Search

Purpose: Numerous navigation devices for percutaneous, CT-guided interventions exist and are, due to their advantages, increasingly integrated into the clinical workflow. However, effective training methods to ensure safe usage are still lacking. This study compares the potential of an augmented reality (AR) training application with conventional instructions for the Cube Navigation System (CNS), hypothesizing enhanced training with AR, leading to safer clinical usage., Methods: An AR-tablet app was developed to train users puncturing with CNS. In a study, 34 medical students were divided into two groups: One trained with the AR-app, while the other used conventional instructions. After training, each participant executed 6 punctures on a phantom (204 in total) following a standardized protocol to identify and measure two potential CNS procedural user errors: (1) missing the coordinates specified and (2) altering the needle trajectory during puncture. Training performance based on train time and occurrence of procedural errors, as well as scores of User Experience Questionnaire (UEQ) for both groups, was compared., Results: Training duration was similar between the groups. However, the AR-trained participants showed a 55.1% reduced frequency of the first procedural error (p > 0.05) and a 35.1% reduced extent of the second procedural error (p < 0.01) compared to the conventionally trained participants. UEQ scores favored the AR-training in five of six categories (p < 0.05)., Conclusion: The AR-app enhanced training performance and user experience over traditional methods. This suggests the potential of AR-training for navigation devices like the CNS, potentially increasing their safety, ultimately improving outcomes in percutaneous needle placements., Competing Interests: Declarations. Conflict of interest: The authors TS, QL, and MM declare no conflict of interest. SM, AU, RH, and SW are employees of and/or shareholders in Medical Templates. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Ethical approval: All studies have been approved and performed in accordance with ethical standards. Informed consent: This article does not contain patient data. Informed consent was obtained from all participants included in the study., (© 2024. The Author(s).)

Needle selection plays a pivotal role in determining the success of fine needle aspiration (FNA) procedures. Two commonly utilized puncture needles for thyroid FNA are the conventional syringe needle and the stylet needle. Syringe needles are known for their cost-effectiveness in comparison to stylet needles. This study aimed to determine if FNA with syringe needles is non-inferior to FNA with stylet needles in terms of specimen adequacy while also comparing the direct costs associated with both needle types. A total of 220 thyroid nodules from 185 patients were prospectively included in this study. The same operator performed a total of four punctures on the same nodule twice using a syringe and a stylet needle. The results of this study show that the utilization of syringe needles for thyroid FNA was non-inferior to the use of stylet needles in terms of specimen adequacy. Cost analysis revealed that syringe needle FNA was not only less expensive (CNY 500.9 versus CNY 780) but also more effective (adequacy 85.91% versus 84.55%). In summary, given the global prevalence of FNA procedures, the economic considerations are paramount, and our findings support the routine use of syringe needles in thyroid FNA., (© 2024. The Author(s).)

Background and Objective: Ultrasound-guided interventions (such as biopsies) of unclear lesions are indicated if microcirculatory changes indicate possible malignant lesions. These place high demands on the ultrasound device used. In order to potentially reduce the often associated high technical effort, the wireless ultrasound device Vscan AirTM was examined as a possible ultrasound device for the intervention biopsy., Methods: As part of an advanced training course on Computertomographie- and ultrasound-guided biopsy and ablation procedures, participants were asked about the image quality of the handheld device used by means of questionnaires. Various lesions were evaluated at a depth of 1.0 to 5.0 cm in an in vitro liver model. The image quality was evaluated independently before, during and after the intervention. The rating scale contained values from 0 (no assessment possible) to 5 (maximum high image quality). A high-end device was used as a reference., Results: A total of 11 participants took part in the study (n = 4 male [36.4%], n = 7 female [63.6%]). A total of five tumor like lesions at different depths (1 cm, 2 cm, 3 cm, 4 cm, >4 cm) were assessed separately. In all cases, an adequate biopsy of the target lesion (1 cm in length, core filling 5 mm) was successful. From a depth of 3 cm, the image quality of the mobile device increasingly decreased, but the image quality of the high-end system was still not impaired. Compared to the high-end device, there was a highly significant difference in image quality from a depth of 3 cm (p < 0.01). Assessment by inexperienced examiners using a handheld device was adequately possible., Conclusions: Mobile interventional ultrasound represents a potential alternative for the biopsy of unclear tumorous lesions with microcirculatory disorders with limited depth localization.

Objective: Optimization of the method of puncture treatment of acute bacterial maxillary sinusitis (ABMS) through the development of original devices for drainage of the maxillary sinus (MS)., Material and Methods: Registration and comparative analysis of the results of puncture methods of treatment of 120 patients with ABMS using developed new original devices for drainage of MS with one channels and with two channels in comparison with the Kulikovsky's needle (KN) was carried out. Based on the results of the analysis, the effectiveness of the original devices was assessed. During the clinical study, patients were divided into two groups: in group I, patients underwent of the MS puncture using KN, in group II, using original devices. Groups I and II, depending on the absence or presence of a block of the natural anastomosis MS, was divided into subgroups A and B, respectively. After puncture of the MS, the pain syndrome was assessed by patients using Visual Analogue Scale (VAS) and by doctors - using Touch Visual Pain (TVP) scale., Results: Our study showed that when puncturing the upper jaw with an original needle with one channels and with two channels, compared with the use of KN, there is a decrease in pain (the average VAS score was 1.5±0.3 and 1.7±0.3 points, respectively; the average TVP scale score was 0.9±0.2 and 1.8±0.3 points, respectively, the difference is significant, p ≤0.05). Patients of subgroup IB were manipulated with two KN, patients of subgroup IIB manipulated using the original device with two channels without an additional needle (the average VAS score was 3.0±0.4 and 1.3±0.3 points, respectively; the average TVP scale score was 2.7±0.4 and 1.0±0.2 points, respectively, the difference is significant, p ≤0.05). The doctors also assessed the devices used for puncture of the upper jaw. As a result of the study, the high efficiency and safety of using new original devices was established.

This prospective study compared methods using both arterial and venous needles with back eyes with those using only arterial needle with back eye for arteriovenous fistula cannulation. Sixty-one patients receiving hemodialysis (HD) via an arteriovenous fistula were evaluated. All patients underwent arteriovenous fistula puncture using only arterial needle with back eye in first 3 months and both arterial and venous needles with back eyes in following 3 months. Arterial and venous pressures, blood flow velocities, total blood volume cleared, and Kt/V values were compared. Mean blood flow velocity, arterial pressure, Kt/V, and cleared total blood volume values were higher and venous pressure was lower in patients who underwent cannulation using both needles with back eyes than in those with only the arterial needle with back eye. For arteriovenous fistula cannulation, using both arterial and venous needles with back eyes provides adequate HD more successfully., (© 2021 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy.)

