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Journal of Neurosurgery Apr 2015Dural arteriovenous fistulas (DAVFs) of the hypoglossal canal (HCDAVFs) are rare and display a complex angiographic anatomy. Hitherto, they have been referred to as... (Meta-Analysis)
Meta-Analysis Review
Dural arteriovenous fistulas (DAVFs) of the hypoglossal canal (HCDAVFs) are rare and display a complex angiographic anatomy. Hitherto, they have been referred to as various entities (for example, "marginal sinus DAVFs") solely described in case reports or small series. In this in-depth review of HCDAVF, the authors describe clinical and imaging findings, as well as treatment strategies and subsequent outcomes, based on a systematic literature review supplemented by their own cases (120 cases total). Further, the involved craniocervical venous anatomy with variable venous anastomoses is summarized. Hypoglossal canal DAVFs consist of a fistulous pouch involving the anterior condylar confluence and/or anterior condylar vein with a variable intraosseous component. Three major types of venous drainage are associated with distinct clinical patterns: Type 1, with anterograde drainage (62.5%), mostly presents with pulsatile tinnitus; Type 2, with retrograde drainage to the cavernous sinus and/or orbital veins (23.3%), is associated with ocular symptoms and may mimic cavernous sinus DAVF; and Type 3, with cortical and/or perimedullary drainage (14.2%), presents with either hemorrhage or cervical myelopathy. For Types 1 and 2 HCDAVF, transvenous embolization demonstrates high safety and efficacy (2.9% morbidity, 92.7% total occlusion). Understanding the complex venous anatomy is crucial for planning alternative approaches if standard transjugular access is impossible. Transarterial embolization or surgical disconnection (morbidity 13.3%-16.7%) should be reserved for Type 3 HCDAVFs or lesions with poor venous access. A conservative strategy could be appropriate in Type 1 HCDAVF for which spontaneous regression (5.8%) may be observed.
Topics: Central Nervous System Vascular Malformations; Cerebral Angiography; Drainage; Endovascular Procedures; Humans; Occipital Bone
PubMed: 25415064
DOI: 10.3171/2014.10.JNS14377 -
The Journal of Trauma and Acute Care... Aug 2014Diagnosis of vascular injury in pediatric trauma is challenging as clinical signs may be masked by physiologic compensation. We aimed to (1) investigate the prevalence... (Review)
Review
BACKGROUND
Diagnosis of vascular injury in pediatric trauma is challenging as clinical signs may be masked by physiologic compensation. We aimed to (1) investigate the prevalence of noniatrogenic pediatric venous injuries, (2) discuss options in management of traumatic venous injury, and (3) investigate mortality from venous injury in pediatric trauma. Our objective was to provide the practicing clinician with a summary of the published literature and to develop an evidence-based guide to the diagnosis and management of traumatic venous injuries in children.
METHODS
A systematic review of published literature (PubMed) describing noniatrogenic traumatic venous injury in the pediatric population (<17 years) was performed according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] guidelines. Data were retrieved systematically under the following headings: Study Design, Population Demographics (dates of recruitment, mean age, mechanism of injury), Diagnostic Approach, Vessel Injured, Management (operative technique), and Mortality.
RESULTS
Thirteen articles were included in this systematic review. In total, 508 noniatrogenic traumatic venous injuries were reported in children between the year 1957 and present day. Mechanisms of injury included blunt trauma from seat belt-related injury and fall from height or penetrating trauma from gunshot and foreign object. Injury to the inferior vena cava was most frequently reported, followed by femoral vein and internal jugular injuries. Primary repair was the most frequently reported technique for surgical repair (38%), followed by ligation (25%) and end-to-end anastomosis (15%). Mortality in pediatric trauma patients who had venous injury was reported as 0% to 67% in published series, highest in the series in which the most frequently reported injury was of the inferior vena cava.
CONCLUSION
Traumatic venous injury in the pediatric population is uncommon but may be associated with significant morbidity and mortality. Intra-abdominal venous injuries are associated with high mortality from exsanguination. Early diagnosis and intervention are therefore essential in such cases.
