Autonomous Vascular Access Devices: Current Solutions and Future Challenges.

Should Arterial Lines Remain Routine in Shock? A Nursing Viewpoint

Abstract: Arterial lines remain a mainstay in intensive care units for continuous blood pressure monitoring (figure 1), frequent arterial blood sampling including blood gases, connection to pulse contour analysis devices for advanced hemodynamic parameters such as stroke volume, cardiac output, and pulse pressure variation, and guidance during cardiopulmonary resuscitation. The EVERDAC trial by Muller et al. challenges routine placement, showing that in critically ill patients with shock, deferring arterial catheterization and using initial noninvasive monitoring with an automated brachial cuff was noninferior to early invasive monitoring for 28-day mortality (34.3% versus 36.9%; adjusted risk difference, −3.2 percentage points; 95% CI, −8.9 to 2.5). Strikingly, only 14.7% of patients in the noninvasive group required later arterial line insertion, while the invasive group experienced higher rates of hematoma or hemorrhage (8.2% versus 1.0%). Device-related pain or discomfort was slightly more common in the noninvasive group (13.1% versus 9.0%), but secondary outcomes, including Sequential Organ Failure Assessment score evolution, ventilator-free days, and 90-day mortality (42.7% versus 44.0%), showed no significant differences.

A Review of Peripheral Vascular Intervention Technologies

Background/Objectives: Chronic limb-threatening ischemia (CLTI) is the end stage of peripheral arterial disease (PAD) and leads to severe morbidity and mortality. With an increase in diabetes mellitus (DM) and an aging population, tibial artery CLTI is becoming more prevalent. Conventional endovascular devices are often limited by both length and size, highlighting the need for improved endovascular microcatheters. Methods: Here we provide a narrative review of CLTI in tibial disease and current treatment options, highlighting current endovascular techniques, the mechanics and challenges of current catheters, and call attention to the need for novel micro-steerable catheters. Results: Although PAD endovascular treatments have advanced over the past several decades, active tip steering for tibial and intrahospital microcatheters remains limited and without prospective clinical outcome data despite broader advances in peripheral endovascular therapy and catheter tip steering for larger vessels. Challenges in developing steerable microcatheters include the geometry and mechanics of the catheter’s tip on a microscale (50 µm–900 µm). Micro-fabrication methods have shown early promise in creating intricate microstructures; however, challenges remain in precise fabrication and assembly. Further research and development of novel microcatheters for the treatment of tibial disease is needed, as larger steerable catheters have been shown to improve patient outcomes with decreased procedure time, fluoroscopy time, required contrast, and procedural complications. Conclusions: The refinement of steerable micro catheters in tibial vessel intervention would expand current endovascular treatment and diagnostic capabilities, likely improving patient outcomes.

Point-of-Care Ultrasound-Guided Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation Cannulation in Adult Patients.

Point-of-care ultrasound (POCUS) has become an important imaging modality for guiding peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) cannulation. This protocol describes the integration of POCUS throughout the peripheral VA-ECMO cannulation workflow, including pre-procedural assessment, real-time procedural guidance, and post-cannulation verification. During the pre-procedural assessment, POCUS facilitates differentiation of arteries from veins, measurement of vessel diameter to estimate appropriate cannula size, and identification of vascular pathology, including plaques, thrombosis, and stenosis. During cannulation, combined out-of-plane and in-plane ultrasound techniques enable real-time visualization of the guidewire, confirmation of guidewire placement within the target vessel, and avoidance of posterior wall perforation or injury to adjacent structures. Following cannulation, POCUS is used to verify drainage cannula positioning at the inferior vena cava-right atrium junction and arterial return cannula positioning at the external or common iliac artery level, and to assess for complications such as cardiac tamponade, cannula malposition, and thrombosis. Compared with landmark-based or fluoroscopy-guided techniques, POCUS provides bedside imaging without ionizing radiation and supports continuous procedural guidance without interrupting resuscitation. This protocol provides a practical, evidence-based approach for ultrasound-guided peripheral VA-ECMO cannulation and focuses specifically on vascular access and cannulation rather than broader VA-ECMO management.

Evaluating Partial Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Battlefield Trauma: A Comparative Analysis of Commercially Available Catheters.

Temporary Mechanical Circulatory Support.

Chronic Venous Intervention Using a Large-Bore, Vacuum-Assisted Aspiration System: A New Era?

BACKGROUND Chronic venous thromboembolism can affect various vascular beds and is often treated medically. Although endovascular intervention is an option, it is challenging with currently available equipment and revascularization techniques. CASE SUMMARY Patient 1 presented with superior vena cava obstruction due to a thrombosed superior vena cava graft after thymectomy. Successful revascularization was achieved using both the Symphony aspiration catheter (Imperative Care) and the ClotTriever catheter (Inari), with placement of an additional covered stent. There was immediate resolution of symptoms. Patient 2 had a history of implantable cardioverter-defibrillator insertion, who presented for chronic pulmonary embolism. Symphony catheter aspiration yielded both chronic thrombus and organized tissue. She was later diagnosed with an implantable cardioverter-defibrillator infection, complicated with septic pulmonary embolization. She was further managed with lead extraction, percutaneous vegetation aspiration and antibiotics. TAKE-HOME MESSAGE With newer generation devices, chronic venous intervention is becoming more feasible and could potentially be offered to more patients who fail medical therapy.