Objective: To evaluate the midterm outcomes of in situ fenestration (ISF) with an adjustable puncture device for aortic arch branch preservation during thoracic endovascular aortic repair (TEVAR)., Methods: From October 2016 to April 2019, patients with complicated type B aortic dissection, thoracic aortic aneurysm > 5.5 cm in diameter, or aortic penetrating ulcer with a base > 20 mm or depth > 15 mm, who received TEVAR requiring a proximal sealing beyond zone 3 and underwent ISF using an adjustable puncture device, were included. After the procedure, patients were monitored at one, three, six, and 12 months, and annually thereafter. Peri-operative and follow up data were collected and analysed., Results: Fifty of 51 patients (98%) received successful ISFs. One, two, or three aortic arch branches were preserved in 44, six, and one patient, respectively. Intra-operatively, eight type Ia endoleaks and one type II endoleak were found on angiography. One patient died of cerebral hernia three days post-procedure from a severe stroke; one patient suffered from transient paraplegia but recovered in two weeks; one patient had a non-disabling stroke. The median follow up was 31 months (22.5 - 36.5 months). At six month follow up, all nine unmanaged endoleaks had disappeared. One new type Ia endoleak was identified in a patient at the one month follow up which resolved spontaneously one year later. All revascularised arteries were patent at the last follow up. No fractures, migrations, or bridging stent kinks were found., Conclusion: In this largest mechanical based ISF study to date, an adjustable puncture device was shown to facilitate the procedure of ISF during endovascular repair of aortic diseases involving the aortic arch, with high success. The midterm outcome demonstrates the efficacy and safety of the device in assisting with preservation of aortic arch branches., (Copyright © 2021 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: To determine what importance is given to the puncture and assistive technologies in percutaneous nephrolithotomy (PNL) in the current urological literature., Methods: PubMed was searched for English publications and reviews for the keywords: 'percutaneous nephrolithotomy', 'percutaneous nephrostomy', 'puncture'. The search was limited to the last 5 years, January 2016 until February 2021. Based on 183 abstracts, 121 publications were selected, read, and reviewed. References, older or seminal papers were read and cited if they contributed to a better understanding. A total of 198 references form the basis of this narrative review., Results: The puncture is frequently referred to as the most crucial part of PNL. In contrast, the influence of the puncture on the failure rate of PNL and the specific puncture-related complications seems to be low in the single-digit percentage range. However, there are no universally accepted definitions and standards measuring the quality of puncture. Consequently, the impact of the puncture on general PNL complications, on stone scores predicting success rates and on learning curves evaluating surgeons' performance have not been systematically studied. Assistive technologies rely on fluoroscopy and ultrasonography, the latter of which is becoming the preferred imaging modality for monitoring the entire procedure. Needle bending, a problem relevant to all puncture techniques, is not addressed in the urological literature., Conclusions: The importance attached to puncture in PNL in the current urological literature is subjectively high but objectively low. Some basics of puncture are not well understood in urology. Disciplines other than urology are more actively involved in the development of puncture techniques., (© 2021 The Authors BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

Background: The aim of the present study is to evaluate the short-term efficacy and feasibility of radiofrequency ablation in the treatment of complex diffuse arteriovenous (AV) malformations., Methods: The data of 18 patients (8 male and 10 female) with complex AV malformations treated between December 2014 and June 2019 were analyzed retrospectively. The lesion area was 10 × 7 cm ~ 28 × 30 cm. Under duplex ultrasound guidance, the site with the most abundant blood flow signals in the lesion was percutaneously punctured with the radiofrequency ablation needle (electrode). The impedance automatic adjustment mode was adopted, and ablation was monitored usingduplex ultrasoundduring the entire process., Results: Of the included patients, 1 had a high fever after two rounds of treatment, 2 had transient hemoglobinuria, and 1 had tissue necrosis in the original ruptured tumor area as well as a penetrating defect in the cheek, which was repaired with a pedicled trapezius myocutaneous flap. In 9 patients who experienced bleeding, the bleeding stopped after one round of treatment. During the follow-up period of 1-5 years, there were 0 grade I (poor) cases, 0 grade II (medium) cases, 7 grade III (good) cases, and 11 grade IV (excellent) cases., Conclusion: The "high power and continuous" radiofrequency ablation technique conducted under real-time duplex ultrasoundmonitoring can completely destroy the deep core lesions of AV malformations and effectively control life-threatening massive hemorrhage; it is an effective alternative treatment method for complex diffuse AV malformations in which interventional embolization, sclerotherapy, and surgery are ineffective., (© 2021. The Author(s).)

Aim: This study aims to describe the feasibility and safety of direct occluded vessel puncture as a new access site for complex peripheral artery occlusive disease., Methods: Eleven consecutive patients with symptomatic peripheral artery disease underwent endovascular therapy using the direct occluded vessel puncture technique. The occluded vessel was punctured using a dedicated 20 G needle and the Hi-Torque Command 18 ST guidewire under duplex echo or fluoroscopic guidance, and a 6 Fr sheath was then inserted. Hemostasis was achieved with the Exoseal ® Vascular Closure Device., Results: Direct occluded vessel puncture was achieved in 10 of 11 cases (90.9%), and procedural success was achieved in all cases. There were no in-hospital deaths or any complications, including bleeding, pseudoaneurysms, thrombosis, or surgical conversion., Conclusion: The direct occluded vessel puncture technique using a 20 G needle and the Hi-Torque Command 18 ST is feasible and safe. This technique may also be used as an alternative option when there are no appropriate approach sites.

The current narrative review provides an update of available knowledge on venous access techniques for cardiac implantable electronic device implantation, with a focus on axillary vein puncture. Lower procedure-related and lead-related complications have been reported with extrathoracic vein puncture techniques compared with intrathoracic accesses. In particular, extrathoracic lead access through the axillary vein seems to be associated with lower complication incidence than subclavian vein puncture and higher success rate than cephalic vein cutdown. In literature, many techniques have been described for axillary vein access. The use of contrast venography-guided puncture has facilitated the diffusion of the axillary vein approach for device implantation. Venography may be particularly useful in specific demographic and clinical device implantation contexts. Ultrasound-guided or microwire-guided vascular access for lead positioning can be considered a valid alternative to venography, although current applications for axillary vein puncture need further evaluations., (Copyright © 2020 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Introduction: Ultrasound-guidance of radial artery catheter insertion improves the first attempt success and reduces the occurrence of hematomas. Needle-tracking devices optimize needle-ultrasound beam alignment by displaying in real-time the needle tip position. We compared the median time need by experienced physicians to achieve radial artery puncture using either a conventional ultrasonography device (CUD) or a magnetic needle-tracking ultrasound device (MUD) in a simulation training arm model., Methods: Fifty experienced residents and physicians performed two punctures in randomized order with the CUD and the MUD. The primary outcome was puncture duration; the secondary outcomes were puncture success, rate of accidental vein puncture, and practitioner's comfort (subjective scale 0-10)., Results: The median [lower-upper quartile] puncture time was 10 [6-14] seconds when using CUD and 4 [3-7] seconds when using MUD (P < .01). In the multivariate analysis, MUD use was associated with decreased puncture duration whatever the puncture order (OR 1.13 [1.07-1.20], P < .01). The participants performed 99 (99%) successful punctures: 50 with the MUD (100%) and 49 with the CUD (98%). There was no accidental venous puncture. The practitioner's comfort level was 6.5 [6, 7] with the CUD and 8 [7-9] with the MUD (P < .01)., Conclusion: MUD reduced radial artery puncture time and improved physician comfort in a simulation training arm model., (© 2020 Wiley Periodicals LLC.)

