A new strategy of using peripherally inserted central catheters (PICCs) as the first choice for central venous access is becoming widespread. The document discusses how ultrasound guidance and the use of microintroducer techniques have improved the safety and effectiveness of PICC insertion by nurses. Tip placement is now routinely confirmed with intracavitary electrocardiography during the procedure rather than relying on chest x-rays after, improving accuracy and allowing treatment to begin immediately. This real-time verification with a low-cost method is beneficial to patients and the healthcare system.
Direct thrombin inhibitors (DTIs) directly bind to and inhibit thrombin. Older DTIs like hirudin, lepirudin, and desirudin are peptides that bind irreversibly or reversibly to thrombin's active site and exosite I. They are used to treat heparin-induced thrombocytopenia but require coagulation monitoring. Bivalirudin binds reversibly and is used in angioplasty with less bleeding risk. Argatroban is a smaller DTI used in heparin-induced thrombocytopenia. Ximelagatran was an oral prodrug but was withdrawn due to rare liver toxicity.
This document reviews endovascular repair (TEVAR) for ruptured thoracic aortic aneurysms. It provides data on the incidence, mortality rates, and management of ruptured thoracic aneurysms. Open surgical intervention has mortality rates of 18-27% while TEVAR has shown lower 30-day mortality rates of 11-17% in single-institution studies. However, TEVAR is associated with higher mortality risks in older patients (>75 years old) and those with hemodynamic instability. The document recommends TEVAR as a less invasive alternative to open surgery for ruptured thoracic aneurysms, particularly when performed at experienced centers.
This document discusses restenosis of drug-eluting stents. It begins by introducing the topic and defining in-stent restenosis. It then discusses classifications of in-stent restenosis and the underlying mechanisms. Various treatment approaches are mentioned, including medical management, balloon angioplasty, cutting/scoring balloon angioplasty, and drug-eluting balloons. Imaging with IVUS and OCT can help identify factors associated with stent failure. Overall, the document provides an overview of in-stent restenosis and approaches to managing it.
The document discusses Nutcracker syndrome, which is caused by compression of the left renal vein between the abdominal aorta and superior mesenteric artery. It can cause hematuria, anemia, abdominal or pelvic pain. Diagnosis involves imaging tests like ultrasound, MRI, CT. Treatment options include analgesics, transposition surgery of the renal vein or superior mesenteric artery, stent placement, or nephrectomy in severe cases. Complications may include renal vein thrombosis. Nutcracker syndrome is underdiagnosed but should be considered in patients with left flank pain and hematuria or pelvic congestion.
This document discusses the role of interventional radiology in treating trauma-related hemorrhage. It describes how angiography and embolization can be used to treat bleeding from the pelvis, liver, spleen, and kidneys, which are commonly injured organs. The document reviews the angiographic techniques and technical success rates for embolizing various arterial branches to control bleeding in these organs.
The document discusses tips for managing ascites, including performing large volume paracentesis with albumin and continuing diuretics if renal sodium excretion is over 30 mmol/day. It also discusses using non-selective beta-blockers and transjugular intrahepatic portosystemic shunts (TIPS) to treat refractory ascites, noting that TIPS significantly reduces hepatic encephalopathy compared to large volume paracentesis alone. TIPS is an effective option for controlling ascites but carries a higher risk of hepatic encephalopathy compared to large volume paracentesis.
Mr. Sajal, age 35, presented with chest pain for 5 hours. His ECG showed signs of myocardial infarction, but his coronary angiogram (CAG) revealed non-obstructive coronary arteries. This is known as myocardial infarction with non-obstructive coronary arteries (MINOCA). MINOCA can affect up to 14% of AMI patients, particularly younger patients and women. Cardiac magnetic resonance imaging (CMR) can identify the underlying cause in up to 87% of MINOCA cases. While initially thought to be benign, MINOCA carries similar mortality risks as MI with obstructive coronary artery disease. Identifying the specific cause through tests like CMR is important to determine the proper long-
Direct thrombin inhibitors (DTIs) directly bind to and inhibit thrombin. Older DTIs like hirudin, lepirudin, and desirudin are peptides that bind irreversibly or reversibly to thrombin's active site and exosite I. They are used to treat heparin-induced thrombocytopenia but require coagulation monitoring. Bivalirudin binds reversibly and is used in angioplasty with less bleeding risk. Argatroban is a smaller DTI used in heparin-induced thrombocytopenia. Ximelagatran was an oral prodrug but was withdrawn due to rare liver toxicity.
This document reviews endovascular repair (TEVAR) for ruptured thoracic aortic aneurysms. It provides data on the incidence, mortality rates, and management of ruptured thoracic aneurysms. Open surgical intervention has mortality rates of 18-27% while TEVAR has shown lower 30-day mortality rates of 11-17% in single-institution studies. However, TEVAR is associated with higher mortality risks in older patients (>75 years old) and those with hemodynamic instability. The document recommends TEVAR as a less invasive alternative to open surgery for ruptured thoracic aneurysms, particularly when performed at experienced centers.
This document discusses restenosis of drug-eluting stents. It begins by introducing the topic and defining in-stent restenosis. It then discusses classifications of in-stent restenosis and the underlying mechanisms. Various treatment approaches are mentioned, including medical management, balloon angioplasty, cutting/scoring balloon angioplasty, and drug-eluting balloons. Imaging with IVUS and OCT can help identify factors associated with stent failure. Overall, the document provides an overview of in-stent restenosis and approaches to managing it.
The document discusses Nutcracker syndrome, which is caused by compression of the left renal vein between the abdominal aorta and superior mesenteric artery. It can cause hematuria, anemia, abdominal or pelvic pain. Diagnosis involves imaging tests like ultrasound, MRI, CT. Treatment options include analgesics, transposition surgery of the renal vein or superior mesenteric artery, stent placement, or nephrectomy in severe cases. Complications may include renal vein thrombosis. Nutcracker syndrome is underdiagnosed but should be considered in patients with left flank pain and hematuria or pelvic congestion.
This document discusses the role of interventional radiology in treating trauma-related hemorrhage. It describes how angiography and embolization can be used to treat bleeding from the pelvis, liver, spleen, and kidneys, which are commonly injured organs. The document reviews the angiographic techniques and technical success rates for embolizing various arterial branches to control bleeding in these organs.
The document discusses tips for managing ascites, including performing large volume paracentesis with albumin and continuing diuretics if renal sodium excretion is over 30 mmol/day. It also discusses using non-selective beta-blockers and transjugular intrahepatic portosystemic shunts (TIPS) to treat refractory ascites, noting that TIPS significantly reduces hepatic encephalopathy compared to large volume paracentesis alone. TIPS is an effective option for controlling ascites but carries a higher risk of hepatic encephalopathy compared to large volume paracentesis.
Mr. Sajal, age 35, presented with chest pain for 5 hours. His ECG showed signs of myocardial infarction, but his coronary angiogram (CAG) revealed non-obstructive coronary arteries. This is known as myocardial infarction with non-obstructive coronary arteries (MINOCA). MINOCA can affect up to 14% of AMI patients, particularly younger patients and women. Cardiac magnetic resonance imaging (CMR) can identify the underlying cause in up to 87% of MINOCA cases. While initially thought to be benign, MINOCA carries similar mortality risks as MI with obstructive coronary artery disease. Identifying the specific cause through tests like CMR is important to determine the proper long-
This is a teaching lecture given twice by Prof. Dr. Mohamed Mohi Eldin, professor of neurosurgery, in the weekly conference of kasr El Aini Neurosurgery Department, Cairo University, October 2010 and January 2013.
This document discusses the differences between CABG (coronary artery bypass grafting) and PCI (percutaneous coronary intervention) for treating multivessel coronary artery disease. It notes that both procedures are established treatments, but that factors like mortality benefit, quality of life improvements, costs, and long-term effects need to be considered. The concept of "functional angioplasty" and using FFR (fractional flow reserve) to accurately evaluate clinical ischemia in the catheterization lab are introduced as ways to optimize outcomes from PCI. Several studies comparing outcomes of FFR-guided versus angiography-guided PCI are summarized. The document also discusses unfavorable aspects of CABG like invasiveness and long-term graft failure
The principles of vascular repair with sutures were established in the first decade of the 20th century by Alexis Carrel, who in 1912 was awarded the Nobel Prize for medicine for his work .Since then, technical refinements of suture materials have made possible surgical reconstruction of most arteries from the root of the aorta to microvascular anastomosis or repair of the smallest vessels, e.g., digital arteries or those on the surface of the brain.
This document summarizes the treatment options for carotid artery stenosis, specifically carotid endarterectomy (CEA) versus carotid artery stenting (CAS). CEA has been shown to be superior to medical management alone in reducing stroke risk and is the gold standard treatment. CAS may be preferable for high-risk patients with conditions making CEA difficult, but is associated with a higher risk of perioperative stroke. The choice between CEA and CAS depends on patient characteristics, disease factors, and operator experience. While CAS can be performed less invasively, current evidence shows CEA remains the standard treatment for standard-risk patients.
Gerald Werner - AntegradeApproach Step by StepEuro CTO Club
This document discusses the antegrade approach for treating chronic total occlusions (CTOs). The goals are to restore the original artery anatomy with minimal damage or time/resources. The antegrade approach involves analyzing the lesion and patient, using a step-by-step process starting with softer wires and progressing if needed. Parallel wiring is an early bailout option. Guided reentry may be used if retrograde proves difficult. The strategy aims to select the approach most likely to succeed for each specific lesion and patient.
