Percutaneous transvenous retrieval of intracardiac port-a-cath catheter fragment: a case report

A female patient, 36 years of age, with a metastasised left breast cancer received several courses of chemotherapy for aggressive local tumour growth and multiple metastatic activity. In the current patient, surgical ablation of the left breast was carried out. Also loco-regional radio-therapy was conducted. To facilitate the administration of chemotherapy courses and prevent thrombophlebitis a vascular access port (port-a-cath) was surgically inserted via the right subclavian vein. After a few successful administrations of chemotherapeutic drugs the vascular port stopped functioning. It was demonstrated that a detached catheter fragment had dislodged into the right ventricle. Successful percutaneous, transvenous removal of the entrapped catheter fragment by the Gooseneck retrieval loop snare from the right ventricle was performed via the right femoral vein access. The procedure was uncomplicated and the patient tolerated the procedure well.     

Indwelling catheter and vanishing intracardiac mass

A 36-year-old male was admitted for painful swelling of his right upper extremity. He had had an indwelling port-a-cath placed in his right subclavian vein eight months prior to admission. On admission the patient was afebrile and his vital signs were normal. His right upper extremity was swollen, erythematous and tender. Blood leucocyte count was normal and D-Dimer was elevated. Venous Doppler examination showed partial thrombosis of the distal right subclavian vein. Removal of the port-a-cath by interventional radiology was scheduled.     

The YUMIKO catheter: a useful tool for angiography of the right internal mammary artery via a right brachial approach

The YUMIKO catheter (Goodman, Nagoya, Japan) was recently developed for a left internal mammary artery (IMA) angiography with a right radial or brachial approach. The present authors experienced an interesting case where the YUMIKO catheter was useful for a right IMA angiography via a right brachial artery. A 53-year-old man with bilateral IMA grafts underwent follow-up coronary angiography via a right brachial artery. Native coronary artery and left IMA angiography were performed without difficulty using the Judkins Right and Left and YUMIKO catheters. Angiography of the right IMA was attempted with the Judkins Right catheter and IMA catheter, resulting in a nonselective angiogram with poor imaging. The YUMIKO catheter, however, enabled smooth cannulation to the right IMA and provided good images of the selective right IMA angiography.     

QRS alternans during right ventricular pacing while ablating a concealed left sided accessory pathway

A 16-year-old boy was referred for an electrophysiological study for documented regular narrow complex tachycardia. A diagnosis of a concealed left lateral accessory pathway was made with an eccentric atrial activation sequence both during tachycardia and right ventricular (RV) pacing. The pathway was mapped at the left posterior mitral vestibule during RV pacing, performed through the distal tip of the His bundle catheter pushed into right ventricular outflow tract. An unusual response to ventricular stimulation with alternation of QRS complex width and morphology was noted. The possible mechanisms are hereby discussed.     

The effect of growth hormone on biogenic amines in the hepatic portal circulation of the dog

The effects of a spike concentration of growth hormone (GH) on hepatic portal and peripheral levels of free serotonin and catecholamines were studied by improved radioenzymatic methods in trained, conscious, normal, adult dogs fitted with an indwelling portal catheter. An injection of ovine GH (6 or 100 micrograms/kg) into a cephalic vein produced in the hepatic portal circulation a transient, statistically significant rise of serotonin and a concomitant significant reduction in the concentration of dopamine, norepinephrine, and epinephrine. No change was found in the peripheral circulation, partly because the amines were conjugated to sulfates and glucuronides and these derivatives are not detectable by our assays. Thus, a pulse of GH not only stimulates the release of pancreatic hormones and glucose turnover, but also affects the portal profile of glucoregulatory bioamines. The present investigation lends further support to our view that the splanchnic area represents an endocrine system whose preferential target is the liver.     

Intermittent sampling of portal venous blood and bile from guinea pigs

A technique is described for intermittent collection of portal venous blood from guinea pigs through a catheter advanced from an ileal tributary of the cranio-mesenteric vein into the portal vein and for the collection of bile from a catheter in the gallbladder after ligature obstruction of the common bile duct.     

Intrahepatic ramification of the portal vein in the right and caudate lobes of the liver

We defined the subsegmental divisions and the ramification patterns of the portal vein in the right and caudate lobes using 25 human liver casts. The ramifications of the portal vein and the subdivisions of the liver were classified based on the major portal veins with the largest diameter and those having a diameter of not less than two thirds of the largest vein in each subsegment. The following results were obtained. (1) The portal trunk showed three ramification patterns and the basic pattern was bifurcation (80%). (2) The anterior portal vein first ramified into several anterior-inferior portal veins (P5) and ran toward the superior direction to bifurcate into 2 major portal veins in the anterior-superior subsegment (S8). (3) There were three types of ramification patterns of the portal veins in S8: bifurcation (84%), trifurcation and one-pedicle type. (4) There were also three branching types of the largest vein (P5-max) in P5: ramification from the anterior portal vein, P8-anterior vein supplying the anterior region of S8 and P8-posterior vein supplying the posterior region of S8. (5) The posterior portal vein showed two ramification patterns of the bifurcation (36%) and nonbifurcation type. (6) The major portal veins in the caudate subsegment ramified at various sites such as the portal trunk, left, right and/or other portal veins.     