Purpose: Anterior stromal puncture is an inexpensive technique for treating recurrent corneal erosions but is often ineffective and cannot be used in the optical axis because of scarring. These studies tested a novel microfabricated imprinting instrument to assess its potential efficacy for the treatment of corneal epithelial disease in the optical axis., Methods: The device is made using glass rods, bundled and drawn through multiple iterative cycles, and then fused under high heat to generate a solid rod comprised of many parallel, aligned, cladded fibers. The rods are sliced into discs and then etched to yield designable spikes based on the borosilicate composition of the glass., Results: Imprinting the cornea yields a regular pattern of imprints. Histologic studies showed both nonpenetrating stable deformations of Bowman layer, with formation of stable epithelial attachments, and full thickness penetration, with superficial ingrowth of the basal epithelium., Conclusions: Microimprinted corneal tissue shows focal subepithelial scarring without evidence of optically evident anterior stromal scarring, and may be an effective way of treating recurrent corneal erosions in the optical axis, which is not currently possible using standard anterior stromal puncture methods.

Background: We aimed to introduce the puncture technique based on a novel device for preperitoneal tunneling in laparoscopic PD catheter placement and to evaluate the safety and efficacy of this technique., Methods: This novel device was used in our center from May 2016. We conducted a retrospective analysis of patients undergoing laparoscopic PD catheter placement. The traditional method was performed in 20 patients and the novel procedure in 18 patients. A straight Tenckhoff PD catheter was placed in all patients., Results: No intraoperative complications were encountered in both groups. Compared the traditional technique group, the procedure based on the novel device had a shorter operative time (49.2 ± 11.8 vs 53.9 ± 12.5). One patient in the traditional tunneling group underwent catheter obstruction. There were no pericatheter leakage, exit site and subcutaneous infection, hernia and peritonitis in the early postoperative days. No mortality was observed in these patients. The 6-month survival rate of the catheter was 100%., Conclusions: Laparoscopic preperitoneal tunneling technique is an effective way to implant intra-abdominal catheter. Our method based on a novel puncture device for preperitoneal tunneling is safe and efficient.

The purpose of the present study was to integrate an interactive gradient-based needle navigation system and to evaluate the feasibility and accuracy of the system for real-time MR guided needle puncture in a multi-ring phantom and in vivo in a porcine model. The gradient-based navigation system was implemented in a 1.5T MRI. An interactive multi-slice real-time sequence was modified to provide the excitation gradients used by two sets of three orthogonal pick-up coils integrated into a needle holder. Position and orientation of the needle holder were determined and the trajectory was superimposed on pre-acquired MR images. A gel phantom with embedded ring targets was used to evaluate accuracy using 3D distance from needle tip to target. Six punctures were performed in animals to evaluate feasibility, time, overall error (target to needle tip) and system error (needle tip to the guidance needle trajectory) in vivo. In the phantom experiments, the overall error was 6.2±2.9 mm (mean±SD) and 4.4±1.3 mm, respectively. In the porcine model, the setup time ranged from 176 to 204 seconds, the average needle insertion time was 96.3±40.5 seconds (min: 42 seconds; max: 154 seconds). The overall error and the system error was 8.8±7.8 mm (min: 0.8 mm; max: 20.0 mm) and 3.3±1.4 mm (min: 1.8 mm; max: 5.2 mm), respectively., Competing Interests: The authors have read the journal's policy and the authors of this manuscript have the following competing interests: LP is a paid employee of Siemens Healthineers. KQ receives grant support from Siemens Healthineers and was an intern employee while working on this project. BF and AM are paid employees of Robin Medical. EN is the founder and a stock owner of Robin Medical, the company that developed the EndoScout tracking system. CW receives grant support from Siemens Healthineers, BTG, and Medtronic, and is a consultant for BSCI and Medtronic. FW receives institutional funding from Siemens Healthineers. There are no patents, products in development or marketed products associated with this research to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Pericardial access is complicated by two difficulties: confirming when the needle tip is in the pericardial space, and avoiding complications during access, such as inadvertently puncturing other organs. Conventional imaging tools are inadequate for addressing these difficulties, as they lack soft-tissue markers that could be used as guidance during access. A system that can both confirm access and avoid inadvertent organ injury is needed., Methods: A 21G micropuncture needle was modified to include two small electrodes at the needle tip. With continuous bioimpedance monitoring from the electrodes, the needle was used to access the pericardium in porcine models (n  =  4). The needle was also visualized in vivo by using an electroanatomical map (n  =  2). Bioimpedance data from different tissues were analyzed retrospectively., Results: Bioimpedance data collected from the subcutaneous space (992.8 ± 13.1 Ω), anterior mediastinum (972.2 ± 14.2 Ω), pericardial space (323.2 ± 17.1 Ω), mid-myocardium (349.7 ± 87.6 Ω), right ventricular cavity (235.0 ± 9.7 Ω), lung (1142.0 ± 172.0 Ω), liver (575.0 ± 52.6 Ω), and blood (177.5 ± 1.9 Ω) differed significantly by tissue type (P < .01). Phase data in the frequency domain correlated well with the needle being in the pericardial space. A simple threshold analysis effectively separated lung (threshold  =  1120.0 Ω) and blood (threshold  =  305.9 Ω) tissues from the other tissue types., Conclusions: Continuous bioimpedance monitoring from a modified micropuncture needle during pericardial access can be used to clearly differentiate tissues. Combined with traditional imaging modalities, this system allows for confirming access to the pericardial space while avoiding inadvertent puncture of other organs, creating a safer and more efficient needle-access procedure., (© 2020 Wiley Periodicals LLC.)

Background: Successful percutaneous nephrolithotomy (PCNL) relies on a technically challenging, precise needle puncture of the renal collecting system. We aimed to compare, in an ex vivo model, the use of a real time image guidance system (the SabreSource™) and a mechanical stabilising device with conventional manual techniques for the accuracy of needle placement., Methods: The SabreSource™ system (Minrad International Inc.; New York, USA) is a real time image guidance system. The system platform is mounted on a C-arm fluoroscope. It employs targeting cross hairs on the fluoroscopic image that can be easily positioned to target the desired renal calyx. The system directs a visible laser beam onto the patient which is precisely aligned with the cross hairs on the fluoroscopic image. This provides the correct "bull's-eye" angle of approach to the calyx, even after the x-ray source is turned off. The locator then stabilises the needle in the "bull's-eye" position so that only screening for depth is required. Objective assessment using a simulated PCNL puncture was performed by 7 urologic trainees on a kidney phantom with and without using the SabreSource™. Fluoroscopy screening time (FST) and amount of radiation (mGy) used to achieve successful puncture were compared., Results: Simulated PCNL puncture was quicker and resulted in reduced radiation exposure when the apparatus was used. The mean FST for traditional "bull's-eye" vs SabreSource™ puncture was 17 vs 5 seconds ( p = 0.01), and the mean radiation exposure to puncture was 0.7 vs 0.2 mGy ( p = 0.03), respectively., Conclusion: The SabreSource™ is a novel assistant to achieving successful PCNL puncture. In combination with "the locator" the preliminary in vitro testing suggests that the device reduces fluoroscopy exposure and is quicker. The device warrants further evaluation in the clinical setting., (Copyright© Authors.)

