Percutaneous approach

Access problems occur with either the percutaneous approach or open surgical approach to the vessels for endograft insertion. The femoral artery may be injured and require immediate repair with a patch or replacement of a segment. In addition, distal thrombosis may occur from the blockage of the flow into the lower extremities by the sheath and... 

Against this backdrop, research into less invasive approaches to treat valvular disease has been intensified. In the surgical realm, minimally invasive techniques, with its attendant patient and procedural related limitations, have been tried with some success but traditional valvular operations still remain the norm. At the same time, great strides have been made in percutaneous approaches to treatment of valvular disease. Two valvular disease states in which percutaneous balloon valvuloplasty have had great success are in the treatment of pulmonic stenosis and mitral stenosis. 

Of the myriad percutaneous approaches currently proposed for the treatment of mitral regurgitation, the MitraClip (E-valve , Menlo Park, CA) and CARILLON Mitral Contour System (Cardiac Dimension , Kirkland, WA) have recently received CE Mark approval in Europe but none by the U.S. FDA. 

As both procedures are safe to perform, the number of contraindications is relatively low. However, in children with a severe non-correctable coagulopathy, severe respiratory or cardiac problems a surgical approach would be more advisable. In some children their inherent anatomy, i.e. the absence of a good percutaneous route, or previous gastric surgery, will preclude a percutaneous approach. Dewald etal. (1999) reported this to occur in 4.4% of... 

In 1996, Shandling and Chait were the first to describe a percutaneous approach to cecostomy placement in 15 patients. In more recent publications, Kaye et al. (2000a), Kaye and Towbin (2002) and Chait et al. (2003) describe the percutaneous ACE procedure in detail. The patient is placed on a two-day pre-admission fluid diet and Fleet (CB Fleet CO. Inc., Lynchburg, Va., Canada) phospho-soda bowel regimen (45 ml on the night before admission... 

Another venous lead implantation approach of historical interest is the jugular vein. The first method to acces the vein was nonpercutaneous, in which two incisions are required. The first skin incision, performed above the clavicle between the posterior rim of the sternocleidomastoid muscle and the anterior rim of the trapezius muscle, is necessary to reach the external jugular vein or, extended forward, the carotid sheath wherein internal jugular vein is present. A second infraclavicu-lar incision is then necessary to fashion the pocket over the pectoral muscle. Only the latter is required for the percutaneous approach, but regardless of the method used, in both cases, the lead must be tunneled to the pocket (usually over the clavicle). These techniques have been abandoned due to frequent complications related to lead failure. Outside the vein, the lead must run at an acute angle to reach the pocket, which is the reason for the recurrent lead fracture related to this venous approach. However, this is probably the better approach in case of lead extraction. 

The direct puncture percutaneous approach to pancreatic aneurysm embolization was first described... 

Dual-chambered pacing calls for the introduction of an atrial and ventricular electrode. The cutdown technique is less suited for this approach because all too often the cephalic vein can hardly acconunodate one electrode, and even less two. The percutaneous approach appears ideally suited for dual-chambered pacing as there is potential for unlimited access to the venous circulation. Various options for dual-chambered pacing venous access are listed in Table 4.10. There are four percutaneous approaches for dual-chambered pacing. 

There are a number of proposed mechanisms and potential solutions (62-65). Electrodes of a more complex design, such as bipolar coaxial construction, are most susceptible to this phenomenon. A more lateral percutaneous approach... 

Venous access can be carried out by either cutdown or the percutaneous approach. If the initial electrode has been placed via cutdown, the isolation of a second vein for venous access will prove extremely difficult. In this case, percutaneous approach should be attempted. Conversely, if the initial electrode has been placed percutaneously, then a second percutaneous approach or a cut-down is always possible. The second percutaneous puncture is usually carried out just lateral to the initial venous entry site. The initial lead can be used as a marker of the venous anatomy. If any difficulty is encountered, fluoroscopy is used to guide the lead using the chronic ventricular lead for reference (85,86). There is potential risk of damaging the initial electrode and care should be taken to avoid its direct puncture. The use of radiographic materials can also help define the venous structure as well as its patency. 