This document discusses various echocardiographic scoring systems used to assess mitral valve anatomy and predict outcomes of percutaneous balloon mitral valvuloplasty (PBMV). The Wilkins score and Commissural Calcification score are described in detail. The Wilkins score grades leaflet thickening, mobility, calcification and subvalvular involvement on a scale of 4-16. A score ≤8 indicates favorable anatomy for PBMV. The Commissural Calcification score quantifies calcification at each commissure. Other discussed scores include the Cormier score, RT-3DE score, Chen score, Reid score and Nobuyoshi score. Limitations of the scoring systems and ideas for an ideal future scoring
This document provides an overview of in-stent restenosis. It defines in-stent restenosis as the narrowing of a vessel segment at the site of a previously placed stent due to neointimal proliferation. The incidence of in-stent restenosis ranges from 3-20% with drug-eluting stents and 16-44% with bare-metal stents. Predictors of in-stent restenosis include patient characteristics like diabetes, lesion characteristics like length and diameter, and procedural characteristics like incomplete stent expansion. The document discusses the etiology, clinical presentation, assessment, and treatment options for in-stent restenosis.
review of literature for transjugular intrahepatic portosystemic shunt placement and balloon occluded retrograde transvenous obliteration in management of patients with varices hemorrhage
This document discusses coronary guidewires used in percutaneous coronary intervention (PCI). It describes the components, classifications, and appropriate uses of guidewires for different clinical scenarios. Guidewires are classified based on tip flexibility, device support, coating, and tip load. Commonly used guidewires include Balance Middleweight Universal, Choice Floppy, and BMW. Guidewire selection depends on vessel anatomy, lesion morphology, devices used, and operator experience. Special guidewires are discussed for procedures like left main PCI, bifurcation PCI, dissections, calcified lesions, and chronic total occlusions.
- Drug-eluting stents significantly reduced restenosis rates compared to bare-metal stents, but in-stent restenosis still occurs in 5-10% of cases.
- Restenosis can be focal or diffuse and is classified based on its severity and treatment approach. Higher grades of restenosis are associated with poorer outcomes.
- Factors contributing to in-stent restenosis include patient and lesion characteristics, stent design and materials, drug effects, inflammation, neoatherosclerosis, low wall shear stress areas, and potential thrombus formation.
- Earlier and more rapid neoatherosclerosis may occur inside drug-eluting stents compared to bare-metal stents,
This document summarizes stroke treatment procedures at Beaumont Hospital from 2010-2013. It finds that 107 patients underwent mechanical thrombectomy for ischemic stroke, with 12 receiving general anesthesia. Risk factors for the GA patients included hypertension, smoking, and atrial fibrillation. Most strokes involved the middle cerebral or internal carotid arteries. Complications from the procedure included hemorrhage and low MRS scores at 3 months for GA patients. The need for GA may increase over time, requiring improved protocols to ensure safer anesthesia for high-risk stroke patients undergoing emergent clot retrieval.
This document discusses beta blockers for acute myocardial infarction (AMI). It provides an overview of their mechanism of benefit in AMI, indications and recommendations, and evidence supporting their use. The evidence shows beta blockers reduce infarct size, mortality, and arrhythmias when started early after AMI. Intravenous initiation is generally not recommended for fibrinolytic-treated patients, but oral initiation within 24 hours is. Long-term beta blocker therapy for up to 3 years is also indicated to reduce mortality post-AMI.
This document discusses the history and evidence for cardiac resynchronization therapy (CRT). It notes that approximately 25% of heart failure patients have intraventricular conduction delays that cause dyssynchronous contraction. CRT aims to resynchronize contraction by pacing both ventricles simultaneously. Randomized controlled trials found CRT improves symptoms, exercise capacity, and survival in patients with low ejection fraction and wide QRS. Guidelines recommend CRT for class III/IV heart failure patients with LBBB morphology and QRS >120ms. Some evidence also supports benefit in milder heart failure. Response can vary and not all patients respond equally.
This document discusses vascular access during cardiac catheterization. It covers various access sites including femoral, radial, brachial and ulnar arteries as well as internal jugular, subclavian and femoral veins. Potential complications of vascular access like hematoma, pseudoaneurysm, retroperitoneal hemorrhage and arteriovenous fistula are described. Risk factors, diagnosis and management of these complications are provided. Prevention strategies to avoid vascular access complications are also mentioned.
22.2.2018 acute limb ischemia vs critical limb ischemiaMai Parachy
This document summarizes the key differences and management recommendations for acute limb ischemia (ALI) and critical limb ischemia (CLI). It defines ALI as an acute condition lasting less than 2 weeks characterized by severe limb hypoperfusion, while CLI is a chronic condition lasting over 2 weeks characterized by rest pain and non-healing wounds. For ALI, the recommended treatments include heparin, oxygen, analgesia, and emergent revascularization via catheter-directed thrombolysis or surgical embolectomy. For CLI, the recommendations include physiological testing, imaging to guide revascularization, and endovascular or open surgical procedures based on the lesion location. Revascularization aims to improve tissue perfusion and prevent amputation for
Strategies of handling side branch during pciManjunath D
This document summarizes strategies for handling side branches during percutaneous coronary interventions (PCI) involving coronary bifurcations. It discusses:
1. Bifurcation lesions account for 15-20% of PCIs and have lower success rates and higher restenosis than other PCIs.
2. Classification systems for bifurcation lesions including the Medina and Duke classifications.
3. Techniques for stenting bifurcation lesions including provisional stenting, T-stenting, crush techniques, and double stenting.
4. Randomized trials have found that provisional stenting is generally as effective as more complex double stenting techniques for treating bifurcation lesions.
The document provides information on the role of transjugular intrahepatic portosystemic shunt (TIPS) in treating liver diseases. It discusses how TIPS works to create a channel between the hepatic vein and portal vein using a metal stent to reduce portal pressure. The document outlines guidelines for using TIPS to treat variceal hemorrhaging and describes factors like MELD scores that can help identify high-risk patients who may benefit from early TIPS placement. It also reviews the history of TIPS development and provides details on how to perform the TIPS procedure and assess outcomes.
Central and PICC Line: Care and Best Practices Mary Larson
This document provides information and best practices for central and peripherally inserted central catheter (PICC) lines. It discusses indications for central lines, types of central lines including non-tunneled and PICC lines. Proper catheter dressing changes and flushing are outlined, including using chlorhexidine to cleanse the skin and flushing with saline before and after each use. Assessment of catheter sites and documentation standards are also reviewed.
This document provides information and best practices for central and peripherally inserted central catheters (PICCs). It discusses indications for central lines, types of central lines including non-tunneled and PICCs, catheter placement and tips, dressing changes, flushing procedures, and documentation standards. The document emphasizes following Centers for Disease Control and Prevention guidelines to prevent infections, including using sterile technique and chlorhexidine for dressing changes and site access. It also stresses the importance of daily site assessments and prompt removal of unnecessary lines.
This is a teaching lecture given twice by Prof. Dr. Mohamed Mohi Eldin, professor of neurosurgery, in the weekly conference of kasr El Aini Neurosurgery Department, Cairo University, October 2010 and January 2013.
This document discusses the differences between CABG (coronary artery bypass grafting) and PCI (percutaneous coronary intervention) for treating multivessel coronary artery disease. It notes that both procedures are established treatments, but that factors like mortality benefit, quality of life improvements, costs, and long-term effects need to be considered. The concept of "functional angioplasty" and using FFR (fractional flow reserve) to accurately evaluate clinical ischemia in the catheterization lab are introduced as ways to optimize outcomes from PCI. Several studies comparing outcomes of FFR-guided versus angiography-guided PCI are summarized. The document also discusses unfavorable aspects of CABG like invasiveness and long-term graft failure
The principles of vascular repair with sutures were established in the first decade of the 20th century by Alexis Carrel, who in 1912 was awarded the Nobel Prize for medicine for his work .Since then, technical refinements of suture materials have made possible surgical reconstruction of most arteries from the root of the aorta to microvascular anastomosis or repair of the smallest vessels, e.g., digital arteries or those on the surface of the brain.
This document summarizes the treatment options for carotid artery stenosis, specifically carotid endarterectomy (CEA) versus carotid artery stenting (CAS). CEA has been shown to be superior to medical management alone in reducing stroke risk and is the gold standard treatment. CAS may be preferable for high-risk patients with conditions making CEA difficult, but is associated with a higher risk of perioperative stroke. The choice between CEA and CAS depends on patient characteristics, disease factors, and operator experience. While CAS can be performed less invasively, current evidence shows CEA remains the standard treatment for standard-risk patients.
Gerald Werner - AntegradeApproach Step by StepEuro CTO Club
This document discusses the antegrade approach for treating chronic total occlusions (CTOs). The goals are to restore the original artery anatomy with minimal damage or time/resources. The antegrade approach involves analyzing the lesion and patient, using a step-by-step process starting with softer wires and progressing if needed. Parallel wiring is an early bailout option. Guided reentry may be used if retrograde proves difficult. The strategy aims to select the approach most likely to succeed for each specific lesion and patient.