LEVEL OF EVIDENCE
Systematic review, level IV.
Topics: Child; Evidence-Based Medicine; Humans; Mortality; Prevalence; Veins
PubMed: 25058265
DOI: 10.1097/TA.0000000000000312 -
Clinical Anatomy (New York, N.Y.) May 2014The thoracic duct (TD) transports ingested fat, drains lymph from the gastrointestinal vascular bed, and delivers the lymph to central veins in the neck. Preliminary... (Review)
Review
The thoracic duct (TD) transports ingested fat, drains lymph from the gastrointestinal vascular bed, and delivers the lymph to central veins in the neck. Preliminary evidence suggests that diversion of TD lymph may mitigate the severity of end-organ dysfunction in critical illness. Variations in the anatomy of the TD may determine whether reliable and safe cannulation of the duct, a necessary step for diversion, is possible. A systematic review was undertaken using the Google Scholar, MEDLINE, PubMed, and Scopus databases until 31st March, 2013. Both English and non-English articles were searched for, and surgical, cadaveric, and radiologic studies were included. Fifty-seven articles from the past 102 years were retrieved. There are significant variations in the anatomy of the TD in terms of its formation at the cisterna chyli, its course through the thorax, and its termination in the venous system. The most common site of termination is at the internal jugular vein (46%), followed by the jugulosubclavian angle (32%), and the subclavian vein (18%). An improved understanding of the anatomy of the TD would help surgeons to avoid inadvertent injury and potentially afford new opportunities for diagnosis and intervention in patients with critical illness.
Topics: Anatomic Variation; Humans; Neck; Thoracic Duct
PubMed: 24302465
DOI: 10.1002/ca.22337 -
Scandinavian Journal of Trauma,... Dec 2013Cervical immobilisation is commonly applied following trauma, particularly blunt head injury, but current methods of immobilisation are associated with significant... (Review)
Review
Cervical immobilisation is commonly applied following trauma, particularly blunt head injury, but current methods of immobilisation are associated with significant complications. Semi-rigid disposable cervical collars are known to cause pressure ulcers, and impede effective airway management. These collars may also exacerbate a head injury by increasing intracranial pressure as a result of external compression of the jugular veins. There is a clear imperative to find ways of effectively immobilising the cervical spine whilst minimising complications, and any assessment of existing or new devices should include a standardized approach to the measurement of tissue interface pressures and their effect on jugular venous drainage from the brain. This systematic review summarises the research methods and technologies that have been used to measure tissue interface pressure and assess the jugular vein in the context of cervical immobilisation devices. 27 papers were included and assessed for quality. Laboratory investigations and biomechanical studies have gradually given way to methods that more accurately reflect clinical care. There are numerous accounts of skin ulceration associated with cervical collars, but no standardised approach to measuring tissue interface pressure. It is therefore difficult to compare studies and devices, but a pressure of less than 30 mmHg appears desirable. Cervical collars have been shown to have a compressive effect on the jugular veins, but it is not yet certain that this is the cause of the increased intracranial pressure observed in association with cervical collar use. This is the first review of its type. It will help guide further research in this area of trauma care, and the development and testing of new cervical immobilisation devices.
Topics: Airway Management; Cervical Vertebrae; Humans; Immobilization; Jugular Veins; Pressure; Regional Blood Flow
PubMed: 24299024
DOI: 10.1186/1757-7241-21-81 -
Journal of Clinical Nursing Jul 2013To describe potential repositioning techniques of malpositioned peripherally inserted central catheters. (Review)
Review
AIMS AND OBJECTIVES
To describe potential repositioning techniques of malpositioned peripherally inserted central catheters.
BACKGROUND
Various repositioning methods have been applied in clinical practice in managing malpositioned peripherally inserted central catheters, and many of them are proved effective. However, little publication reviewed on those literatures describing repositioning techniques to malpositioned peripherally inserted central catheters.
DESIGN
Systematic review. The repositioning techniques were classified and concretely described according to different locations of malpositioned peripherally inserted central catheter tips.
