Hiroshi Nishimaki

Hybrid treatment combining emergency surgery and intraoperative interventional radiology for severe trauma

OBJECT To evaluate the efficacy of hybrid treatment combining emergency surgery and intraoperative interventional radiology (IVR) for severe trauma. PATIENTS AND METHODS The records of 63 severely injured patients who underwent concurrent emergency surgery and IVR at our emergency centre from 1999 through 2013 were retrospectively reviewed. Mobile digital subtraction angiography device was used in the operating room when performing IVR. Patients undergoing hybrid treatment combining intraoperative IVR and emergency surgery (intraoperative IVR group) were compared with those undergoing IVR in the angiography suite before or after emergency surgery (control group). RESULTS Thirteen patients underwent hybrid treatment (intraoperative IVR group). Of these 13 patients, 7 underwent treatment for abdominal organ injuries, and 6 for multiregional injuries. Emergency operations were laparotomy (n=12), thoracotomy (n=1), craniotomy (n=1), and haemostasis of the lower extremities (n=1). Five patients underwent damage control surgery. IVR included transarterial embolisation (n=12), endovascular stent or stent-graft placement (n=2), and embolisation of a portal vein by laparotomy (n=2). The mean ISS was 40. The actual overall survival rate was 85%, and the probability of survival (Ps) was 62%. The control group included 45 patients. Five patients who met exclusion criteria were not included in the control group. Age, ISS, RTS, Ps, pH and base excess on arrival, and blood transfusion volume during operation and IVR did not differ significantly between the groups. Total time during operation and IVR was significantly shorter in the intraoperative IVR group than in the control group (229 [SD 72]min vs. 355 [SD 169]min; p=0.007). The mortality were 15 (95% CI 2-45) % in the intraoperative IVR group vs. 36 (95% CI 22-51) % in the control group. CONCLUSION Hybrid treatment combining emergency surgery and intraoperative IVR can be a novel treatment strategy for severe trauma, and it will improve patient outcomes due to reduction of the time for resuscitation.

Candy-Plug Technique Using an Excluder Aortic Extender for Distal Occlusion of a Large False Lumen Aneurysm in Chronic Aortic Dissection.

Purpose: To describe the candy-plug technique using an Excluder aortic extender for distal occlusion of a large false lumen aneurysm in chronic aortic dissection. Technique: A 60-year-old female patient with a history of chronic type B aortic dissection and high-dose steroid use for Churg-Strauss syndrome developed a large 6.2 cm maximum diameter false lumen aneurysm. She underwent thoracic endovascular aortic repair from the left common carotid artery to the descending aorta to cover the proximal entry at the level of distal arch, with coil embolization of the left subclavian artery. To occlude the large false lumen from the reentry just below the level of the left renal artery ostium, a modified 32×45-mm Excluder aortic extender was deployed in the false lumen through the reentry, and a 16-mm Amplatzer Vascular Plug I was deployed in the waist of the modified Excluder aortic extender for complete occlusion. No obvious technical complication was seen. Contrast-enhanced computed tomography at 1 and 14 months revealed no endoleaks and showed complete false lumen thrombosis. Conclusion: The candy-plug technique using the Excluder aortic extender is feasible for occlusion of a large false lumen aneurysm in chronic aortic dissection.

Imipenem/cilastatin sodium (IPM/CS) as an embolic agent for transcatheter arterial embolisation: a preliminary clinical study of gastrointestinal bleeding from neoplasms

PurposeTo evaluate the feasibility and usefulness of imipenem/cilastatin sodium (IPM/CS) as an embolic agent for intestinal bleeding from neoplasms.Materials and methodsSeven patients who underwent 11 transarterial embolisations (TAEs) using IPM/CS as an embolic material for duodenal or small/large intestinal tumour bleeding from January 2004 to December 2011 were retrospectively evaluated. A mixture of IPM/CS and contrast medium was introduced through the microcatheter positioned at the feeding artery to the tumour until extravasation disappeared or stasis of blood flow to the tumour staining was observed.ResultsHaemostasis was obtained in all patients. Therefore, the technical success rate was 100%. Rebleeding was observed in four patients. All of them underwent repeat TAE using IPM/CS, and haemostasis was obtained successfully. No complication was identified following laboratory and clinical examinations. No haemorrhagic death occurred. Haemorrhagic parameters, including blood haemoglobin and the amount of blood transfusion, improved after TAE.ConclusionThe safety, feasibility, and effectiveness of TAE using IPM/CS as an embolic material for intestinal bleeding from neoplasms were suggested by this study. The mild embolic effect of IPM/CS may be adequate for oozing from tumours. Although rebleeding may occur after embolotherapy using IPM/CS, repeat embolisation is effective as treatment for rebleeding.