This document discusses various echocardiographic scoring systems used to assess mitral valve anatomy and predict outcomes of percutaneous balloon mitral valvuloplasty (PBMV). The Wilkins score and Commissural Calcification score are described in detail. The Wilkins score grades leaflet thickening, mobility, calcification and subvalvular involvement on a scale of 4-16. A score ≤8 indicates favorable anatomy for PBMV. The Commissural Calcification score quantifies calcification at each commissure. Other discussed scores include the Cormier score, RT-3DE score, Chen score, Reid score and Nobuyoshi score. Limitations of the scoring systems and ideas for an ideal future scoring
This document provides an overview of in-stent restenosis. It defines in-stent restenosis as the narrowing of a vessel segment at the site of a previously placed stent due to neointimal proliferation. The incidence of in-stent restenosis ranges from 3-20% with drug-eluting stents and 16-44% with bare-metal stents. Predictors of in-stent restenosis include patient characteristics like diabetes, lesion characteristics like length and diameter, and procedural characteristics like incomplete stent expansion. The document discusses the etiology, clinical presentation, assessment, and treatment options for in-stent restenosis.
review of literature for transjugular intrahepatic portosystemic shunt placement and balloon occluded retrograde transvenous obliteration in management of patients with varices hemorrhage
This document discusses coronary guidewires used in percutaneous coronary intervention (PCI). It describes the components, classifications, and appropriate uses of guidewires for different clinical scenarios. Guidewires are classified based on tip flexibility, device support, coating, and tip load. Commonly used guidewires include Balance Middleweight Universal, Choice Floppy, and BMW. Guidewire selection depends on vessel anatomy, lesion morphology, devices used, and operator experience. Special guidewires are discussed for procedures like left main PCI, bifurcation PCI, dissections, calcified lesions, and chronic total occlusions.
- Drug-eluting stents significantly reduced restenosis rates compared to bare-metal stents, but in-stent restenosis still occurs in 5-10% of cases.
- Restenosis can be focal or diffuse and is classified based on its severity and treatment approach. Higher grades of restenosis are associated with poorer outcomes.
- Factors contributing to in-stent restenosis include patient and lesion characteristics, stent design and materials, drug effects, inflammation, neoatherosclerosis, low wall shear stress areas, and potential thrombus formation.
- Earlier and more rapid neoatherosclerosis may occur inside drug-eluting stents compared to bare-metal stents,
This document summarizes stroke treatment procedures at Beaumont Hospital from 2010-2013. It finds that 107 patients underwent mechanical thrombectomy for ischemic stroke, with 12 receiving general anesthesia. Risk factors for the GA patients included hypertension, smoking, and atrial fibrillation. Most strokes involved the middle cerebral or internal carotid arteries. Complications from the procedure included hemorrhage and low MRS scores at 3 months for GA patients. The need for GA may increase over time, requiring improved protocols to ensure safer anesthesia for high-risk stroke patients undergoing emergent clot retrieval.
This document discusses beta blockers for acute myocardial infarction (AMI). It provides an overview of their mechanism of benefit in AMI, indications and recommendations, and evidence supporting their use. The evidence shows beta blockers reduce infarct size, mortality, and arrhythmias when started early after AMI. Intravenous initiation is generally not recommended for fibrinolytic-treated patients, but oral initiation within 24 hours is. Long-term beta blocker therapy for up to 3 years is also indicated to reduce mortality post-AMI.
This document discusses the history and evidence for cardiac resynchronization therapy (CRT). It notes that approximately 25% of heart failure patients have intraventricular conduction delays that cause dyssynchronous contraction. CRT aims to resynchronize contraction by pacing both ventricles simultaneously. Randomized controlled trials found CRT improves symptoms, exercise capacity, and survival in patients with low ejection fraction and wide QRS. Guidelines recommend CRT for class III/IV heart failure patients with LBBB morphology and QRS >120ms. Some evidence also supports benefit in milder heart failure. Response can vary and not all patients respond equally.
This document discusses vascular access during cardiac catheterization. It covers various access sites including femoral, radial, brachial and ulnar arteries as well as internal jugular, subclavian and femoral veins. Potential complications of vascular access like hematoma, pseudoaneurysm, retroperitoneal hemorrhage and arteriovenous fistula are described. Risk factors, diagnosis and management of these complications are provided. Prevention strategies to avoid vascular access complications are also mentioned.
22.2.2018 acute limb ischemia vs critical limb ischemiaMai Parachy
This document summarizes the key differences and management recommendations for acute limb ischemia (ALI) and critical limb ischemia (CLI). It defines ALI as an acute condition lasting less than 2 weeks characterized by severe limb hypoperfusion, while CLI is a chronic condition lasting over 2 weeks characterized by rest pain and non-healing wounds. For ALI, the recommended treatments include heparin, oxygen, analgesia, and emergent revascularization via catheter-directed thrombolysis or surgical embolectomy. For CLI, the recommendations include physiological testing, imaging to guide revascularization, and endovascular or open surgical procedures based on the lesion location. Revascularization aims to improve tissue perfusion and prevent amputation for
Strategies of handling side branch during pciManjunath D
This document summarizes strategies for handling side branches during percutaneous coronary interventions (PCI) involving coronary bifurcations. It discusses:
1. Bifurcation lesions account for 15-20% of PCIs and have lower success rates and higher restenosis than other PCIs.
2. Classification systems for bifurcation lesions including the Medina and Duke classifications.
3. Techniques for stenting bifurcation lesions including provisional stenting, T-stenting, crush techniques, and double stenting.
4. Randomized trials have found that provisional stenting is generally as effective as more complex double stenting techniques for treating bifurcation lesions.
The document provides information on the role of transjugular intrahepatic portosystemic shunt (TIPS) in treating liver diseases. It discusses how TIPS works to create a channel between the hepatic vein and portal vein using a metal stent to reduce portal pressure. The document outlines guidelines for using TIPS to treat variceal hemorrhaging and describes factors like MELD scores that can help identify high-risk patients who may benefit from early TIPS placement. It also reviews the history of TIPS development and provides details on how to perform the TIPS procedure and assess outcomes.
Central and PICC Line: Care and Best Practices Mary Larson
This document provides information and best practices for central and peripherally inserted central catheter (PICC) lines. It discusses indications for central lines, types of central lines including non-tunneled and PICC lines. Proper catheter dressing changes and flushing are outlined, including using chlorhexidine to cleanse the skin and flushing with saline before and after each use. Assessment of catheter sites and documentation standards are also reviewed.
This document provides information and best practices for central and peripherally inserted central catheters (PICCs). It discusses indications for central lines, types of central lines including non-tunneled and PICCs, catheter placement and tips, dressing changes, flushing procedures, and documentation standards. The document emphasizes following Centers for Disease Control and Prevention guidelines to prevent infections, including using sterile technique and chlorhexidine for dressing changes and site access. It also stresses the importance of daily site assessments and prompt removal of unnecessary lines.
Doppler ultrasound in deep vein thrombosisSamir Haffar
Doppler ultrasound is the preferred method for diagnosing deep vein thrombosis (DVT). It has high specificity and sensitivity for detecting thrombi in the proximal leg veins. Isolated calf vein thrombi can be missed by Doppler in up to 30% of cases. Clinical evaluation alone is only positive for DVT in about 50% of cases. While D-dimer tests are sensitive, they are not specific for DVT. Doppler ultrasound can directly visualize thrombi as noncompressible segments within veins. Indirect signs of DVT on Doppler include loss of phasicity with respiration and loss of flow augmentation with distal compression. Contrast venography remains the gold standard but is rarely used due to risks of contrast agents and limited
The document describes a company called Dry Corp that manufactures waterproof protective covers for medical needs like PICC lines and casts. It details Dry Corp's product lines including PICC line and cast/bandage covers, benefits of the products, growth of the company, and positive customer testimonials about being able to shower or swim with the protective covers. The covers provide a waterproof barrier while allowing freedom of movement and improved quality of life for patients.
This document discusses intestinal failure services in Australia. It notes there is variability in care across jurisdictions and no national policy. It discusses the role of specialized centers, multidisciplinary teams, and intestinal rehabilitation. It also addresses issues like HPN funding models and variability. The document advocates for AuSPEN to help establish standards for an intestinal failure registry, model of care, and advocacy to improve access to specialized care nationwide.
Heparin induced thrombocytopenia (HIT) is a complication of heparin therapy where platelet counts decrease. There are two types: immune-mediated HIT which can be dangerous and cause clots, and non-immune mediated HIT which is self-limited. Symptoms include bleeding or clots. Diagnosis involves platelet count drops and antibody tests. Treatment requires stopping heparin and using alternative anticoagulants to prevent dangerous clots. Nurses monitor patients on heparin closely for signs of HIT and intervene appropriately.
By: Mark Meissner, M.D.
Visit VeinGlobal at http://www.veinglobal.com/ for more presentations and videos on this topic, or for more information on venous disease news, education and research.
Idiopathic DVT refers to a DVT case where there is no obvious underlying cause such as recent surgery, trauma or known malignancy identified. About 30-40% of DVT cases are considered idiopathic. Evaluation should aim to rule out occult cancer or inherited or acquired thrombophilia. Treatment is the same as DVT with known risk factors.
This document discusses prophylaxis for deep vein thrombosis (DVT) in the surgical intensive care unit (SICU). It outlines the importance and risk factors for DVTs, as well as methods for prophylaxis including mechanical, chemical, and inferior vena cava filter options. The document recommends different prophylaxis strategies based on a patient's level of risk for DVT, with higher risk patients warranting more aggressive prophylaxis like low molecular weight heparin over 3400 units daily.
1) The document describes the major arteries of the systemic circulation, including branches off the aorta such as the coronary, carotid, and brachial arteries.
2) It also details important veins that drain blood from the head, neck, arms and abdomen, including the internal and external jugular veins, brachial veins, and hepatic portal vein.
3) The hepatic portal system is summarized as carrying nutrient-rich blood from the abdominal viscera to the liver through the hepatic portal vein and its tributaries, before the blood continues to the inferior vena cava and heart.