METHODS
Literature and relevant guidelines were reviewed, focusing on malpositioned locations and incidence, as well as repositioning skills to peripherally inserted central venous catheters. Six databases were searched, including MEDLINE, web of science, CINAHL, Cochrane library, Wanfang database and Chinese National Knowledge Infrastructure. The articles (n = 21) were analysed using inductive content analysis.
RESULTS
The malpositioned locations of postplacement peripherally inserted central catheter tips mainly include right atrium, right ventricular, axillary vein, ipsilateral and contralateral internal jugular vein, subclavian vein, brachiocephalic vein, other small venous branches or catheter looped. Repositioning techniques contained automatic reposition, manual repositioning techniques, re-advancing catheters and catheters' replacement according to different malpositioned patterns.
CONCLUSIONS
The most appropriate repositioning techniques should be adopted on the basis of malpositioned locations, direction and length of the malpositioned tip, patients' integrated conditions and available medical equipments to maintain the catheter tip in the best position.
RELEVANCE TO CLINICAL PRACTICE
The repositioning techniques described in this review can be applied in clinical practice to ensure the infusion therapy through peripherally inserted central catheter more economical and safe.
Topics: Catheterization, Central Venous; Humans; Infant, Newborn
PubMed: 23240918
DOI: 10.1111/jocn.12004 -
The Cochrane Database of Systematic... Dec 2012Multiple sclerosis (MS) is a leading cause of neurological disability in young adults. The most widely accepted hypothesis regarding its pathogenesis is that it is an... (Review)
Review
BACKGROUND
Multiple sclerosis (MS) is a leading cause of neurological disability in young adults. The most widely accepted hypothesis regarding its pathogenesis is that it is an immune-mediated disease. It has been hypothesised more recently that chronic venous congestion may be an important factor in the pathogenesis of MS. This concept has been named 'chronic cerebrospinal venous insufficiency' (CCSVI) and is characterised by stenoses of either the internal jugular or azygos veins, or both. It is suggested that these stenoses restrict the normal blood flow from the brain, causing the deposition of iron in the brain and the eventual triggering of an auto-immune response. The proposed treatment for CCSVI is percutaneous transluminal angioplasty, also known as the 'liberation procedure', which is claimed to improve the blood flow in the brain thereby alleviating some of the symptoms of MS.
OBJECTIVES
To assess the effects of percutaneous transluminal angioplasty for the treatment of CCSVI in people with MS.
SEARCH METHODS
We searched the following databases up to June 2012: The Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register, CENTRAL in The Cochrane Library 2012, Issue 5, MEDLINE (from 1946), EMBASE (from 1974), and reference lists of articles. We also searched several online trials registries for ongoing trials.
SELECTION CRITERIA
Randomised controlled trials assessing the effects of percutaneous transluminal angioplasty in adults with multiple sclerosis, that have been diagnosed to have CCSVI.
DATA COLLECTION AND ANALYSIS
Our searches retrieved 159 references, six of which were to ongoing trials. Based on assessment of the title or abstract, or both, we excluded all of the studies, with the exception of one which was evaluated following examination of the full text report. However, this study also did not meet our inclusion criteria and was subsequently excluded.
MAIN RESULTS
No randomised controlled trials met our inclusion criteria.
AUTHORS' CONCLUSIONS
There is currently no high level evidence to support or refute the efficacy or safety of percutaneous transluminal angioplasty for treatment of CCSVI in people with MS. Clinical practice should be guided by evidence supported by well-designed randomised controlled trials: closure of some of the gaps in the evidence may be feasible at the time of completion of the six ongoing clinical trials.
Topics: Angioplasty; Azygos Vein; Cerebrovascular Circulation; Chronic Disease; Humans; Hyperemia; Jugular Veins; Multiple Sclerosis; Spinal Cord Ischemia; Venous Insufficiency
PubMed: 23235683
DOI: 10.1002/14651858.CD009903.pub2 -
Critical Care Medicine Aug 2012Catheter-related bloodstream infections are an important cause of morbidity and mortality in hospitalized patients. Current guidelines recommend that femoral venous... (Comparative Study)
Comparative Study Meta-Analysis Review
The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis.