Purpose: Percutaneous interventions rely on needle puncture to deliver medical devices into lesions. For lung tumours, respiratory motion makes effective puncture procedures difficult to achieve. To address this issue, a needle puncture method considering respiration is proposed to improve the accuracy of lung puncture., Methods: The accuracy of puncture is ensured by visualization and needle guidance. Dynamic visualization of the respiratory motion is developed for needle path planning based on four-dimensional computed tomography (4DCT) images. The rendered image is synchronized with the actual breathing by using respiratory signals. A robotic needle insertion strategy for velocity adjustment based on these respiratory signals is designed to guide the needle towards the moving tumour., Results: The dynamic visualization was tested on multiple 4DCT datasets and achieved a frame rate of over 32 frames per second (FPS). A computer simulation was carried out to verify the feasibility of the needle insertion strategy. Needle puncture was performed on a phantom, and a mean accuracy of 1.34±0.18 mm was achieved., Conclusions: In this paper, an efficient and robust method is proposed to improve the visualization and targeting of lung puncture, which reduces the impact of respiratory motion on the accuracy., (Copyright © 2020 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.)

Objective: We wondered if a modification of the conventional transseptal puncture technique performed with an angioplasty wire could be useful in patients with contrast hypersensitivity or allergy-like reactions., Methods: This study comprised our initial experience in 22 patients with atrial fibrillation who were scheduled for an electrophysiology study (EPS) and pulmonary vein ablation and who had a contraindication for iodinated contrast administration., Results: Of the 22 patients, 16 were men and ages ranged from 27 to 74 years (mean 56 years). Overall successful transseptal access was achieved in all 22. A control echocardiogram was performed in all patients. There were no complications in any case and no significant differences were found from the conventional transseptal puncture technique regarding procedure or fluoroscopy time., Conclusions: A modification of the conventional transseptal puncture technique performed with fluoroscopy and EPS catheters for anatomical reference and an angioplasty wire is an option in cases with severe contrast hypersensitivity., (Copyright © 2020 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Various adjunctive techniques for neurointerventional procedures require a large-bore sheath introducer, but there is concern that this could result in more puncture site hemorrhagic complications despite using a vascular closure device. The purpose of this study was to assess the relationship between use of large-bore sheath introducer and post-procedural complications. Between January 2016 and April 2018, 126 neurointerventional procedures were performed in our hospital using 8 or 9 Fr sheath introducer in size and the Angio-Seal STS PLUS (St. Jude Medical, Minnetonka, USA). Hemorrhagic complications were defined as obvious swelling or bleeding at the puncture site or as extravascular bleeding detected by ultrasonography or contrast-enhanced computed tomography. The procedures were divided into a group with post-puncture bleeding (group B, n = 21) and a group without bleeding (group N, n = 105). Risk factors were compared between the groups according to the incidence of post-puncture bleeding. In addition, we assessed the outcome and approach to hemostasis in the procedures with bleeding. In result, hemorrhagic complications occurred in 21 procedures (17%), and pseudoaneurysm was detected in 4 procedures (3.2%). In 20 of group B (16%), manual compression was performed for an average of 36.4 min. One patient (0.79%) required surgical angioplasty. Risk factors for bleeding were not significantly different between the two groups. None of the patients with bleeding showed a decrease on the modified Rankin Scale. In conclusion, use of a large-bore sheath introducer may increase the incidence of post-puncture bleeding, but the outcome of this complication is acceptable., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Brainstem hemorrhage is an acute and severe neurosurgical disease. Cerebral hemorrhage is surgically treated via hematoma puncture drainage because of its minimally invasive nature. However, the placement of puncture must be extremely accurate due to the special anatomical location of the brainstem and its physiological functions. The present study aimed to evaluate whether the application of a three-dimensional (3D)-printed navigation mold achieved good outcomes in the surgical treatment of brainstem hemorrhage., Material and Methods: The present study included seven patients (three men and four women aged 40-56 y) who underwent 3D print-assisted hematoma puncture drainage between June 2016 and March 2018 at Binzhou Medical University Hospital. The amount of brainstem hemorrhage was 15-47 mL. We analyzed the basic surgical conditions, deviation distance, and postoperative clinical improvement., Results: In all cases, the operation was completed successfully; no patient died or contracted an infection intraoperatively. The end of the puncture tube was located in the hematoma cavity in all cases. The deviation distance ranged from 2.5 to 7.2, and this distance gradually reduced with improvements in the technique. The hematoma drainage achieved satisfactory postoperative outcomes, with improvements in symptoms such as respiratory failure and hyperthermia., Conclusions: Use of a 3D-printed navigation mold for puncture drainage of brainstem hemorrhage realized the purpose of individualized and precision medicine, which is important in maintaining the vital signs of patients with severe brainstem hemorrhage., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Image-guided surgery is growing in importance with each year. Various imaging technologies are used. The objective of this study was to test whether a new mixed reality navigation system (MRNS) improved percutaneous punctures. This system allowed to clearly visualize the needle tip, needle orientation, US probe and puncture target simultaneously with an interactive 3D computer user inferface. Prospective pre-clinical comparative study. An opaque ballistic gel phantom containing grapes of different sizes was used to simulate puncture targets. The evaluation consisted of ultrasound-guided (US-guided) needle punctures divided into two groups, standard group consisted of punctures using the standard approach (US-guided), and assisted navigation group consisted of punctures using MRNS. Once a puncture was completed, a computed tomography scan was made of the phantom and needle. The distance between the needle tip and the center of the target was measured. The time required to complete the puncture and puncture attempts was also calculated. Total participants was n = 23, between surgeons, medical technicians and radiologist. The participants were divided into novices (without experience, 69.6%) and experienced (with experience > 25 procedures, 30.4%). Each participant performed the puncture of six targets. For puncture completion time, the assisted navigation group was faster (42.1%) compared to the standard group (57.9%) (28.3 s ± 24.7 vs. 39.3 s ± 46.3-p 0.775). The total punctures attempts was lower in the assisted navigation group (35.4%) compared to the standard group (64.6%) (1.0 mm ± 0.2 vs. 1.8 mm ± 1.1-p 0.000). The assisted navigation group was more accurate than the standard group (4.2 ± 2.9 vs. 6.5 ± 4.7-p 0.003), observed in both novices and experienced groups. The use of MRNS improved ultrasound-guided percutaneous punctures parameters compared to the standard approach.