This document discusses current methods for treating deep vein thrombosis (DVT) and the impact of post-thrombotic syndrome (PTS). It provides statistics on the prevalence and costs of DVT and PTS in the US. The document reviews changes to DVT treatment guidelines supporting early thrombus removal through pharmacomechanical thrombolysis. Clinical studies demonstrate pharmacomechanical thrombolysis improves outcomes over anticoagulation alone by increasing patency and reducing long-term PTS symptoms. The document concludes that early thrombus removal through pharmacomechanical techniques is the new standard of care for proximal DVT due to decreased complications and improved patient outcomes compared to anticoagulation or catheter-directed thrombolysis alone.
The document summarizes key aspects of cardiac catheterization and hemodynamic data collection. It describes the normal cardiac cycle, pressure measurement systems, normal pressure waveforms, methods to measure cardiac output like thermodilution and Fick, how to evaluate valvular stenosis and regurgitation, determine vascular resistance and shunts. Specific details are provided on assessing aortic stenosis, mitral stenosis, right-sided valves and quantifying regurgitant fractions. Oxygen saturation analysis and Fick principles are outlined for shunt determinations.
Ultrasound Assessment Of Chronic Venous Diseasejavier.fabra
This document summarizes how to perform an ultrasound scan to assess chronic venous disease in the lower limbs. It outlines the anatomy of the venous system, including the superficial and deep veins and perforating veins. It describes how to evaluate for reflux in the veins using Doppler ultrasound, and provides guidance on scanning the different areas of the lower limbs to investigate sources of reflux or varicose veins. The goal is to identify reflux or obstructions in the deep or superficial veins and perforating veins to determine the cause of chronic venous disease.
Modern management of dvt dr. sharfuddin chowdhuryShakila Rifat
This document discusses modern management of deep vein thrombosis (DVT). It covers the epidemiology, classification, clinical presentation, diagnosis, and imaging of DVT. DVT is common in hospitalized patients, especially following surgery or injury. Diagnosis involves assessing pre-test probability with Wells criteria and testing D-dimer levels. Ultrasound is the primary imaging method due to its non-invasiveness and accuracy, though computed tomography venography can also be used. Treatment involves anticoagulation to prevent pulmonary embolism complications.
Deep vein thrombosis is the formation of a blood clot in the deep veins, usually in the leg. It is caused by Virchow's triad of venous stasis, endothelial damage, and hypercoagulability. Common risk factors include surgery, trauma, pregnancy, oral contraceptives, and inherited coagulation disorders. Patients may present with calf pain, swelling, warmth, or tenderness. Diagnosis involves Wells criteria, D-dimer testing, ultrasound, venography or MRI. Treatment focuses on anticoagulation to prevent pulmonary embolism.
2. central venous access devices (cvads)ChartwellPA
Central venous catheters can be categorized into four groups based on their design: peripherally inserted central catheters, temporary central venous catheters, permanent tunneled central venous catheters, and implantable ports. It is the nurse's responsibility to understand the design, purpose, and care of each type of catheter and educate patients. PICC lines are long, flexible tubes inserted into a peripheral vein and threaded into the central circulation. They are commonly used for short or long-term therapies and have a lower risk of complications than other central lines. Implantable ports are implanted subcutaneously and consist of a portal body and catheter, providing vascular access without an external component.
Central venous lines and their problemsSunil Agrawal
The document discusses central venous lines and their placement and complications. It describes how central venous lines can be placed in the internal jugular, subclavian, femoral, and umbilical veins using the Seldinger technique. Potential acute complications include hematoma, cellulitis, arterial puncture, pneumothorax, malposition, and air embolism. Chronic complications include infection and thrombosis. The document recommends using antimicrobial-impregnated catheters, avoiding antibiotic ointments, not scheduling routine catheter changes, and removing catheters when no longer needed to help prevent complications.
Central Venous Access and Catheters. Their indications and contraindications, Different types of central catheters and their advantages and disadvantages, Technique of insertion, and Complications related to central venous lines.
Catheter ablation of Idiopatic ventricular tachycardiaMarina Mercurio
1. The study assessed the feasibility, success rate, and safety of catheter ablation for idiopathic ventricular tachycardia without the use of fluoroscopy.
2. Nineteen patients underwent ablation guided by electroanatomical mapping and intracardiac echocardiography without fluoroscopy.
3. The procedure was successful in all patients with no complications. At 18-month follow up, recurrences occurred in two patients. The study demonstrates catheter ablation for idiopathic VT can be performed safely and effectively without fluoroscopy.
CT-SCAN provides concise summaries of medical documents. This document discusses the history and evolution of computed tomography (CT) scanning technology. It begins with definitions of CT scanning and diagrams of early CT scanner designs. It then summarizes the key developments, including the invention of CT scanning by Godfrey Hounsfield in 1971, the installation of the first CT prototype, and improvements in processing time. The document outlines the generations of CT scanners from first to fifth generation and describes advances in multi-slice and multi-detector array technologies. It concludes with examples of clinical applications and cases imaged with various CT techniques.
Vascular Access Part 1: Reducing risk and increasing catheter longevityCoda Change
Vascular access is essential for critically ill patients in the ICU. Nearly all patients will require some form of vascular device such as a PIVC, PICC, or CVC. While necessary, these devices carry risks of complications and infection if not inserted and managed properly. The document emphasizes that insertion is only a small part of device management, and more attention needs to be paid to the 99% of time the device is in use. It provides recommendations for proper device selection, insertion technique including use of ultrasound and micro-puncture, dressing and securement, and tip location to reduce risks and improve device longevity during the critical care stay.
The document provides an overview of transcatheter aortic valve implantation (TAVI), including a brief history of its development, descriptions of the Edwards Sapien valve and delivery systems, approaches for TAVI, and complications. It also discusses patient screening and risk stratification, as well as newer valve devices that are being developed.
The document summarizes recent developments in transcatheter interventions for tricuspid valve disease. It describes various devices that have been developed to address tricuspid regurgitation through approaches such as leaflet repair, annuloplasty, and valve replacement. Clinical trials of devices like the MitraClip, Trialign, and TriCinch show promise in reducing regurgitation and improving symptoms, though longer-term outcomes remain to be seen. Ongoing research aims to optimize patient selection and develop new technologies for treating different failure mechanisms of the tricuspid valve.
This document provides an overview of imaging techniques used in the evaluation of thoracic trauma. It begins with an introduction to the epidemiology of thoracic injuries and the importance of rapid diagnosis. The initial assessment involves a primary and secondary survey with a focus on airway, breathing and circulation. The imaging survey typically begins with a portable chest x-ray to evaluate for pneumothorax, hemothorax and other injuries followed by an ultrasound to assess for pericardial effusion. Additional sections discuss specific injuries like flail chest, hemothorax and tension pneumothorax that may be seen on CXR. The role of CT in thoracic trauma evaluation is also reviewed.
Cardiac CT provides a noninvasive way to evaluate the coronary arteries and cardiac structure. It has largely replaced invasive coronary angiography due to improvements in temporal and spatial resolution allowing for clear images of the heart. Cardiac CT is indicated to rule out coronary artery disease in low-moderate risk patients, assess anomalies, evaluate grafts and stents, and aid in surgical planning. It has limitations including irregular heart rates over 80 bpm, high calcium scores, small vessels, and radiation exposure. Proper patient selection and preparation are important to optimize results.
Cardiac CT uses X-rays and computer technology to image the heart and coronary arteries. It can detect calcium buildup in arteries, assess coronary arteries via angiography, and evaluate heart function. The test involves injecting contrast dye and potentially heart rate control drugs. Images are taken rapidly during breath-holds to freeze heart motion. Cardiac CT can diagnose heart disease by identifying plaque and blockages without the risks of angiography.
This document provides an overview of cardiac catheterization procedures. It discusses how cardiac catheterization can be used to measure intracardiac pressures, oxygen saturation, and cardiac output. It also describes how it is used for angiography, angioplasty, valvuloplasty, and cardiac biopsy. Key indications for cardiac catheterization include valve disease, heart muscle disease, heart failure, congenital heart disease, and suspected cardiomyopathy. The document outlines techniques for measuring pressures in the heart chambers and great vessels, as well as complications. It also discusses coronary angiography and digital subtraction angiography.
Free hand pedicle screw placement is a reliable technique for the lumbar and lower thoracic spine. The entry point is identified based on bony landmarks and screws are directed along the pedicle axis with a slight medial trajectory. Accuracy rates of 90-95% have been reported. In the upper and mid thoracic spine, free hand placement is more challenging due to smaller pedicle sizes and riskier medial violations. Intraoperative imaging or navigation may be most useful in the T4-T6 region, where breach rates are highest.
The document discusses guidelines for the diagnosis and treatment of aortic diseases. It covers the epidemiology of aortic aneurysms and aortic dissection, providing statistics on prevalence and mortality. It also describes the clinical assessment and various imaging modalities used to evaluate the aorta, including echocardiography, CT, MRI, and angiography. Recommendations are presented regarding imaging and measurement of the aorta, as well as medical, endovascular, and surgical treatment approaches for different aortic conditions.
The document summarizes a study that compared the use of single catheter concepts (OCC) versus dual catheter concepts (TCC) for transradial coronary angiography. The study found that while angiography times were similar between OCC and TCC, OCC had significantly higher crossover rates to other catheters, longer fluoroscopy times, and higher contrast volumes. Specifically, OCC failed more often due to unstable catheter positioning at coronary ostia and suboptimal visualization of the left coronary system. Therefore, TCC using standard Judkins catheters remains a more reliable option for transradial coronary angiography.