Long-Term Catheterization of the Intestinal Lymph Trunk and Collection of Lymph in Neonatal Pigs

Catheterization of the intestinal lymph trunk in neonatal pigs is a technique allowing for the long-term collection of large quantities of intestinal (central) efferent lymph. Importantly, the collection of central lymph from the intestine enables researchers to study both the mechanisms and lipid constitutes associated with lipid metabolism, intestinal inflammation and cancer metastasis, as well as cells involved in immune function and immunosurveillance. A ventral mid-line surgical approach permits excellent surgical exposure to the cranial abdomen and relatively easy access to the intestinal lymph trunk vessel that lies near the pancreas and the right ventral segment of the portal vein underneath the visceral aspect of the right liver lobe. The vessel is meticulously dissected and released from the surrounding fascia and then dilated with sutures allowing for insertion and subsequent securing of the catheter into the vessel. The catheter is exteriorized and approximately 1 L/24 hr of lymph is collected over a 7 day period. While this technique enables the collection of large quantities of central lymph over an extended period of time, the success depends on careful surgical dissection, tissue handling and close attention to proper surgical technique. This is particularly important with surgeries in young animals as the lymph vessels can easily tear, potentially leading to surgical and experimental failure. The video demonstrates an excellent surgical technique for the collection of intestinal lymph.     

Blood flow measurements by the reference sample method with microsphere injection in to the aorta: an accurate and easy approach.

The validity of hemodynamic measurements by the reference sample method with microspheres injection into the aorta, via a carotid artery catheter, was evaluated in rats and compared with the results obtained after left ventricle injection. In the aorta injection group, a good mix of microspheres was observed in 83% of the animals. Moreover, a symmetrical distribution of microspheres was observed in 10 out of 12 rats (83%). An excellent correlation between right and left kidney-testes blood flows was observed (r = 0.93 and 0.96, respectively; P less than 0.01). Mean arterial pressure was not modified during microspheres injection into the aorta. Cardiac output (104 +/- 26 vs 101 +/- 23 ml/min, NS) and portal blood flow (14.2 +/- 3.3 vs 13.5 +/- 2.2 ml/min, NS) were similar after aorta and left ventricle injections series, respectively. Our results indicate that the injection of microspheres into the aorta is an adequate and easy approach to systemic and splanchnic hemodynamic measurements. This approach could be a good alternative to left ventricle injection of microspheres in experimental studies in rats.     

Simultaneous sampling of portal, hepatic and systemic blood during intragastric loading and tracer infusion in conscious pigs

A surgical model for catheterization at multiple sites has been developed for use in long-term metabolic studies. For blood sampling, catheters were inserted into the portal and hepatic veins and the common carotid artery. The hepatic vein catheter was inserted from the margin of a liver lobe and led through the venous system, until the tip was close to the bifurcation with the inferior vena cava. A new technique was developed to ensure correct placement of the hepatic vein catheter using the specific extraction of indocyanin-green over the liver during surgery. Gastrostomy was performed using a Pezzer catheter. Catheters in the artery and hepatic and portal veins were patent for blood withdrawal for up to 4 weeks, and thus allowed repeated metabolic studies. Studies were performed in conscious animals familiar with the experimental situation.     

Somatostatin mediates the effect of growth hormone surges on splanchnic biogenic amines

Experiments were conducted in trained, conscious dogs fitted with an indwelling portal catheter. Radioenzymatic methods were employed for the quantitative measurement of plasma-free serotonin and catecholamines. An injection of ovine growth hormone (GH, 100 micrograms/kg) or an equimolar amount of somatostatin (somatotropin release inhibitory factor, SRIF, 7.5 micrograms/kg) into a saphenous vein led, within the first 15 min, to a transient but significant increase in plasma serotonin and a decrease in the concentrations of dopamine, norepinephrine, and epinephrine. The changes were frequently in excess of 40% of baseline values, and were found only in the portal and not in the peripheral circulation. When the animals were pretreated with an antiserum specifically directed against SRIF, GH surges no longer caused alterations in the portal levels of biogenic amines. Thus, the effects of spike concentrations of GH on plasma serotonin and catecholamines are apparently mediated by SRIF, a novel and unexpected function for a hormone that is known as an inhibitor of GH secretion.     