Objective: To evaluate the clinical effect of the second puncture and injection technique during a percutaneous vertebroplasty (PVP) procedure., Methods: Patients treated with a second puncture and injection (group A) or a single puncture and injection (group B) during PVP at our institution during 2010-2017 were reviewed. Vertebral height loss, visual analogue scale (VAS) score, Oswestry disability index (ODI), adjacent vertebral fractures, and cement leakage were compared between the groups., Results: A total of 193 patients were enrolled (86 cases in group A, 107 cases in group B). The follow-up period was 15.64 (12-20) months. The loss of anterior (group A 0.01 ± 0.03; group B 0.14 ± 0.17) and middle (group A 0.13 ± 0.12; group B 0.16 ± 0.11) vertebral height in group B was significantly higher than that in group A (P < 0.05). The VAS score and ODI were also significantly higher in group B than in group A at the final follow-up; the VAS score and ODI in group B were 1.65 ± 0.70 and 14.50 ± 4.16, respectively, and those in group A were 1.00 ± 0.74 and 12.81 ± 4.02, respectively (P < 0.05). Three patients in group A and two in group B experienced adjacent vertebral fractures. Regarding mild, moderate, and severe cement leakage, there were 25 (29%), 5 (5%), and 0 cases, respectively, in group A and 28 (26%), 3 (2.8%), and 1 (0.009%) case, respectively, in group B (P > 0.05)., Conclusions: The second puncture and injection technique may effectively increase the dispersion of cement, thus preventing recompression of the cemented vertebral body, and it does not increase the risk of cement leakage or adjacent vertebral fracture.

Objective: Needle insertion is a common component of most diagnostic and therapeutic interventions. Needles with asymmetrically sharpened points such as the bevel point are ubiquitous. Their insertion path is typically curved due to the rudder effect at the point. However, the common planned path is straight, leading to targeting errors. We present a simple technique that may substantially reduce these errors. The method was inspired by practical experience, conceived mathematically, and refined experimentally. Methods: Targeting errors are reduced by flipping the bevel on the opposite side (rotating the needle 180° about its axis), at a certain depth during insertion. The ratio of the flip depth to the full depth of insertion is defined as the flip depth ratio (FDR). Based on a model, FDR is constant 0.3. Results: Experimentally, the ratio depends on the needle diameter, 0.35 for 20Ga and 0.45 for 18Ga needles. Thinner needles should be flipped a little shallower, but never less than 0.3. Conclusion: Practically, a physician may expect to reduce ∼80% of needle deflection errors by simply flipping the needle. The technique may be used by hand or with guidance devices.

In order to improve the precision and stability of puncture surgical operations to assist doctors in completing fine manipulation, a new of type puncturing needle sensor is proposed based on a fiber Bragg grating (FBG). Compared with the traditional puncture needle sensor, the new type of puncturing needle sensor is able to sense not only the axial force, but also the torque force during the puncture process. A spoke-type structure is designed near the needle tip. In order to eliminate the influence of temperature and realize temperature compensation, a reference fiber method using three FBGs is applied. FBG1 and the reference FBG2 are pasted on the upper and lower surfaces of the new-type elastic beam, and FBG3 is pasted into the groove on the surface of the new type of puncturing needle cylinder. The difference of Bragg wavelength between FBG1 and the reference FBG2 is calibrated with the torque force, while the difference between the Bragg wavelength of the FBG3 and the reference FBG2 is calibrated with the axial force. Through simulation and sensing tests, when the torque force calibration range is 10 mN·m, the torque average sensitivity is 22.8 pm/mN·m, and the determination coefficient R 2 is 0.99992, with a hysteresis error Y H and repetition error Y R of 0.03%FS and 0.81%FS, respectively. When the axial force calibration rang is 5 N, the axial force average sensitivity is 0.089 nm/N, and the determination coefficient R 2 is 0.9997, with hysteresis error Y H and repetition error Y R of 0.014%FS and 0.11%FS, respectively. The axial force resolution and torque resolution of the new type of puncturing needle sensor are 0.03 N and 0.8 mN·m, respectively. The experimental data and simulation analysis show that the proposed new type of puncturing needle sensor has good practicability and versatility.

Purpose: We aimed to assess the technical success of the combined percutaneous direct puncture of occluded artery - antegrade intervention technique, as well as the clinical effectiveness of treatment, on the basis of changes in the Rutherford classification., Methods: Between June 2015 and July 2018, 441 patients underwent endovascular recanalization due to lower limb peripheral arterial disease at our center. Of these, 18 patients (4%; 15 males, 3 females; mean age, 63.2 years) had failed antegrade recanalization and percutaneous retrograde access because of long segment occlusion, arterial rupture or dissection. Combined percutaneous direct puncture of occluded artery and antegrade approach was applied to these patients. Clinical follow-up examinations were performed at 1 month, 3 months, 6 months, and annually thereafter., Results: The mean follow-up period was 22.8±10.9 months. The mean procedure time was 93.6±28.2 min. Technical success was achieved in 14 patients (78%). Complete restoration of arterial flow in the punctured vessel could not be achieved in 4 patients (22%). Minor complications occurred in 4 of 18 procedures (22%). Amputation-free survival and limb salvage rates (83.3% and 100%, respectively) were the same for 12 and 24 months., Conclusion: Technical success in lower limb peripheral arterial disease may be improved with the use of a combined percutaneous direct puncture of occluded artery - antegrade intervention, particularly for patients in whom other techniques are not a viable option.

Background: Vascular interventions imply radiation exposure to the operating physician (OP). To reduce radiation exposure, we propose a novel passive robotic device for fluoroscopy-guided arterial puncturing., Methods: X-ray dose rates were measured for a total of 30 fluoroscopy-guided puncture femoral arteries in 15 pigs. Fifteen punctures were performed with the device while the other 15 were performed without the device by an interventional cardiologist with 10 years of experience. Parametric t test was used., Results: The success rate with the device was 100%. Overall, the OP received more radiation (0.41 mSv/h) as compared to the assistant (0.06 mSv/h) (p <  0.001) and, amongst OP's body parts, hands received more radiation than other body parts (p <  0.001). The radiation dose rate to the OP's hands during arterial puncturing performed manually without the device was 0.95 ± 0.25 mSv/h whereas it was 0.14 ± 0.006 mSv/h using the device, resulting in an 85% reduction (p <  0.001). For the head, the dose was reduced from 0.16 mSv/h to 0.08 mSv/h (50% reduction, p <  0.001), and for the dominant arm, from 0.12 mSv/h to 0.07 mSv/h (42% reduction, p <  0.001). The fluoroscopy time was reduced from 4.5 ± 0.15 min to 4.3 ± 0.11 min device (p = 0.002)., Conclusions: In a swine model, fluoroscopy time and radiation exposure for the OP puncturing femoral artery were significantly reduced by using the passive robotic device.