Cardiovascular CT is a valuable tool for evaluating congenital heart disease in children. It provides high spatial and temporal resolution to depict complex anatomy. Key applications include assessing pulmonary blood flow in pulmonary atresia, vascular rings prior to surgery, coronary artery anomalies, and postoperative complications. Careful patient preparation and protocols are needed given pediatric concerns. CT enables simultaneous evaluation of vascular structures, airways, and cardiac function to comprehensively evaluate complex congenital heart disease.
This study evaluated the safety and efficacy of ablation for atrioventricular nodal reentrant tachycardia (AVNRT) using 3D electroanatomic mapping (EAM) with an irrigated ablation catheter, aiming for a minimal or zero fluoroscopic approach. The study included 50 patients who underwent AVNRT ablation. Acute success was 100% and mid-term success at 12 months was 96%. The average fluoroscopy time was very low at 0.63 minutes and 88% of procedures used no fluoroscopy at all. Catheter stability during radiofrequency ablation was high, with a standard deviation below 1.2 mm in all axes. No major complications occurred, demonstrating that AVNRT ablation can be
The document discusses transcatheter aortic valve implantation (TAVI), including its approval and increasing use in Europe and the United States. It provides details on the team approach, devices, procedures, outcomes, and complications of TAVI based on clinical trials such as PARTNER. TAVI is an alternative to surgical aortic valve replacement for high-risk or inoperable patients with severe aortic stenosis.
TAVI has become an accepted treatment for severe aortic stenosis, especially in high-risk patients. The PARTNER trial showed non-inferiority of TAVI compared to surgery in high-risk patients, with lower rates of major bleeding and new onset atrial fibrillation for TAVI. A team approach including cardiologists and cardiac surgeons is recommended for optimal patient outcomes with TAVI.
This document provides an overview of extracorporeal membrane oxygenation (ECMO). It describes what ECMO is, the differences between conventional cardiopulmonary bypass and ECMO, the types of ECMO circuits, ECMO flow calculations, cannulation techniques, indications for ECMO in neonates, pediatrics and adults, management of ECMO, and complications. The key points covered are: ECMO can provide both cardiac and respiratory support for longer durations than cardiopulmonary bypass; the two main types are venovenous and venoarterial ECMO; cannulation sites include femoral, axillary and internal jugular vessels; and indications and management vary between age groups.
This document discusses considerations for starting a vein clinic to treat varicose veins. Varicose veins impact over 50 million Americans and can cause complications beyond cosmetic issues like pain, swelling, and ulcers. A vein clinic needs equipment like ultrasound Doppler and sclerotherapy tools to properly classify and treat varicose veins by eliminating reflux through methods like sclerotherapy, laser ablation, or phlebectomy. The document recommends being the local expert through marketing, having a clinic manager, and obtaining insurance coverage to successfully run a vein treatment clinic.
This document discusses the endovascular management of peripheral arteriovenous malformations (AVMs). It defines AVMs as abnormal connections between arteries and veins, bypassing the capillary network. The pathophysiology involves an ectatic capillary bed lacking proper sphincter control. Clinical presentation depends on location and shunting degree, and can include pain, overgrowth, bleeding, and high output cardiac failure in large shunts. Diagnosis is typically clinical and confirmed with imaging showing high flow characteristics. Treatment involves endovascular embolization to occlude arterial feeders using various embolic agents like coils, liquids, and recently the liquid polymer Onyx, which has greater potential to occlude AVMs due to
Mechanical thrombectomy devices show some advantages for treating deep vein thrombosis (DVT) but have limitations as standalone therapies. When used in combination with thrombolytics, mechanical thrombectomy can speed lysis, potentially reduce lytic doses and treatment time, and allow treatment of patients who cannot receive thrombolytics. However, data on their long-term safety and efficacy compared to thrombolysis alone is still limited. Standalone mechanical thrombectomy often provides only partial clot removal for DVT.
This document discusses chronic venous occlusions, including tools and techniques for treatment. It provides an overview of central venous occlusions in the upper and lower extremities. General rules for treatment include that more than one access may be required, procedures can be unpredictable and frustrating, and familiarity with venous anatomy is important. Stenting is often needed for chronic occlusions, though stent selection depends on the location of the occlusion. The document reviews literature on outcomes of stenting for venous occlusions. It concludes that reestablishing flow is needed for symptomatic chronic venous occlusions and an endovascular approach is generally first-line therapy.
Dr. Iyad Feteih presents information on the history and development of inferior vena cava (IVC) filters. The document discusses early surgical methods of IVC interruption and their complications. It then summarizes the development of endoluminal IVC filters beginning with the Mobin-Uddin umbrella in 1967 and the iconic Greenfield filter in 1973. The document provides details on various commercially available IVC filters from companies such as Bard, Cook Medical, Cordis, and Crux Biomedical including specifications, clinical trial results, and complications.
The document discusses the anatomy of the great saphenous vein (GSV) and treatments for varicose veins. It describes the GSV as the main superficial vein in the leg that connects to the femoral vein. It summarizes current treatments as including sclerotherapy, surgery such as vein stripping, and newer endovascular techniques like radiofrequency ablation and endovenous laser therapy to close the GSV non-invasively. These minimally invasive methods are presented as promising new alternatives to surgery with benefits of shorter recovery times and fewer complications.
This document contains brief summaries of several patients' medical histories and conditions related to thoracic or abdominal aortic aneurysms. It describes patients ranging from ages 38 to 77 with histories of Marfan's syndrome, aortic dissections, previous open or endovascular surgeries, and expanding aneurysms. The patients underwent treatments including custom stent grafts, total endovascular aneurysm repair, robotic cannulation, and hybrid graft procedures.
Renal Artery Revascularization: where we arePAIRS WEB
This document discusses renal artery stenosis (RAS), which is narrowing of the renal arteries that can be caused by conditions like atherosclerosis or fibromuscular dysplasia. The two most common causes are atherosclerotic renal artery stenosis and fibromuscular dysplasia. RAS can lead to hypertension, renal impairment, and ischemic nephropathy. While renal artery stenting was often used as treatment, recent clinical trials found no clear added benefits of stenting over medical management alone for atherosclerotic cases. Stenting may still benefit cases of fibromuscular dysplasia or treatment-resistant high blood pressure. The best approach for RAS continues to be evaluated based on ongoing research.
1) Renal angiomyolipomas (rAMLs) are benign tumors composed of fat, blood vessels, and smooth muscle that can cause bleeding. Embolization using ethanol is an effective non-surgical treatment for rAMLs.
2) The document reports on the Singapore General Hospital's experience treating 34 patients with rAMLs via embolization. Technical success was 100% with few major complications. Embolization successfully stopped bleeding in most cases and reduced tumor size in 69% of treated lesions.
3) Embolization is concluded to be a safe and effective alternative to surgery for controlling acute bleeding from rAMLs and preventing rebleeding that can also help reduce tumor size
Renal Artery Denervation Patient Selection and ResultsPAIRS WEB
- Resistant hypertension is defined as blood pressure that remains above goal despite concurrent use of 3 antihypertensive agents of different classes, including a diuretic. More than 10% of treated hypertensive patients have resistant hypertension.
- Renal denervation is a potential treatment for resistant hypertension, as the sympathetic nervous system drives hypertension. However, early renal denervation studies have been criticized for relying on uncontrolled office blood pressure measurements rather than ambulatory blood pressure monitoring.
- Accurately defining and diagnosing resistant hypertension remains an issue, as office and ambulatory blood pressure measurements can differ substantially. Further research is still needed to establish the effectiveness and appropriate patient selection for renal denervation.
Endovascular Repair of Thoracoabdominal AneurysmPAIRS WEB
This document discusses total endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) using fenestrated and branched endovascular aneurysm repair (F-EVAR/B-EVAR) techniques. It summarizes outcomes from 86 high-risk patients treated with F-EVAR/B-EVAR for TAAA between 2007-2014, finding a 30-day mortality of 2.3%, 1-year survival of 91%, and 3-year survival of 88%. The use of staged procedures was associated with reducing spinal cord ischemia from 10% to 0%. The conclusion is that F-EVAR/B-EVAR provides good outcomes for high-risk TAAA patients when
1. Endovascular repair (TEVAR) is now the standard treatment for thoracic aortic injuries graded ≥2, while grade 1 injuries can be observed.
2. Technological advances in endografts have allowed for treatment of anatomies previously not amenable to endovascular repair.
3. Long-term outcomes remain unknown as follow-up imaging recommendations are vague and patient compliance with follow-up can be challenging.
Hybrid repair of Thoracoabdominal AneurysmPAIRS WEB
1. Classifications and treatment options for thoracoabdominal aortic aneurysms (TAAAs) are discussed, including open repair, endovascular repair (TEVAR), and hybrid procedures combining open and endovascular techniques.
2. Complications of open TAAA repair can include ischemia-induced injury to organs and spinal cord paralysis, while endovascular options may reduce blood loss, stress response, and recovery time.
3. Hybrid procedures involving surgical debranching of visceral arteries combined with TEVAR can benefit high-risk patients and provide alternatives to open repair, with lower reported complications and mortality compared to open surgery.
This document discusses different mechanical atherectomy devices used to treat peripheral artery disease, including directional atherectomy devices like SilverHawk, orbital atherectomy devices like Diamondback, rotational atherectomy like Jetstream, and excimer laser atherectomy. It provides details on the types of lesions each device is best suited for and outcomes from studies on device safety and efficacy.