Successful treatment of acquired uterine arterial venous malformation using N-butyl-2-cyanoacrylate under balloon occlusion

We present two cases of acquired uterine arterial venous malformation (AVM) which was diagnosed because of massive genital bleeding successfully treated with transcatheter arterial embolization (TAE), using N-butyl-2-cyanoacrylate (NBCA) under balloon occlusion. Balloon occlusion at the uterine artery was performed in both patients for diffuse distribution of NBCA in multiple feeding branches, as well as to the pseudoaneurysm, and for the prevention of NBCA reflux. In one of our patients, balloon occlusion of the draining vein was simultaneously performed to prevent NBCA migration through accompanying high-flow arteriovenous fistula (AVF). Doppler ultrasound at 6 months of both patients documented persistent complete occlusion of AVM. Complete and safe obliteration of acquired uterine AVM was accomplished using NBCA as embolic agent, under balloon occlusion at the communicating vessels of acquired uterine AVM.

A Case of Common Peroneal Nerve Palsy Associated with Internal Iliac Artery Embolization by Using N-butyl-2-cyanoacrylate (NBCA)

A 64-year-old man was scheduled to undergo endovascular aneurysm repair for an abdominal aortic aneurysm (AAA). Since preoperative computed tomography showed an AAA with common iliac artery and internal iliac artery (IIA) aneurysms, IIA embolization was scheduled. Embolization using a coil was supposed to be performed; however, the lateral sacral artery could not be selected. For this reason, IIA embolization using N-butyl-2-cyanoacrylate (NBCA) was undertaken. During embolization, the median sacral artery was unexpectedly embolized through the lateral sacral artery. The patient complained of drop foot just after embolization; he was diagnosed with iatrogenic common peroneal nerve palsy. We have learned that sciatic nerve palsy can occur in cases of embolization with a liquid NBCA–Lipiodol mixture to the lateral or sacral median artery.

Early and Mid-Term Results of Endovascular Aortic Repair Using a Crossed-Limb Technique for Patients with Severely Splayed Iliac Angulation

Objective: We evaluated early and mid-term results of endovascular aortic repair (EVAR) using crossed-limb and non-crossed-limb techniques. Material and Methods: From December 2011 to October 2013, 37 patients (31 men; mean age 75.4 years) were treated with EVAR (crossed-limb, 21 and non-crossed-limb, 16). We compared technical success, maximum short-axis diameter of abdominal aortic aneurysm, iliac angulation, time for catheterization of the short contralateral limb gate of the main body (SCT), and complications between the groups. Results: The mean follow-up period was 810±230 days. The technical success rate was 100%. There was no significant difference between the groups in terms of mean short-axis diameter. Iliac angulation was significantly wider in the crossed-limb group (53.3±14.6 vs. 39.4±13.0, p=0.0049). There was no significant difference between the groups in terms of SCT. Limb occlusion occurred in two cases (one crossed-limb and one non-crossed-limb). There were no aneurysm-related deaths. Conclusion: There were no differences between the crossed-limb and non-crossed-limb techniques in terms of early and mid-term results of EVAR. A crossed-limb technique can be performed safely without prolonged SCT even in severely splayed iliac angulation cases.

Life-Saving Embolization in a Patient with Recurrent Shock Due to a Type II Endoleak after Endovascular Aortic Repair for a Ruptured Abdominal Aortic Aneurysm.

A man in his 80s underwent urgent endovascular aortic repair (EVAR) for a ruptured abdominal aortic aneurysm (RAAA). Surgery was completed without apparent complications, and the patient was returned to the Cardiac Care Unit. Two hours later, he again developed shock, and contrast-enhanced Computed Tomography showed extravasation from a type II endoleak (T2EL) involving the IMA. Transcatheter arterial embolization (TAE) was immediately performed, and the patients vital signs stabilized soon after embolization. Abdominal compartment syndrome was suspected during the procedure, so a retroperitoneal hematoma evacuation was performed. The patients postoperative course was satisfactory, and he transferred to another hospital. EVAR for RAAA would be useful, but it is necessary to be considered that T2EL can cause the aggravation of unstable circulation.