Purpose of Review: Transseptal puncture is a routinely performed interventional cardiology procedure for an array of cardiac diseases. We aimed to review the current status of available devices and techniques of transseptal puncture with consideration to specific interventions., Recent Findings: Except for a few modifications, devices for transseptal puncture technique has not changed much compared to when it was first described almost 60 years ago. For difficult transseptal puncture, a few newer techniques such as radio frequency needle puncture system have been used but there is lack of robust clinical study. Advanced imaging, such as intracardiac echocardiography and transesophageal echocardiography, has been found to make transseptal puncture safer. A new transseptal approach that incorporates 3D non-fluoroscopic catheter tracking systems has shown promising results in two human studies. While various modifications in the transseptal technique tailored to the specific interventions have improved procedural safety, further improvement in existing devices focusing on distinct procedure might be needed in the future.

Background: In the Dupuytren Rotterdam randomized controlled trial, percutaneous aponeurotomy with lipofilling (PALF) was as effective as limited fasciectomy in correcting primary Dupuytren's contracture after 1 year. The authors report the 5-year results of this trial, with a special focus on recurrence of contractures., Methods: The authors invited all patients who had undergone PALF or limited fasciectomy to participate in a posttrial follow-up assessment. Thirty-one PALF patients and 21 limited fasciectomy patients were assessed by an independent examiner for the degree of contracture and whether patients had undergone a secondary procedure. The primary composite endpoint was recurrence rate, defined as either 20 degrees or greater worsening in contracture (relative to week 3) or as having undergone a secondary procedure for a new or worsening contracture., Results: At 5 years, more joints in the PALF group than in the limited fasciectomy group had a recurrence (74 percent versus 39 percent; p = 0.002). When redefining recurrence as a worsening in total extension deficit of at least 30 degrees for treated digits as often reported, this was 77 percent versus 32 percent (p = 0.001). Total extension deficit was also worse for PALF-reated digits (53 degrees versus 31 degrees; p < 0.010)., Conclusions: Although the authors previously reported that PALF offers a shorter convalescence and fewer long-term complications but a similar degree of contracture correction at 1-year follow-up, at 5 years, the corrections were less durable than those for limited fasciectomy. This again highlights that limited fasciectomy and different types of needle aponeurotomy have specific advantages and disadvantages to weigh by patients and clinicians., Clinical Question/level of Evidence: Therapeutic, II.

The use of skin puncture techniques may facilitate the delivery of topically applied drugs for photodynamic therapy (PDT). The main aim of this prospective study was to evaluate the efficacy and cosmetic outcome of curettage, multiple needle puncture, and methyl-aminolaevulinate (MAL)-PDT in basal cell carcinoma (BCC). All tumours received curettage and 15-20 needle punctures/cm 2 before two sessions of MAL-PDT. The primary endpoint was clinically observed recurrence at follow-up. Overall, 284 patients with 299 histologically verified BCC (70 superficial, 190 nodular, 35 aggressive, and four not subtyped) were included. Following PDT, the mean follow-up period was 6.7 months. After follow-up, 274 (92%) of 299 treatment sites showed no clinical signs of recurrence, with >90% complete response for each BCC subtype. The cosmetic outcome was rated as excellent/good in 81% of cases. Good short-term treatment results were shown following curettage, multiple needle puncture, and MAL-PDT for BCC of different subtypes.

Purpose: Ventriculoperitoneal shunt (VPS) remains as one of the main treatment for hydrocephalus. The traditional technique for placing the distal ends of shunts is via a mini-laparotomy. However, laparotomies are relatively time consuming. Trocars to penetrate abdominal wall by blind puncture have been used. Here, we report on the abdominal wall puncture technique, and compare the possible complications and outcomes with traditional mini-laparotomy., Materials and Methods: We use a 5mm incision at the inverse McBurney point. The abdominal wall on both sides of the incision point is lifted with two towel clips prior to puncture to create a potential gap between the abdominal wall and viscera. After the puncture, a guide wire is inserted followed by a dilator, introducer and the distal shunt tubing using a Seldinger technique. In this process, the operator feels resistance give with breakthrough of parietal peritoneal. After the insertion of introducer, a negative pressure injection test helps confirm whether the introducer is inside the peritoneum., Results: Operative time is less than with mini-laparotomies. Postoperative abdominal symptoms are mild. Out of 29 patients there were no puncture related complications., Conclusion: The improved abdominal-wall puncture technique is a simple, fast, economical and effective method. Patients, who are treated by the method, generally experience rapid postoperative recoveries.

Purpose: To report percutaneous transcranial puncture, embolization and occlusion of a very symptomatic hypoglossal canal/anterior condylar vein dural arteriovenous fistula (DAVF) using syngo iGuide navigational software in a patient in whom transarterial and transvenous embolization and surgery had failed., Methods: After unsuccessful arterial and venous embolization and surgical treatment of a symptomatic hypoglossal canal DAVF, a 47-year-old man was transferred for further management. With exquisite anatomic detail provided by C-arm cone-beam computed tomography (CBCT) equipment (Artis zee Biplane, Dyna CT VC21H, Siemens Healthcare GmbH, Germany) and syngo iGuide needle guidance navigational software (Siemens Healthcare GmbHy) for planning a safe direct approach, the hypoglossal/anterior condylar vein, the dominant outflow vein of the fistula, was needle punctured percutaneously at the hypoglossal foramen and occluded with ethylene vinyl alcohol copolymer liquid embolic agent (Onyx, Medtronic, Minneapolis, Minnesota, USA) after placing two anchoring platinum coils (Target detachable coils, Stryker Neurovascular, Fremont, California, USA)., Results: After a year of progressively severe left eye proptosis, chemosis and increased intraocular pressure, the symptoms quickly subsided after this embolization and the patient was symptom free at his 3-month and later checkups., Conclusion: With guidance and imaging provided by CBCT and syngo iGuide navigational software, an otherwise untreatable DAVF was successfully embolized and obliterated by an aggressive unique percutaneous trans-cranial needle puncture of the dominant outflow vein in the hypoglossal canal., Competing Interests: Competing interests: PC: full-time paid research scientist, Siemens Medical Solutions USA Inc., Hoffman Estates, Illinois, USA. All other authors: none declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: A recent meta-analysis and systematic review suggested that single-incision laparoscopic cholecystectomy (SILC) had a higher procedure failure rate with more blood loss and that it required a longer surgical time than conventional laparoscopic cholecystectomy. Herein, we introduce our experience with the needlescopic grasper-assisted and bendable retractor-assisted SILC technique and evaluate its safety and sustainability., Methods: The present retrospective cohort study included 407 Japanese patients who underwent needlescopic grasper-assisted and bendable retractor-assisted SILC between January 2012 and April 2017 at our institution., Results: In the present study, all patients successfully underwent needlescopic grasper-assisted and bendable retractor-assisted SILC without conversion to open surgery. Regarding surgical outcomes, mean surgical time was 58.2±23.2 minutes, and additional ports were required in 9 patients (2.2%). Postoperative morbidity developed in only 6 patients (1.4%)., Conclusions: The surgical approaches defined herein were safe and sustainable with favorable surgical outcomes. Compared with conventional SILC, needlescopic grasper-assisted and bendable retractor-assisted SILC might become a mainstream procedure for minimally invasive surgery from the viewpoint of surgical difficulty.