This document discusses evidence related to drug-coated balloons (DCBs) for the treatment of below-the-knee peripheral artery disease. It summarizes key studies including the DEBATE-BTK trial which found that DCBs reduced restenosis compared to angioplasty alone at 1 year. It also summarizes the IN.PACT DEEP trial, the first large randomized trial of DCBs for below-the-knee lesions, which did not meet its primary endpoints of reducing late lumen loss or reintervention rates compared to angioplasty alone at 1 year, though it did meet its primary safety endpoint of non-inferiority. Upcoming randomized controlled trials are
This document discusses the concept of angiosomes, which are three-dimensional zones in the body supplied by specific source arteries and drained by specific veins. It summarizes several studies that found treating ulcers by revascularizing the specific angiosome had better healing rates than treating the boundary artery. However, other studies found indirect revascularization through collateral vessels provided similar results to direct revascularization. The document calls for more high-quality randomized controlled trials to standardize definitions and account for confounding factors to better understand the effect of indirect revascularization through collaterals on outcomes. It concludes that obtaining a direct revascularization to the foot, even if not to the specific injured angiosome, improves results and subsequent appropriate podiatric care is
1) Endovascular treatment is the preferred strategy for revascularization below-the-knee (BTK) due to involvement of multiple lesions, but requires a thorough toolbox of devices.
2) Access selection and catheter positioning are critical, with ultrasound guidance recommended for pedal access. Wires are the most important devices, with specialty wires needed for different lesion types.
3) Other key devices include balloons matched to lesion length, stents for suboptimal angioplasty, and debulking devices to modify complex plaques, all of which require understanding their performance characteristics.
This document summarizes techniques for endovascular treatment of aorto-iliac occlusive disease. It discusses:
1) Technical success rates are high but complications can occur, especially with chronic total occlusions. Primary stenting is preferred over PTA with provisional stenting for long lesions.
2) Patency rates at 5-10 years range from 46-96% depending on the location and type of lesion. Risk factors for restenosis include occlusion length and poor runoff.
3) Endovascular treatment has advantages over open surgery like shorter hospital stays and lower complications/mortality, though open bypass has higher long term patency. Drug-eluting devices may help address issues of rest
This document discusses the TASC (TransAtlantic Inter-Society Consensus) process and documents for classifying and making treatment recommendations for peripheral artery disease (PAD). It notes that while the TASC classification is useful, the revascularization recommendations are often ignored in practice due to changes in technology. Additionally, the TASC process is subject to political influence from vascular societies that can prevent publication of documents not aligned with their views, hindering progress. Overall, the classification aspect of TASC remains important, but the process could be improved by reducing political influences from professional societies.
EPIDEMOLOGY AND CLINICAL PRESENTATION IN ARAB WORLDPAIRS WEB
- Risk factors for PAD such as diabetes, obesity, and smoking are highly prevalent in the Arab world, particularly in Egypt and Gulf countries.
- PAD is slightly more common in this population, with diabetics comprising 52-91% of PAD patients depending on the location of the lesions.
- Multi-level disease is present in 20% of cases. Approximately 50% of patients have a single runoff vessel.
- TASC D lesions representing the most severe cases are highly prevalent. Diabetic foot infection is also common in Arabs.
- Inflammatory arterial diseases such as Behcet's, Beurger's, and non-specific arteritis are more common in the Middle East.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
How to Control Your Asthma Tips by gokuldas hospital.Gokuldas Hospital
Respiratory issues like asthma are the most sensitive issue that is affecting millions worldwide. It hampers the daily activities leaving the body tired and breathless.
The key to a good grip on asthma is proper knowledge and management strategies. Understanding the patient-specific symptoms and carving out an effective treatment likewise is the best way to keep asthma under control.
Are you looking for a long-lasting solution to your missing tooth?
Dental implants are the most common type of method for replacing the missing tooth. Unlike dentures or bridges, implants are surgically placed in the jawbone. In layman’s terms, a dental implant is similar to the natural root of the tooth. It offers a stable foundation for the artificial tooth giving it the look, feel, and function similar to the natural tooth.
PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
Since our release of the PGx capabilities in VarSeq, we’ve had a few months to gather some insights from various use cases. Some users approach PGx workflows by means of array genotyping or what seems to be a growing trend of adding the star allele calling to the existing NGS pipeline for whole genome data. Luckily, both approaches are supported with the VarSeq software platform. The genotyping method being used will also dictate what the scope of the tertiary analysis will be. For example, are your PGx reports a standalone pipeline or would your lab’s goal be to handle a dual-purpose workflow and report on PGx + Diagnostic findings.
The purpose of this webcast is to:
Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
Following genotyping, explore alternative tertiary workflow concepts in VarSeq to handle PGx reporting.
Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
“Psychiatry and the Humanities”: An Innovative Course at the University of Mo...Université de Montréal
“Psychiatry and the Humanities”: An Innovative Course at the University of Montreal Expanding the medical model to embrace the humanities. Link: https://www.psychiatrictimes.com/view/-psychiatry-and-the-humanities-an-innovative-course-at-the-university-of-montreal
1. A new trend in venous access programs:
PICC first
Mauro Pittiruti
Catholic University, Rome - Italy
2. PICC first
• A new worldwide strategy which is changing the
world of venous access
– PICC has become the first choice for both intra-
hospital and extra-hospital central venous access
3. Something’s changed after 2001…
…with regards to PICC insertion:
–HOW ? – US-guidance, EKG-guidance !
–WHY ? – safety and cost-effectiveness !
–WHEN ? – for any central line !
–BY WHOM ? – nurses !
6. Ultrasound have changed the
fundamental features of PICCs
• Traditional PICCs vs US-guided PICCs:
– Two radically different devices, in terms of:
• Indication
• Technique of insertion
• Rate of complications at insertion
• Rate of late complications
• Patient’s comfort
7. PICC in XX century:
‘blind’ insertion
Basilic or cephalic vein
in the antecubital fussa
(veins which can be
seen or palpated)
8. “blind” PICC insertion
• Catheter through needle
(breakaway needle)
• Catheter through cannula
• Catheter over guidewire
(Seldinger diretto)
• Catheter through
introducer
(Seldinger ‘indiretto’)
9. PICC in the XX century
were inserted exclusively without US
• HIGH INCIDENCE OF COMPLICATIONS AT INSERTION
• Failure (even 30% !)
• Malpositions ( > 20%)
• HIGH INCIDENCE OF LATE COMPLICATIONS
• Infection
• Venous thrombosis
• MINIMAL PATIENT COMFORT
11. US-guided insertion of PICC
• Puncture of deep peripheral veins
located at the upper midarm
• Exit site: above the antecubital fussa
1. INSERTION IN ANY PATIENT (even in
patients with ‘no veins’)
2. VERY LOW INCIDENCE OF
COMPLICATIONS AT INSERTION
3. VERY LOW INCIDENCE OF LATE
COMPLICATIONS
4. OPTIMAL PATIENT COMFORT
12. Which veins ?
1.BASILIC vein
First choice
Adequate diameter (3 – 6 mm.)
Not in proximity of arteries or nerves
2.BRACHIAL veins
Second choice
Close to brachial artery and median
nerve
3.CEPHALIC veins
Only in selected patients (obese, etc,)
Too superficial
Too many valves
Non-linear trajectory
13. US anatomy
• training required
• Few, simple notions
Vein:
Round, empty
circle
Vein:
- Easy to collapse
- No pulsation
17. 3. Cephalic vein
• Third choice
• Not a ‘deep’ vein
• Enters the axillary vein at 90°
• Higher risk of thrombosis
• Higher risk di malpositions
• Useful in morbidly obese patients
18. Traditional method for
estimation of the
distance between
puncture site and cavo-
atrial junction
Before PICC insertion
Midclav.
Distance between
midclavicular
point and 3°
intercostal space
Distance between
puncture site and
midclavicular point
19. Alternative method
(Ocado) for estimation of
the distance between
puncture site and cavo-
atrial junction
Before PICC insertion
Notch
Add 10 cm (right)
or 15 cm (left)
Distance between
puncture site and
suprasternal notch
20. Technical choices
• Relationship between vein and probe
– Short axis vs. long axis
• Relationship between vein and needle direction
– ‘In plane’ puncture vs. ‘out of plane’ puncture
• Needle guide
– Needle-guide vs. free hand
26. Technical choices
• Routine recommendations:
– Vein visualization in short axis (transversal,
panoramic view of all crucial structures)
– ‘Out of plane’ puncture (needle’s trajectory not
included in the plane of the probe)
– Free hand technique (more versatile and effective)
• needle guide only during training
33. But US-guidance is not enough
• Successful puncture and cannulation of the vein is
not enough
• We need proper placement of the tip of the central
line:
EKG guidance
35. Intracavitary ECG (lead II)
The intracavitary electrode is
the tip of the catheter
Based on changes of P wave
during the progression of the
catheter into the central veins
CAVO-ATRIAL JUNCTION:
maximal peak of the P wave
(Stas, Yeon, Schummer,
Pittiruti, La Greca, etc,)
( = CRISTA TERMINALIS)
IC-EKG method
37. A very old method…
Von Hellerstein HK
Recording of intracavitary potentials through a single-
lumen saline filled cardiac catheter. Proc Soc Exp Biol
Med 71:58-60, 1949
42. Applicability
- The IC-EKG method is applicable to any central
venous access, valved or not, peripherally inserted or
not, independently from the access technique.
- Current limit of IC-EKG method: it is applicable only
in patients with evident P wave in the surface ECG
This excludes 7 – 9 % of patients: atrial fibrillation,
pacemaker (if constantly active), so called ‘junctional
rhythm’, atrial flutter, etc.
43. Feasibility
Feasibility = in which % of cases do we get an ‘atrial
P’ in the intracavitary EKG?