Implantable device for drug delivery and blood sampling in the rat

An implantable drug-delivery and venous sampling device is described that is constructed from a polyvinyl chloride catheter and a rubber intravenous catheter plug coated with Silastic. The implant was used for repeated venous sampling and for both administration of parenteral solutions and injections into the right colon of the rat for periods to 1 mo.     

The right ventricular working heart preparation

An isolated working rat heart preparation was modified to study right ventricular (RV) performance. All hearts were perfused with a Krebs-Henseleit bicarbonate buffer via a Langendorff column at 90 mm Hg. Right atrial filling (preload) was varied by raising a buffer reservoir from 5 cm below to 10 cm above the right atrium while pulmonary artery outflow resistance remained fixed. RV systolic pressure and the maximum rise and decrease in pressure development (+/- dP/dt) were measured via a catheter in the RV. Cardiac output was collected with a catheter placed in the pulmonary artery. One group of hearts, monitored at a fixed preload (0 cm H2O) for 2 hr, and another group of hearts, in which two ventricular function curves were performed, demonstrated the stability and reproducibility of the preparation. Additionally, the ability of this preparation to measure changes in inotropy was studied. A negative inotropic effect was measured after verapamil (5 X 10(-8) M) treatment. Positive dP/dt showed the greatest depression (30%) and was significantly lower at every preload. A positive inotropic effect was demonstrated by reducing the buffer Ca2+ concentration to 1.9 mM for the first work curve followed by an addition of Ca2+ (2.8 mM final concentration) or ouabain (5 X 10(-5) M) for the second work curve. Again, the greatest effect was found in the dP/dt measurements (elevated by 20 and 30%, respectively). Thus, this preparation manifests qualities similar to those used in studying the left ventricle and allows investigation of various cardiac diseases which may affect RV pump function.     

Halo-shape technique for leadless pacemaker implantations: A case report

A 92-year-old woman underwent an implantation of a leadless pacemaker (Micra; Medtronic, Inc, Minneapolis, MN) for complete atrioventricular block after a transvenous lead extraction due to a pocket infection of a dual chamber pacemaker. Marked scoliosis and a humpback due to an advanced age made it impossible to direct the tip of the pacemaker delivery catheter towards the right ventricular septum or apex and shape the catheter into a gooseneck-shape. Thus, by attaining a halo-catheter shape of the delivery catheter, the catheter tip could be directed toward the infero-basal portion of the right ventricular septum. The pacemaker was successfully deployed at that site without any complications, and good device parameters were achieved. The halo-shape technique may be also an alternative method for delivering a leadless pacemaker in patients with an unsuccessful delivery of a leadless pacemaker to the right ventricular septum using the conventional gooseneck-shape technique.     

90% of general hospital care now accredited

Embolization of catheter fragments or fractured spring guidewires used during cardiac catheterization or fractured central venous pressure (CVP) lines is not uncommon. Although CVP lines are usually used in seriously ill patients, often with complications secondary to prior surgical intervention, if the catheter fragments are not removed they can give rise to serious illness or death in about 50% of patients. Experience with the removal of nine such catheter fragments is reported. In eight patients a helical basket was available for removal through a Dotter retrieval catheter. With prolonged hyperalimentation therapy polyethylene catherters become very brittle. They are relatively easy to grip with the wire basket. Silicone elastomer catheters remain pliable but are so bouncy that they are difficult to grip. For removal of catheter fragments from vessels of small diameter, such as the subclavian vein, or vessels in which the catheter has to take an acute bend to enter, such as the right or left pulmonary artery, a smaller, more pliable Bean-Smith-Mahorner biliary stone helical basket was adapted by extending the length of wire to 100 cm. For removal of catheter fragments from the right pulmonary artery it is probably better to use a softer, 100-cm-long no. 8 French right heart catheter. A Dotter retriever catheter set with both large and small helical wire baskets should be available in any cardiac catheterization laboratory.     

Measurement of pulsatile insulin secretion in the rat: direct sampling from the hepatic portal vein

It has previously been shown that insulin is secreted in discrete secretory bursts by sampling directly from the portal vein in the dog and humans. Deficient pulsatile insulin secretion is the basis for impaired insulin secretion in type 2 diabetes. However, while novel genetically modified disease models of diabetes are being developed in rodents, no validated method for quantifying pulsatile insulin secretion has been established for rodents. To address this we 1) developed a novel rat model with chronically implanted portal vein catheters, 2) established the parameters to permit deconvolution of portal vein insulin concentrations profiles to measure insulin secretion and resolve its pulsatile components, and 3) measured total and pulsatile insulin secretion compared with that in the dog, the species in which this sampling and deconvolution approach was validated for quantifying pulsatile insulin secretion. In rats, portal vein catheter patency and function were maintained for periods up to 2-3 wk with no postoperative complications such as catheter tract infection. Rat portal vein insulin concentration profiles in the fasting state revealed distinct insulin oscillations with a periodicity of approximately 5 min and an amplitude of up to 600 pmol/l, which was remarkably similar to that in the dogs and in humans. Deconvolution analysis of portal vein insulin concentrations revealed that the majority of insulin ( approximately 70%) in the rat is secreted in distinct insulin pulses occurring at approximately 5-min intervals. This model therefore permits direct accurate measurements of pulsatile insulin secretion in a relatively inexpensive animal. With increased introduction of genetically modified rat models will be an important tool in elucidating the underlying mechanisms of impaired pulsatile insulin secretion in diabetes.     