BACKGROUND
Catheter-related bloodstream infections are an important cause of morbidity and mortality in hospitalized patients. Current guidelines recommend that femoral venous access should be avoided to reduce this complication (1A recommendation). However, the risk of catheter-related bloodstream infections from femoral as compared to subclavian and internal jugular venous catheterization has not been systematically reviewed.
OBJECTIVE
A systematic review of the literature to determine the risk of catheter-related bloodstream infections related to nontunneled central venous catheters inserted at the femoral site as compared to subclavian and internal jugular placement.
DATA SOURCES
MEDLINE, Embase, Cochrane Register of Controlled Trials, citation review of relevant primary and review articles, and an Internet search (Google).
STUDY SELECTION
Randomized controlled trials and cohort studies that reported the frequency of catheter-related bloodstream infections (infections per 1,000 catheter days) in patients with nontunneled central venous catheters placed in the femoral site as compared to subclavian or internal jugular placement.
DATA EXTRACTION
Data were abstracted on study design, study size, study setting, patient population, number of catheters at each insertion site, number of catheter-related bloodstream infections, and the prevalence of deep venous thrombosis. Studies were subgrouped according to study design (cohort and randomized controlled trials). Meta-analytic techniques were used to summarize the data.
DATA SYNTHESIS
Two randomized controlled trials (1006 catheters) and 8 cohort (16,370 catheters) studies met the inclusion criteria for this systematic review. Three thousand two hundred thirty catheters were placed in the subclavian vein, 10,958 in the internal jugular and 3,188 in the femoral vein for a total of 113,652 catheter days. The average catheter-related bloodstream infections density was 2.5 per 1,000 catheter days (range 0.6-7.2). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian/internal jugular sites in the two randomized controlled trials (i.e., no level 1A evidence). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian sites. The internal jugular site was associated with a significantly lower risk of catheter-related bloodstream infections compared to the femoral site (risk ratio 1.90; 95% confidence interval 1.21-2.97, p=.005, I²=35%). This difference was explained by two of the studies that were statistical outliers. When these two studies were removed from the analysis there was no significant difference in the risk of catheter-related bloodstream infections between the femoral and internal jugular sites (risk ratio 1.35; 95% confidence interval 0.84-2.19, p=0.2, I=0%). Meta-regression demonstrated a significant interaction between the risk of infection and the year of publication (p=.01), with the femoral site demonstrating a higher risk of infection in the earlier studies. There was no significant difference in the risk of catheter-related bloodstream infection between the subclavian and internal jugular sites. The risk of deep venous thrombosis was assessed in the two randomized controlled trials. A meta-analysis of this data demonstrates that there was no difference in the risk of deep venous thrombosis when the femoral site was compared to the subclavian and internal jugular sites combined. There was, however, significant heterogeneity between studies.
CONCLUSIONS
Although earlier studies showed a lower risk of catheter-related bloodstream infections when the internal jugular was compared to the femoral site, recent studies show no difference in the rate of catheter-related bloodstream infections between the three sites.
Topics: Catheter-Related Infections; Catheters, Indwelling; Femoral Vein; Humans; Jugular Veins; Risk Factors; Sepsis; Subclavian Vein
PubMed: 22809915
DOI: 10.1097/CCM.0b013e318255d9bc -
Emergency Medicine Journal : EMJ May 2013The superiority of ultrasonic-guided compared with landmark-guided central venous catheter (CVC) placement is not well documented in the Emergency Department. (Review)
Review
INTRODUCTION
The superiority of ultrasonic-guided compared with landmark-guided central venous catheter (CVC) placement is not well documented in the Emergency Department.
OBJECTIVE
To systematically review the literature comparing success rates between ultrasonic- and landmark-guided CVC placement by ED physicians.
METHODS
PubMed and EMBASE databases were searched for randomised controlled trials from 1965 to 2010 using a search strategy derived from the following PICO formulation:
PATIENTS
Adults requiring emergent CVC placement except during cardiopulmonary resuscitation.