•GAVeCeLT multicenter study 2012:
– 1440 patients, any type of VAD
– All pts with evident P on basal ECG
– Both saline technique and guidewire technique
– Overall feasibility 99.3 %
• Feasibility with the saline technique 99.9 %
• Feasibility with the guidewire technique 98.6 %
44. Feasibility
0.7 % of failure (not feasibility) depends on:
Technical problems of the connection between
monitor and catheter
Technical problems of the ECG monitor
Experience of the operator (ability to recognize
P changes)
Low signal (catheter < 3Fr)
45. Accuracy
Accuracy = in which % the ‘atrial P’ corresponds
to the cavo-atrial junction?
Almost 99%
46. IC-EKG - Is it accurate?
In the last two decades, many clinical studies
have proved the accuracy of the EKG method:
- Compared with radiological methods
- Compared with trans-esophageal
echocardiography (TEE)
47. Accuracy
Very high for echocardiography: TTE or TEE
Specially: TTE + CEUS
(contrast-enhanced ultrasonography)
Very low for fluoroscopy and chest x-ray
Subjective interpretation
No common criteria for CAJ
‘Interpretation of shadows’ (M.Costantino)
48. TEE vs IC-EKG
Cavoatrial junction = maximal P wave (EKG)
Cavoatrial junction = crista terminalis (TEE)
100% accuracy - In 30 patients, EKG = TEE
20042004
[12] International Anesthesia Research Journal
56. GAVeCeLT Multicenter Study
8 hospitals, 1440 patients
Any type of central VAD
Intra-procedural IC- EKG vs. post-procedural X-
Ray
X-ray criteria for CAJ:
CAJ = 3 cm below the carina
Lower 1/3 SVC = 1-3 cm below the carina
Upper 1/3 RA = 3-5 cm below the carina
20122012
57. GAVeCeLT Multicenter Study
IC-EKG (intra-op.) vs. Chest X-Ray (postop.)
Total Match (Accuracy): 95,4 %
Mismatch EKG/Xray = 3.8 % (55 cases)
in 44/55 cases, tip was higher on X-Ray
… but in most of these patients post-op- Chest X-Ray
had been performed in standing position
58. GAVeCeLT Multicenter Study
IC-EKG (intraop.) vs. Chest X-Ray (postop.)
…considering the confounding factor that
IC-EKG had been performed in supine
position and Chest X-Ray in standing
position:
Match (Accuracy): 99 %
59. Safety
Yes
GAVeCeLT Multicenter Study 2012:
1440 patients, any type of VAD
No complication - directly or indirectly related to the
EKG method – was reported
The overall incidence of arrhythmias was low (0.7%)
GAVeCeLT Pediatric Multicenter Study 2013:
309 children, any type of VAD
No complication - directly or indirectly related to the
EKG method – was reported
65. Cost effectiveness
Low cost method
‘low cost’ training
Applicable even when X-Ray is contraindicated or
difficult or expensive (pregnancy, morbid obesity,
hospice, home care, etc.)
‘real time’ verification
i.v. treatment can start immediately after
Save money (cost of X-Ray, cost of repositioning)
65
66. Cost effectiveness
In its basic form: IC-EKG is inexpensive
(connection cables cost few euros)
Big saving comes from:
Avoiding expensive equipment (fluoroscopy, TEE)
Avoiding x-ray expenses (direct and indirect)
Avoiding delay due to post-procedural chest x-ray
or post-procedural TEE/TTE)
Avoiding need for reposition (it may happen with
post-procedural chest x-ray or post-procedural
TEE/TTE)
67. In conclusion: IC-EKG
• Applicable in 91-93% of adults and 99% of
children
• Feasible in 99%
• Safety 100%
• Accurate (maximal P = CAJ) in 91-99% of cases
– ‘real’ accuracy (IC-EKG vs TEE): 99%
– ‘standard ‘ accuracy (IC-EKG vs Xray): 91-98%
68. P r a c t i c a l d e c i s i o n a l t r e e
B a s a l E C G
P w a v e e v i d e n t P w a v e n o n -e v i d e n t ( A F , e t c .)
N o d i f f i c u l t y
D i f f i c u l t y
( a n t i c i p a t e d o r
e x p e r i e n c e d d u r i n g
t h e p r o c e d u r e )
T i p l o c a t i o n
b y I C - E C G
T i p n a v i g a t i o n b y C o r p a k
T i p l o c a t i o n b y I C -E C G
N a v i g a t o r ( C o r p a k ) f o r t i p n a v i g a t i o n
a n d f o r a p p r o x i m a t e d t i p l o c a t i o n
( 3 r d i n t e r c o s t a l s p a c e )
C o n f i r m a t i o n o f t i p l o c a t i o n
a f t e r t h e p r o c e d u r e
( c h e s t x -r a y i n a d u l t s
t r a n s -t h o r a c i c e c h o . i n c h i l d r e n )
72. US-PICC = a new venous access device
PICC
Very selected indications
High rate of failure at
insertion
High rate of malpositions
High rate of late
complications (infection,
thrombosis)
No comfort for the patient
US-PICC
Wide indications
Success rate at insertion
close to 100%
No malposition (IC-EKG)
Very low incidence of late
complications (infection,
thrombosis)
Maximal patient compliance
95. Key to uneventful insertion:
Use a bundle of evidence-based, cost-effective
strategies:
US assessment
US guidance
Intracavitary EKG guide
microintroducer technique
sutureless securement
…….
97. The SIP protocol
1. Hand washing, aseptic technique and maximal barrier
protection
2. Bilateral US scan of all veins at arm and neck
3. Choice of the appropriate vein at midarm (vein mm =
or > cath Fr)
4. Clear identification of median nerve and brachial artery
5. Ultrasound guided venipuncture
6. US scan of IJV during introduction of the PICC
7. EKG method for assessing tip position
8. Securing the PICC with a sutureless device
98. 1 - Hand washing, aseptic technique
and maximal barrier protection
• Maximal barrier protection include sterile gloves,
mask, hat, sterile gown and vast body drape over
the patient
• Clorhexidine 2% in alcoholic solution should be
preferred for skin preparation before PICC insertion
99. 2 - Bilateral US scan of all veins at
arm and neck
• Before deciding the vein to be cannulated, a
complete bilateral scan of most deep veins of the
arm (basilic, brachial) and the neck (axillary,
subclavian, internal jugular, brachio-cephalic)
should be performed, so to exclude major
abnormalities, to rule out pre-existing venous
thrombosis, and to choose the most appropriate
vein
• The deep veins of the arm should be evaluated with
and without tourniquet
100. 3 - Choice of the appropriate vein at
midarm (vein mm = or > cath Fr)
• To minimize the risk of local ‘peripheral’ venous
thrombosis, catheters should be inserted in veins
whose diameter is at least three times larger than
the catheter itself:
– 3 Fr catheter: 9 Fr (3 mm) vein or larger
– 4 Fr catheter: 12 Fr (4 mm) vein or larger
– 5 Fr catheter: 15 Fr (5 mm) vein or larger
– 6 Fr catheter: 18 Fr (6 mm) vein or larger
101. 4 - Clear identification of median
nerve and brachial artery
• The most effective method to avoid accidental
nerve injury is the direct visualization of the nerve
before and during venipuncture
• The most effective method to avoid accidental
arterial puncture is to identify and visualize the
brachial artery before and during any venipuncture
102. 5 - Ultrasound guided venipuncture
• Real time ultrasound guided venipuncture of a deep
vein (basilic or brachial) at midarm is the preferred
choice
• A micro-introducer kit is recommended, preferably
with a small gauge (21G) echogenic needle and a
0.018” soft straight tip nitinol guidewire
103. 6 - US scan of IJV during introduction
of the PICC
• While inserting the catheter into the introducer, the
ipsilateral internal jugular vein should be
compressed by the US probe, so to facilitate the
passage of the catheter from the subclavian vein
into the brachio-cephalic vein
• After the maneuvre, evidence of absence of the
catheter in the internal jugular veins of both sides
should be obtained by US scan
104. 7 - EKG method for assessing tip
position
• The EKG method is an inexpensive, effective, simple and
safe methodology for a real time assessment of the position
of the tip of the catheter during the procedure itself.
• A correct position of the tip (in the proximity of the cavo-atrial
junction) reduces the risk of catheter malfunction, fibrin
sleeve and catheter-related ‘central’ venous thrombosis
• Intra-procedural assessment of tip position avoids the costs
and risks associated with repositioning the PICC
105. 8 - Securing the PICC with a
sutureless device
• The PICC should be secured at the exit site
not by standard suture but by a sutureless
device, so to decrease the risk of infection,
dislocation and local thrombosis
106. Goals of the SIP bundle
– Minimize complications related to venipuncture:
• Failure, repeated punctures, nerve injury, arterial injury
– Minimize malpositions
– Minimize venous thrombosis
– Minimize dislocation
– Minimize infection
116. Advantages of US-PICCs vs. CVCs
• Absolutely safe insertion, even in fragile and
high-risk patients (coagulation abnormalities,
tracheostomy, cardio-respiratory disorders, etc.)
• Low cost insertion (nurse-based, bedside)
• Low rate of bacteremic infections (CRBSI)
• More comfortable exit site
• Longer duration
• Appropriate also for extrahospital management
118. US-PICC = low risk of infection
Why ?
-Exit site is distant from nasal/oral/tracheal
secretions
-Low contamination of arm skin
-Physical characteristics of arm skin (dry, thin)
-Exit site allows better cleaning and better
stabilization of the dressing
119. US-PICC = low risk of infection
Studies on CRBSI with ultrasound-guided PICCs
-0/1000 days (Gebauer 2004 – pts on PN)
-0.4/1000 days (Pittiruti 2006 – pts on PN)
-0/1000 days (Harnage 2006)
-0.3/1000 days (Scoppettuolo 2010 – infect.dis.pts)
-0/1000 days (Cotogni 2013 – cancer pts on HPN)
-0/1000 days (Botella 2013 – cancer pts on HPN)
120. Cost-effectiveness
• US-PICC means saving money
• To compare PICC vs. CVC is not just comparing
the raw cost of two devices, but to compare the
costs of two different clinical strategies:
– PICCs = lower insertion cost, lower maintenance costs
due to lower rate of complications, longer duration of
the line, etc.