Air embolism is a complication associated with the use of the Seldinger technique with a percutaneous sheath set. Air embolism is a well-known, well-documented complication of the percutaneous approach. To avoid this problem, it has been recommended that the patient be well hydrated and placed in the Trendelenburg position. The most important step in prevention is awareness on the part of the implanting physician for the risk of air embolization. There are many steps that may be taken to avoid this complication (Table 4.21) (192). The time of greatest risk is when the dilator is removed from the sheath set. In patients with a volume-overload state, there is little or no risk. On the other hand, an elderly dehydrated patient who has been NPO for many hours is at risk for serious air embolization. It is reconunended that prior to any percutaneous pacemaker or ICD procedure, the patient be maintained in a mild state of overhydration. The patient s state of hydration should be assessed just prior to removal of the dilator. 

Sznajder JI, et al. Central vein catheterization failure and complication rates by three percutaneous approaches. Arch Intern Med 1986 146 259. 

The optimal approach for performing RF ablation in the liver is a matter of debate. RF ablation can be performed percutaneouslylaparoscopically or at laparotomy. At our institution the percutaneous approach is preferred because it is the least invasive, has minimal morbidity, can be performed on an outpatient basis, can be performed with ultrasound, CT, or MRI and can be repeated as necessary. Advocates of periopera-... 

RF needles can be placed under ultrasound, CT, or MRI guidance using the percutaneous approach. Ultrasound is the most common guidance method as it has real-time capabilities, allows vascular visualization, and is readily available (Rossi et al. 1998 Livraghi et al. 2000 Francica and Marone 1999 Kainuma et al. 1999). 

Under CT guidance, a 22-gauge needle is inserted into the retrocrural space at the level of T11-T12 by a posterior percutaneous approach. The needle tip is located just lateral to the anterolateral surface of the vertebra where the three thoracic splanchnic nerves are located in close proximity to one another (Fig. 11.8). After injection of 2 ml of bupivacaine diluted with contrast medium confirming the location of the needle tip, 10 ml of ethanol (96%) are injected on both sides. A bilateral block is often essential for relief of upper abdominal pain (Bonica 1990b Kurdziel and Dondelinger 1990). 

Open surgical exposure, laparoscopic exposure and an entirely percutaneous approach have been... 

Fig. 18.8a-d. Selective occipital angiogram in lateral view a demonstrates high-flow scalp AVM which was also supplied by branches of the ipsilateral and contralateral superficial temporal arteries and contralateral occipital artery (not shown). Following transarterial partial embolization with glue and particles of PVA into these vessels a percutaneous approach was performed b,c with injection of glue (50% NBCA/ 50% Lipiodol) resulting in complete obliteration of the AVM nidus as shown on the post embolization left external carotid angiogram d... 

For pseudoaneurysm accessible by percutaneous approach, the procedure can be performed under Doppler guidance (Fig. 23.3a,b). The adequate needle placement is confirmed by contrast injection. Thrombostat (Thrombin, Parke-Davis, Scarborough, On., Canada), 1000 units/cc, is the most commonly used agent. We start with an initial bolus of 200 units. If the flow in the pseudoaneurysm is still present on Doppler ultrasound, we repeat the injection up to a maximal dose of 1000 units. Since there is a possible risk of contamination with Thrombostat, we elected to use human thrombin 500 which is included in a kit available at the blood bank of our institution (Tissel Kit VH, Baxter, USA). Tissue adhesive, Gelfoam, or coils can also be used percu-taneously. 

Ponsky JL, Gauderer MW, Stellato TA, et al. Percutaneous approaches to enteral alimentation. Am J Surg 1985 149 102-115. 

The excellent results with nephrolithotomy in adults (Ball et al. 1986 Boddy et al. 1987 Hulbert et al. 1985) led to its application in children. While in the reported pediatric series most children were over 5 years of age, percutaneous stone removal in younger children has been successful (Ball et al. 1986). The percutaneous approach has been especially useful in managing recurrent renal calculi in children who have had multiple open surgical procedures. 

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