INTERVENTION
CVC placement using real-time ultrasonic guidance. Comparator: CVC placement using anatomical landmarks.
OUTCOME
Comparison of success rates of CVC placement between ultrasonic- versus landmark-guided techniques.
ANALYSIS
Success rates between CVC placement methods using a Forest Plot (95% CI) calculated by Review Manager Version 5.0.
RESULTS
Search identified 944 articles of which 938 were excluded by title/abstract relevance, two not randomised, one cardiac arrest, one no landmark control, one success rate not calculated. A single study of 130 patients (65 ultrasonic- vs 65 landmark-guided) selected for internal jugular vein placement remained. Successful internal jugular CVC was significantly (p=0.02) more likely in the ultrasound-guided (93.9%) compared with landmark-guided (78.5%) techniques with an OR of 1.2 (95% CI 1.0 to 1.4). Complications rates were significantly (p=0.04) lower in ultrasonic (4.6%) versus landmark (16.9%) technique, OR=3.7 (95% CI 1.1 to 12.5).
CONCLUSION
Only one single high quality study illustrating that ED ultrasound- versus landmark-guided internal jugular catheter placement had higher success rates with lower complication rates.
Topics: Administration, Intravenous; Adult; Anatomic Landmarks; Catheterization, Central Venous; Emergency Medicine; Emergency Service, Hospital; Humans; Randomized Controlled Trials as Topic; Ultrasonography, Interventional
PubMed: 22736720
DOI: 10.1136/emermed-2012-201230 -
The Cochrane Database of Systematic... Mar 2012Central venous access (CVA) is widely used. However, its thrombotic, stenotic and infectious complications can be life-threatening and involve high-cost therapy.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Central venous access (CVA) is widely used. However, its thrombotic, stenotic and infectious complications can be life-threatening and involve high-cost therapy. Research revealed that the risk of catheter-related complications varied according to the site of CVA. It would be helpful to find the preferred site of insertion to minimize the risk of catheter-related complications. This review was originally published in 2007 and was updated in 2011.
OBJECTIVES
1. Our primary objective was to establish whether the jugular, subclavian or femoral CVA routes resulted in a lower incidence of venous thrombosis, venous stenosis or infections related to CVA devices in adult patients.2. Our secondary objective was to assess whether the jugular, subclavian or femoral CVA routes influenced the incidence of catheter-related mechanical complications in adult patients; and the reasons why patients left the studies early.
SEARCH METHODS
We searched CENTRAL (The Cochrane Library 2011, Issue 9), MEDLINE, CINAHL, EMBASE (from inception to September 2011), four Chinese databases (CBM, WANFANG DATA, CAJD, VIP Database) (from inception to November 2011), Google Scholar and bibliographies of published reviews. The original search was performed in December 2006. We also contacted researchers in the field. There were no language restrictions.
SELECTION CRITERIA
We included randomized controlled trials comparing central venous catheter insertion routes.
DATA COLLECTION AND ANALYSIS
Three authors assessed potentially relevant studies independently. We resolved disagreements by discussion. Dichotomous data on catheter-related complications were analysed. We calculated relative risks (RR) and their 95% confidence intervals (CI) based on a random-effects model.