121. Cost-effectiveness
Cost-effectiveness depends also on WHERE the US-PICC is inserted,
HOW and by WHOM (Smith, Wisconsin University 2011):
WHO WHERE HOW
$ 5000 surgeon operating
room
fluoroscopy + nurse
$ 2800 radiologist radiology suite fluoroscopy + technician
$ 1800 anaesthesist bedside no fluoro
$ 875 nurse bedside no fluoro
122. Cost-effectiveness
Cost-effectiveness of US PICCs (Catholic University, Rome, Italy
2011):
WHO WHERE HOW
€ 2500 surgeon operating room fluoroscopy + nurse
€ 1850 radiologist radiology suite fluoroscopy + technician
€ 280 nurse bedside IC-EKG
123. Myth
• ‘high incidence of thrombosis…’
NO
- if we consider only US-guided PICCs
- if we do a proper insertion (SIP protocol),
matching the vein diameter with the PICC
diameter
(Simcock 2008, ESPEN guidelines 2009)
124. Myth
• ‘low flow device…’
NO
if we use power polyurethane PICCs, we can get
up to 5 ml/sec !
125. Myth
• ‘high rate of lumen occlusion…’
NO
- if we use power polyurethane PICCs
- if we adopt a proper policy of flushing (saline
only)
126. Myth
• ‘cannot measure the CVP…’
NO
- if we use power polyurethane PICCs
- if we adopt a proper policy of flushing (saline
only)
- if we use open-ended, non-valved PICCs
128. PICC indications
• They have expanded:
– Use of insertion bundles and maintenance bundles
– Widespread use of power poliurethane PICCs
• High resistance
• Low rate of obstruction
• High flow
• Available as single, double or triple lumen
– New methods, such as tunnelling
130. US-PICCs = first-option central line
in hospitalized patients
• With few exceptions:
– Central line needed in the emergency room
– Patients with AV-fistula
– Patients with bilateral local contraindications to PICC
insertion (axillary node dissection, deep vein < 3mm,
skin or bone abnormalities, deep venous thrombosis,
etc.)
– Patients needing a central line with > 3 lumens
– Superior vena cava obstruction
131. Power polyurethane PICCs
• ideal central line for intra-hospital PN
• ideal central line for ‘chronic’ ICU patients
• ideal central line in the perioperative period
132.
133. Other options when PICC cannot be
inserted in the arm
• US-guided insertion of PICC in the axillary vein
(infraclavicular exit site)
• US-guided insertion of PICC in the brachio-
cephalic, subclavian or internal jugular veins
(supraclavicular exit site)
• US guided insertion of PICC in the femoral vein
(exit site at the groin is avoided by tunnelling)
139. Power polyurethane PICC
• ideal central line for short term extra-hospital PN
• ideal central line for palliative care
• ideal central line for advanced-stage cancer
patients at home or in hospice
140. US-PICCs = first-option central line
in non-hospitalized patients
• With few exceptions:
– Patients needing episodic, non-frequent venous access
(1/week or less frequent)
• Central PORT or PICC-PORT is recommended
– Patients needing a long term venous access for life-
time home parenteral nutrition due to benign disease
• Central tunneled/cuffed catheter is recommended
(though, it might be a tunneled/cuffed PICC !)
141. US-PICC in extrahospital setting
• Home care, Hospice, Day Hospital, etc.
• Different options
– Standard PICC
– Tunneled PICC
– Tunneled/cuffed PICC
– PICC port
161. Who is inserting?
• Surgeons, anesthestiologists, oncologists,
radiologists, etc.
• Nurses of different areas (anesthesia, pediatrics,
intensive care, oncology, etc.)
The important is:
• APPROPRIATE METHODOLOGY
• ADEQUATE TRAINING
163. Adequate Training
See the GAVeCeLT ‘4 x 4’ training protocol (for
both nurses and physicians)
-4 hrs of theory
-4 hrs of practice on simulators
-4 insertions seen and discussed with the tutor
-4 insertions done under supervision of the tutor
-Learning curve ( > 25 ins., < 3 mo.)
-Final audit
164.
165. Nurses or physicians?
The spreading of PICC use is clearly linked to the
philosophy of nurse-based venous access
The overall cost-effectiveness of PICCs may be
limited if the insertion is physician-based (even
worse if radiologist-based)
166. PICC/yr
• USA 2,500,000 nurses allowed
• UK 120,000
• Italy 33,000
• Spain 15,000
• Scandinavia 13,000
• France 7,000 nurses not allowed
• Benelux 5,000
• Germany 2,000
167. Italy, 2013
• Approximately 35,000 PICC/yr
– Every year, approx. + 25%
– 80% inserted by nurses
– > 100 hospitals have an active PICC team
– 100% of PICC teams are mixed nurses+physicians
– Intense activity of training/education in PICCs
• University Masters, Intensive courses both universitary
and/or organized by dedicated multiprofessional societies
(GAVeCeLT, WINFOCUS, etc.)
168. Catholic University, Rome - 2013
• More than 3500 PICC/yr for both intra-hospital
use (1300 beds) and extra-hospital use
• One PICC team (3 physicians + 9 nurses)
• 15 nurses specifically trained and formally
authorized for US-guided PICC insertion
• 90% PICCs are inserted by nurses
• Insertion of PICCs in all wards (intensive and
non-intensive, pediatrics and adults, etc.)
169. Catholic University, Rome - 2013
• Education and training
– University Master on Venous Access for nurses
– University Master on Venous Access for physicians
– 15 University courses (4x4) every year, focused
exclusively on PICC insertion
Education/training for both nurses and physicians
170. So, who is inserting?
• The answer is
– THE MULTIDISCIPLINARY,
MULTIPROFESSIONAL PICC TEAM
– Patient-oriented collaboration between nurses and
physicians can cover all possible aspects of venous
access management (definition of indications and
insertion/maintenance policies, prevention and
management of any possible complication, etc.)
172. The keys to a highly effective and
highly efficient venous access team
- ‘PICC first’ strategy
- Specifically trained PICC team
- Bedside approach
- Well defined insertion bundle (SIP bundle!) including:
Ultrasound assessment and ultrasound guidance
Intracavitary EKG guidance
174. WoCoVA
3rd World Congresson
Vascular Access
Berlin, Germany
June 18 -19 - 20, 2014
Be rlinerC ongre ssC ente r,June,18 -2 0 ,2 014
www.wocova.com
Following the success of the 1st and 2nd World
Congress of Vascular Access in 2010 and
2012, WoCoVA is proud to offer a 3rd World
Congress in June, 2014, again highlighting
global vascular access issues, technology
advances, evidence-based practices and an
opportunity to network with professionals
around the world.
All health care professionals interested in the
field of short and long term venous access are
warmly invited to attend this meeting. Scientific
and educational sessions hosted by
international experts will again offer an
exceptional occasion for updating knowledge in
this field, share experiences and learn of future
trends in the area of VADs. Posters and
abstracts will again be an important integral
part of the educational process.
History
WoCoVA, established in 2009 as a foundation
to create an independent platform to organize
worldwide congresses on vascular access, en-
courages all individuals and organizations
around the world involved in this specialty to
participate.
As a multidisciplinary and multi-professional
congress, WoCoVA strives to educate and
share all aspects of vascular access:
indications for the choice of the device,
insertion tech- niques, tip location methods and
prevention and management of all vascular
access device (VAD) related complications,
new technologies, and latest scientific research.
The World Congress on Vascular Access is
organized by the WoCoVA Foundation
P.O. Box 675, 3720 AR Bilthoven
The Netherlands
Berliner Congress Center
Alexanderstr. 11,
10178 Berlin,
Germany
There is a wide variety of accommodations close to the
Berliner Congress Center and the sparkling activities of
the city center.
Organizing Committee
Ton van Boxtel, Chairperson
Mauro Pittiruti, Scientific Committee Chairperson
Jacoline Zilverentant, Project Manager
Corine de Blank, Treasurer
Paul Blackburn, Strategic Planning Committee
Josie Stone, Strategic Planning Committee
Jan Ouwerkerk, Dutch Society Infusion Technology
Australia - Meron Bower /
Tim Spencer
Belgium - Lieve Goossens
Brazil - Pietro Rigamonti
Canada - Erin Davidson /
Sharon Armes
China - Henry Huang
Czech Republic - Martin
Stritesky
France - Eric Desruennes
Germany - Wolfram
Schummer
Italy - Mauro Pittirutti
Iran - Marteza Khavanin
Zadeh
Japan - Yuri Mukai
Mexico - Diego Amaya
New Zealand - Lynette
Lennox
Poland - Marek Pertkiewicz
Romania - Sorin Grunwald
South Africa - Tara
Emmenes
South Korea - Stephanie
Yoon
Spain - Maria Carmen
Carrero Caballero
Sweden - Karin Johansson
Switzerland - Ishan Inan
The Netherlands - Ton van
Boxtel
United Kingdom - Lisa
Dougherty / Carmel Streater
USA - Paul Blackburn / Josie
Stone
Global Committee
The Congress will be held June 18 - 20, 2014 in the
Berliner Congress Center, in the center of the beautiful
eastern part of the city of Berlin, Germany.