Background and Aims: EUS-guided gallbladder drainage (EUS-GBD) is a challenging technique for endoscopists that requires a high level of skill. EUS-GBD is challenging because the gallbladder can be easily collapsed. To resolve this issue, we aimed to develop a retrievable puncture anchor traction (RPAT) method for EUS-GBD. We evaluated and compared the success rate, safety, and outcomes of the RPAT method for EUS-GBD against EUS-GBD without RPAT using a porcine model., Methods: In total, 16 Bama mini pigs (weighing 15-20 kg) were randomly divided into an experimental group (n = 8) and a control group (n = 8). The RPAT method was performed in the experimental group and EUS-GBD without retrievable puncture anchor was performed in the control group. Incidence of operative adverse events, wound healing, and success rates of EUS-GBD were compared and analyzed between the experimental group and the control group., Results: All EUS-GBD procedures were successfully performed in all 8 animals in the experimental group (100%). However, in the control group, EUS-GBD was successfully performed only on 4 pigs (50%); the remaining 4 pigs died because of EUS-GBD failure caused by gallbladder collapse leading to unsuccessful frontal stent release., Conclusions: RPAT helped increase the success rate of EUS-GBD and could reduce gallbladder collapse. Therefore, we believe this method can be applied to EUS-GBD in the near future. Furthermore, RPAT will enhance the safety of EUS-GBD., (Copyright © 2018 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the feasibility and safety of an individualized and reassemblable three-dimensional (3D) printing navigation template for making accurate punctures during sacral neuromodulation (SNM)., Methods: From July 2016 to July 2017, 24 patients undergoing SNM were enrolled. Conventional X-ray guidance was used in the control group, which included 14 patients, while the 3D printing template was used in the experimental group, which included 10 patients. The number of punctures, the average puncture time, the exposure to X-ray, the adjustment time during the operation and the testing of the SNM device, the infection and haemorrhage rate, and the implantable pulse generator (IPG) implantation rates were compared between the two groups., Results: In total, 24 patients successfully underwent stage I. When comparing the control group and the experimental group, the number of punctures were 9.6 ± 7.7 and 1.5 ± 0.7, respectively; the average puncture times were 35.4 ± 14.6 and 4.1 ± 2.2 min, respectively; and the X-ray exposure levels were 8.37 ± 4.83 mAs and 2.34 ± 0.54 mAs, respectively. No postoperative complications were reported in either group. The IPG implantation rates were not different between the two groups., Conclusion: The 3D printing template for SNM can help us to perform accurate and quick punctures into the target sacral foramina, reduce X-ray exposure, and shorten the operation time. For patients with obesity, sacral variation, sacral bone fractures or losses and for patients who are unable to tolerate the prone position during operation, use of the 3D printing template is recommended., (© 2018 Wiley Periodicals, Inc.)

Atrial fibrillation (AF) ablation requires transseptal puncture to access the left atrium. Recently, a radiofrequency (RF) needle was developed. The purpose of this study was to compare the incidence of MRI-confirmed acute cerebral embolism (ACE) during AF ablation procedures performed with RF needle versus mechanical needle transseptal puncture. This study consisted of 383 consecutive patients who underwent catheter ablation for AF that required transseptal puncture with mechanical or radiofrequency transseptal needles. Of those, 232 propensity score-matched patients (116 with each needle type) were included in the analysis. All patients had cerebral MRI performed 1 or 2 days after the procedure. Baseline characteristics were similar between the two groups. Total procedure time was significantly shorter in Group RF than Group non-RF (167 ± 50 vs. 181 ± 52 min, P = 0.01). ACE was detected by MRI in 59 (25%) patients. All patients with ACE were asymptomatic. Incidence of ACE was lower in Group RF than Group non-RF (19 vs. 32%, P = 0.02). B-type natriuretic peptide level was higher in the patients with ACE as compared to those without ACE (65.2 ± 68.7 vs. 44.7 ± 55.1 pg/ml, P = 0.02). In multivariable analysis, the use of RF needle and BNP level was related to the incidence of ACE (OR = 0.499, 95% CI 0.270-0.922, P = 0.03 and OR = 1.005, 95% CI 1.000-1.010, P = 0.03). Use of RF needle for transseptal puncture was associated with lower total procedure time and risk of ACE during catheter ablation of AF.

Purpose: To assess the accuracy of Light Puncture Robot (LPR) as a patient-mounted robot, in positioning a sham needle under MRI guidance for abdominal percutaneous interventions., Materials and Methods: This monocentric, prospective and non-controlled study was approved by the ethics review board. The study evaluated the accuracy of LPR V3 to achieve a virtual puncture in 20 healthy volunteers. Three trajectories were tried on each volunteer, under 3-T MRI guidance., Results: Accuracy under 5 mm in attaining a 10 cm-deep target was reached in 72% of attempts after 2 robot motions with a median error of 4.1 mm [2.1; 5.1]. Median procedure time for one trajectory was 12.9 min [10.2; 18.0] and median installation time was 9.0 min [6.0; 13.0]., Conclusion: LPR accuracy in the deployment of a sham needle inside the MRI tunnel and its setup time are promising. Further studies need to be conducted to confirm these results before clinical trials.

Purpose: To describe a new adjustable puncture system for in situ fenestration in thoracic endovascular aortic repair (TEVAR)., Technique: An adjustable puncture needle for use in conjunction with a steerable 8-F, 55-cm Fustar sheath is demonstrated in a 65-year-old man with acute complicated type B dissection involving the left subclavian artery (LSA). The puncture device features an inflatable balloon at the tip, a central lumen for 0.018-inch guidewires, and a 3-level puncture depth. After thoracic stent-graft deployment at zone 2, the needle/sheath combination was delivered from a left brachial artery access. The needle was adjusted perpendicular to the fabric of the stent-graft with the assistance of the steerable sheath. The balloon at the tip was inflated to center the needle, and the puncture depth was selected on the puncture needle system. Holding the sheath and puncture needle together, a hole was created in the graft fabric. The aperture was sequentially dilated to accommodate the mating stent selected to maintain perfusion to the LSA. This new device has been successfully applied in 6 patients treated with TEVAR for different arch pathologies., Conclusion: This new puncture device could assist in situ fenestration and improve the technical success rate.