MAIN RESULTS
We identified 5854 citations from the initial search strategy; 28 references were then identified as potentially relevant. Of these, we Included four studies with data from 1513 participants. We undertook a priori subgroup analysis according to the duration of catheterization, short-term (< one month) and long-term (> one month) defined according to the Food and Drug Administration (FDA).No randomized controlled trial (RCT) was found comparing all three CVA routes and reporting the complications of venous stenosis.Regarding internal jugular versus subclavian CVA routes, the evidence was moderate and applicable for long-term catheterization in cancer patients. Subclavian and internal jugular CVA routes had similar risks for catheter-related complications. Regarding femoral versus subclavian CVA routes, the evidence was high and applicable for short-term catheterization in critically ill patients. Subclavian CVA routes were preferable to femoral CVA routes in short-term catheterization because femoral CVA routes were associated with higher risks of catheter colonization (14.18% or 19/134 versus 2.21% or 3/136) (n = 270, one RCT, RR 6.43, 95% CI 1.95 to 21.21) and thrombotic complications (21.55% or 25/116 versus 1.87% or 2/107) (n = 223, one RCT, RR 11.53, 95% CI 2.80 to 47.52) than with subclavian CVA routes. Regarding femoral versus internal jugular routes, the evidence was moderate and applicable for short-term haemodialysis catheterization in critically ill patients. No significant differences were found between femoral and internal jugular CVA routes in catheter colonization, catheter-related bloodstream infection (CRBSI) and thrombotic complications, but fewer mechanical complications occurred in femoral CVA routes (4.86% or 18/370 versus 9.56% or 35/366) (n = 736, one RCT, RR 0.51, 95% CI 0.29 to 0.88).
AUTHORS' CONCLUSIONS
Subclavian and internal jugular CVA routes have similar risks for catheter-related complications in long-term catheterization in cancer patients. Subclavian CVA is preferable to femoral CVA in short-term catheterization because of lower risks of catheter colonization and thrombotic complications. In short-term haemodialysis catheterization, femoral and internal jugular CVA routes have similar risks for catheter-related complications except internal jugular CVA routes are associated with higher risks of mechanical complications.
Topics: Bacterial Infections; Catheter-Related Infections; Catheterization, Central Venous; Constriction, Pathologic; Femoral Vein; Humans; Jugular Veins; Randomized Controlled Trials as Topic; Subclavian Vein; Venous Thrombosis
PubMed: 22419292
DOI: 10.1002/14651858.CD004084.pub3 -
Paediatric Anaesthesia Dec 2009Central venous catheter placement is technically difficult in pediatric population especially in the younger patients. Ultrasound prelocation and/or guidance (UPG) of... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Central venous catheter placement is technically difficult in pediatric population especially in the younger patients. Ultrasound prelocation and/or guidance (UPG) of internal jugular vein (IJV) access has been shown to decrease failure rate and complications related to this invasive procedure. The goal of the present study was to perform a systematic review of the advantages of UPG over anatomical landmarks (AL) during IJV access in children and infants.
MATERIAL AND METHODS
A comprehensive literature search was conducted to identify clinical trials that focused on the comparison of UPG to AL techniques during IJV access in children and infants. Two reviewers independently assessed each study to meet inclusion criteria and extracted data. Data from each trial were combined to calculate the pooled odds ratio (OR) or the mean differences (MD), and their 95% confidence intervals [CI 95%]. I(2) statistics were used to assess statistics heterogeneity and to guide the use of fixed or random effect for computation of overall effects. Subgroup analysis was used to clarify the effects of the techniques used (prelocation or guidance) or the experience of practitioners.
RESULTS
Literature found five articles. Most of the patients were cardiac surgery patients. In comparison with AL, UPG had no effect on IJV access failure rate (OR = 0.28 [0.05, 1.47], I(2) = 75%, P = 0.003), the rate of carotid artery puncture (OR = 0.32 [0.06, 1.62], I(2) = 68%, P = 0.01), haematoma, haemothorax, or pneumothorax occurrence (OR = 0.40 [0.14, 1.13], I(2) = 17%, P = 0.30, OR = 0.72, OR = 0.81 [0.18, 3.73], I(2) = 0%, P = 0.94, respectively) and time to IJV access and haemothorax/pneumothorax occurrence. Subgroup analysis found an efficacy of ultrasound when used by novice operators or during intraoperative use.
DISCUSSION
This current meta-analysis does not found the utility of ultrasound during IJV access in children and infants in increasing the success rate and in decreasing complications.
Topics: Carotid Artery Injuries; Catheterization, Central Venous; Child; Child, Preschool; Hematoma; Humans; Infant; Infant, Newborn; Jugular Veins; Randomized Controlled Trials as Topic; Treatment Outcome; Ultrasonography, Interventional
PubMed: 19863734
DOI: 10.1111/j.1460-9592.2009.03171.x