大鼠心脏插管留置术的探讨

目的探讨大鼠右心房插管留置术实验方法。方法20只SD大鼠进行右心房导管置入术,术后随机分为2组（导管穿弹簧正内孔组、导管穿弹簧侧边入内孔组）,每组各10只。导管在体内固定后由颈背部引出,穿过弹簧,导管另一端固定于饲养笼外的支架上,导管外接三通管等。结果24 h对两组模型进行实验观察。（1）导管穿弹簧正内孔组：只有1只导管弹簧设备未完全破坏,另9只模型的导管被咬断或拉出了出来,10只模型都不能从导管抽取血液样本。（2）导管穿弹簧侧边入内孔组：导管和弹簧设备都完好,其中9只模型都能从导管抽取血液样本。结论导管穿弹簧侧边入内孔组模型方法是成功的,有一定的推广价值。     

Cutaneous metastasis of occult hepatocellular carcinoma: a case report

BACKGROUND: Skin metastases from hepatocellular carcinoma (HCC) represented only 0.8% of all known cutaneous metastases in a recent large series. The most frequent site appears to be the head, but this fact has received little attention. An accurate cytologic diagnosis is extremely difficult in patients with unknown liver dysfunction. We report the cytologic features of a face metastasis from occult HCC. CASE: A 65-year-old woman presented with a mass in the right preauricular region of 2 months' duration. Her past medical history was noncontributory. Fine needle aspiration cytology was performed. Following the cytologic diagnosis, computed tomography revealed a 6-cm mass in the right lobe of the liver, portal vein thrombosis and involvement of the superior vena cava. The smears were very cellular. The most frequent pattern was trabecular with transmural endothelization. The cells had an epithelial appearance and polyhedral shape, exhibiting distinct borders. The nuclei were centrally placed, with a prominent nucleolus. The cytoplasm was granular. There were numerous atypical bare nuclei. Subsequent staining with antihepatocyte showed positivity in most tumor cells. The final diagnosis was metastatic HCC. CONCLUSION: HCCs should be considered in the differential diagnosis of carcinomas metastatic to the face, even in the absence of liver symptoms.     

Bedside determination of left atrial pressure

An investigation was conducted to assess the accuracy of left heart filling pressures determined by a right heart catheter introduced at the bedside. Twelve patients were studied after open cardiac surgery by simultaneously recording pressures from both sides of the pulmonary capillary bed with a direct left atrial catheter and a flow-directed pulmonary arterial catheter. The mean pulmonary artery “occluded” pressure was shown to be a highly reliable index of mean left atrial pressure in all cases. It was much more accurate than pulmonary end-diastolic pressure, especially in six patients with pre-existing pulmonary hypertension.     

Characterization of pulmonary vein reconnection post Cryoballoon ablation

BackgroundThe Arctic Front Cryoballoon System is a technology in which substrate alterations in patients with atrial fibrillation (AF) recurrence have not been well characterized. In this study, we evaluated sites of pulmonary vein (PV) reconnections and the accuracy of the Achieve? circular mapping catheter in detecting these reconnections after cryoablation.MethodsThis study included 15 patients undergoing redo AF ablation after a prior single cryoablation procedure. PV reconnection sites were determined by measuring PV signals and high output pacing from 4 vectors of the Achieve catheter. The results were compared with a roving mapping catheter guided by rotational intracardiac echocardiography (ICE) in the left atrium.ResultsAll patients had PV reconnections (2.1 ± 0.8 veins/patient). The left superior PV was most commonly reconnected (n = 11), whereas the right inferior PV was least likely (n = 3). Both carinas (left: n = 11; right: n = 7) and left atrial appendage ridge (n = 11) were also frequently reconnected. Mapping with the Achieve catheter showed a positive predictive value (PPV) 100% and negative predictive value (NPV) 96% when compared with ICE guided mapping. In 2 patients, right superior PV reconnection was not identified by the Achieve.ConclusionDuring redo AF ablation after index cryoablation, multiple PVs are usually reconnected, with both carinas and left atrial appendage ridge being common sites of reconnection. The Achieve mapping catheter was able to identify reconnection with high positive and negative predictive values.