Many recent studies have focused on the potential role of topical agents in the wound healing process. To compare the time to healing of full-thickness wounds treated with topical estrogen, phenytoin, or silver sulfadiazine (SSD), an in vivo study was conducted using 32 male Wistar rats. Animals were housed individually in standard cages in similar environmental conditions, and a single, circular (4 mm in diameter), full-thickness skin wound was created on the dorsum of each rat. Animals were randomly divided into 4 groups of 8 rats each and treated with topical phenytoin, SSD, estrogen cream, or no treatment/control. Each wound was measured and examined daily until healing, defined as complete reepithelialization and closure of the wound. Group mean healing times were calculated, and Tukey's multiple comparison test was used to compare these data. Average times to healing were 11 days in estrogen group, 10 days in phenytoin group, 7.62 days in SSD group, and 11.87 days in control group. Wound healing was significantly faster in the SSD compared to control (P <.01) and the estrogen group (P <.01). No other differences were statistically significant. Further studies, especially randomized clinical trials on human beings with larger sample sizes, are recommended to elucidate if these topical agents affect wound outcomes.

Purpose: Medial soft tissue release in a varus deformity knee during total knee arthroplasty is essential for accurate balancing of the reconstruction. This study attempts to quantify the effect of sequential needle puncturing of the medial collateral ligament (MCL) using a pressure sensor insert (Verasense by OrthoSensor) and gap measurement under tension., Methods: Cruciate-retaining arthroplasties were placed in 14 cadaveric knees. The MCL was elongated by step-wise perforation, in five sets of five perforations, with the use of an 18-gauge needle, followed by valgus stress. Following the fifth set of needle perforations, blade perforation was performed on the remaining tense fibers of the MCL. Following each step-wise perforation, corresponding medial compartment pressures and gap measurements under tension were recorded., Results: Sensor measurements correlated closely with step-wise tissue release (R = 0.73, p < 0.0001), and a significant decrease in pressure was found in early needle puncturing (mean 49 N after 5, 83 N after 15, p values < 0.05), although changes diminished at later stages of needle perforation (90 N after 20). Gap measurement demonstrated small gradual changes with early puncturing, but showed significant opening in the later stages of release. There was minimal variation in pressure or gap measurements in flexion versus extension. This finding suggests that MCL needle puncture will not lead to unequal gaps between flexion and extension. There were no cases of MCL over-release after 15 punctures, one case after 20 punctures, and three after blade perforation., Conclusion: Needle puncturing of the MCL in extension for up to 15 punctures can be a safe and predictable way to achieve medial opening when balancing a varus knee during TKA as demonstrated in this cadaveric model. Blade perforation should be used with caution to avoid over-release. The needle puncture method can be used by surgeons to achieve reliable reductions in medial compartment pressures, to help achieve a balanced TKA, with minimal risk of over-release.

Background: The uric acid (UA) level in patients with gout is a key factor in disease management and is typically measured in the laboratory using plasma samples obtained after venous puncture. This study aimed to assess the reliability of immediate UA measurement with capillary blood samples obtained by fingertip puncture with the HumaSens plus point-of-care meter., Methods: UA levels were measured using both the HumaSens plus meter in the clinic and the routine plasma UA method in the biochemistry laboratory of 238 consenting diabetic patients. HumaSens plus capillary and routine plasma UA measurements were compared by linear regression, Bland-Altman plots, intraclass correlation coefficient (ICC), and Lin's concordance coefficient. Values outside the dynamic range of the meter, low (LO) or high (HI), were analyzed separately. The best capillary UA thresholds for detecting hyperuricemia were determined by receiver operating characteristic (ROC) curves. The impact of potential confounding factors (demographic and biological parameters/treatments) was assessed. Capillary and routine plasma UA levels were compared to reference plasma UA measurements by liquid chromatography-mass spectrometry (LC-MS) for a subgroup of 67 patients., Results: In total, 205 patients had capillary and routine plasma UA measurements available. ICC was 0.90 (95% confidence interval (CI) 0.87-0.92), Lin's coefficient was 0.91 (0.88-0.93), and the Bland-Altman plot showed good agreement over all tested values. Overall, 17 patients showed values outside the dynamic range. LO values were concordant with plasma values, but HI values were considered uninterpretable. Capillary UA thresholds of 299 and 340 μmol/l gave the best results for detecting hyperuricemia (corresponding to routine plasma UA thresholds of 300 and 360 μmol/l, respectively). No significant confounding factor was found among those tested, except for hematocrit; however, this had a negligible influence on the assay reliability. When capillary and routine plasma results were discordant, comparison with LC-MS measurements showed that plasma measurements had better concordance: capillary UA, ICC 0.84 (95% CI 0.75-0.90), Lin's coefficient 0.84 (0.77-0.91); plasma UA, ICC 0.96 (0.94-0.98), Lin's coefficient 0.96 (0.94-0.98)., Conclusions: UA measurements with the HumaSens plus meter were reasonably comparable with those of the laboratory assay. The meter is easy to use and may be useful in the clinic and in epidemiologic studies.

Left atrial appendage occlusion (LAAO) is a rapidly evolving technology. Multi-modality imaging and understanding of left atrial appendage anatomy are sure to advance. Two-dimensional and 3-dimensional transesophageal echocardiography with fluoroscopy are the mainstay for LAAO image-guided therapy. Key to successful LAAO is an understanding of the transseptal puncture, LAAO size selection for the device-specific landing zone, and postdeployment evaluation for leak and complications. With advancements in computed tomography, there may be a greater role for intracardiac echocardiographic imaging in specific types of LAAO anatomy and devices., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Life-threatening bleeding in the head and neck region requires urgent management. These hemorrhagic lesions, for example, a ruptured pseudoaneurysm, are often treated by transarterial embolization (TAE), but prior intervention or surgery, inflammation, anatomic variants, and vessel tortuosity may render an endovascular approach challenging, time-consuming, and sometimes impossible. We report two cases of severe head and neck hemorrhages successfully embolized with n -butyl cyanoacrylate via direct puncture, and propose this approach as a fast, safe, and effective alternative to TAE., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Endovascular embolization is the treatment of choice for carotid-cavernous fistulas (CCFs), but failure to catheterize the cavernous sinus may occur as a result of vessel tortuosity, hypoplasia, or stenosis. In addition to conventional transvenous or transarterial routes, alternative approaches should be considered. The authors present a case in which a straightforward route to the CCF was accessed via transsphenoidal puncture of the cavernous sinus in a neurosurgical hybrid operating suite. This 82-year-old man presented with severe chemosis and proptosis of the right eye. Digital subtraction angiography revealed a Type B CCF with a feeding artery arising from the meningohypophyseal trunk of the right cavernous segment of the internal carotid artery. The CCF drained through a thrombosed right superior ophthalmic vein that ended deep in the orbit; there were no patent sinuses or venous plexuses connecting to the CCF. An endoscope-assisted transsphenoidal puncture created direct access to the nidus for embolization. Embolic agents were deployed through the puncture needle to achieve complete obliteration. Endoscope-assisted transsphenoidal puncture of the cavernous sinus is a feasible alternative to treat difficult-to-access CCFs in a neurosurgical hybrid operating suite.