased over the studied period, to reach 30% of all vascular access in the management OHCA patients. The place of the intraosseous route in the strategy of venous access during the management of prehospital cardiac arrest has yet to be determined.

BACKGROUND: Central line-associated bloodstream infections are a major concern for children with intestinal failure and in animal research using parenteral nutrition (PN). In neonatal piglets receiving PN, we compared sepsis, line occlusions, line replacements, mortality, and costs with and without the use of a 4%-tetrasodium ethylenediaminetetraacetic acid (T-EDTA) locking solution.
METHODS: We performed a retrospective review of piglets with a central venous jugular catheter enrolled in 14-day exclusive PN (TPN) trials or in 7-day short bowel syndrome (SBS) trials, before and after initiation of T-EDTA. Lines were locked with a 1-ml solution for 2 h daily (T-EDTATPN, n = 17; T-EDTASBS, n = 48) and compared with our prior standard of care using 1.5-ml heparin flushes twice daily (CONTPN, n = 34; CONSBS, n = 48). Line patency and signs of sepsis were checked twice daily. Jugular catheters were replaced for occlusions whenever possible. Humane end points were used for sepsis not responding to antibiotic treatment or unresolved catheter occlusions.
RESULTS: Compared with CON, sepsis was reduced using T-EDTA, significantly for TPN (P = 0.006) and with a trend for SBS piglets (P = 0.059). Line occlusions necessitating line changes were reduced 15% in TPN studies (P = 0.16), and no line occlusions occurred for T-EDTA SBS piglets.
CONCLUSIONS: In our neonatal piglet research, use of T-EDTA locking solution decreased sepsis and, although not statistically significant, reduced occlusions requiring line replacements. Given the expense of animal research, adding a locking solution must be cost-effective, and we were able to show that T-EDTA significantly reduced total research costs and improved animal welfare.