Koji Idoguchi

Smaller introducer sheaths for REBOA may be associated with fewer complications.

Introduction Large arterial sheaths currently used for resuscitative endovascular balloon occlusion of the aorta (REBOA) may be associated with severe complications. Smaller diameter catheters compatible with 7Fr sheaths may improve the safety profile. Methods A retrospective review of patients receiving REBOA through a 7Fr sheath for refractory traumatic hemorrhagic shock was performed from January 2014 to June 2015 at five tertiary-care hospitals in Japan. Demographics were collected including method of arterial access; outcomes included mortality and REBOA-related access complications. Results Thirty-three patients underwent REBOA at Zone 1 (level of the diaphragm). Most patients were male (70%), with a mean age (+SD) 50 ± 18 years, mean BMI 23 ± 4, and a median [IQR] ISS of 38 [34, 52]. Ninety-four percent of patients presented after sustaining injuries from blunt mechanisms. Twenty-four percent underwent CPR before arrival, and an additional 15% received CPR after admission. Percutaneous arterial access without ultrasound or fluoroscopy was achieved in all patients. Systolic blood pressure increased significantly following balloon occlusion (mean 62 ± 36 to 106 ± 40 mm Hg, p < 0.001). Median total duration of complete initial occlusion was 26 [range 10–35] minutes. Sixteen patients (49%) survived beyond 24 hours, and 14 patients (42%) survived beyond 30 days. Twenty-four-hour and 30-day survival were 48% and 42%, respectively. Of the patients surviving 24 hours (n = 16), median duration of sheath placement was 28 [range 18–45] hours with all removed using manual pressure to achieve hemostasis. Of 33 REBOAs, 20 were performed by Emergency Medicine practitioners, 10 by Emergency Medicine practitioners with endovascular training, and 3 by Interventional Radiologists. No complication related to sheath insertion or removal was identified during the follow-up period, including dissection, pseudoaneurysm, retroperitoneal hematoma, leg ischemia, or distal embolism. Conclusions 7Fr REBOA catheters can significantly elevate systolic blood pressure with no access-related complications. Our results suggest that a 7Fr introducer device for REBOA may be a safe and effective alternative to large-bore sheaths, and may remain in place during the post-procedure resuscitative phase without sequelae. LEVEL OF EVIDENCE Therapeutic/care management, level V.

Fever in trauma patients: friend or foe?

BACKGROUND In trauma patients, elevated body temperature is a common and noninfective procedure soon after injury. We hypothesized that the absence of this febrile response is associated with failure to meet metabolic demands and results in adverse outcomes. METHODS We collected retrospective data of 253 consecutive trauma patients admitted to the intensive care unit during a 3-year period. Patients were stratified according to their daily maximum body temperature from days 1 to 10 (Tmax 1-10): no fever (<37.5 degrees C), low fever (37.5-38.4 degrees C), moderate fever (38.5-39.0 degrees C), and high fever (>39.0 degrees C). The area under the curve (AUC) of core temperature during the first 24 hours after admission was calculated for each patient at a baseline of 36 degrees C. The infection and mortality rates were measured. RESULTS Sixty-three patients (24.9%) developed an infection, and the overall mortality was 7.5% (19 patients). Patients with no Tmax 1 and a low or high Tmax 4 to 10 had a significantly high infection rate; those with no fever on days 1 and 2 had a significantly high mortality rate. A low AUC was also associated with significantly higher infection and mortality rates. Multiple logistic regression analysis controlled for age, injury severity score, Tmax 1, AUC, initial temperature at admission, and time taken to reach 36 degrees C (if hypothermia was present) revealed that age, injury severity score, low AUC (odds ratio, 0.96; 95% confidence interval, 0.94-0.99; p = 0.002), and initial temperature were independent predictors of infection. Age and lower AUC (odds ratio, 0.87; 95% confidence interval, 0.81-0.92; p < 0.001) were both predictors of mortality. CONCLUSIONS A febrile response until day 4 after injury did not increase morbidity, and a low AUC is independently associated with adverse outcomes. These findings show that a nonfebrile response soon after injury results in poor prognosis.

Fewer REBOA complications with smaller devices and partial occlusion: evidence from a multicentre registry in Japan

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) performed by emergency physicians has been gaining acceptance as a less invasive technique than resuscitative thoracotomy. Objective To evaluate access-related complications and duration of occlusions during REBOA. Methods Patients with haemorrhagic shock requiring REBOA, from 18 hospitals in Japan, included in the DIRECT-IABO Registry were studied. REBOA-related characteristics were compared between non-survivors and survivors at 24 hours. 24-Hour survivors were categorised into groups with small (≤8 Fr), large (≥9 Fr) or unusual sheaths (oversized or multiple) to assess the relationship between the sheath size and complications. Haemodynamic response, occlusion duration and outcomes were compared between groups with partial and complete REBOA. Results Between August 2011 and December 2015, 142 adults undergoing REBOA were analysed. REBOA procedures were predominantly (94%) performed by emergency medicine (EM) physicians. The median duration of the small sheath (n=53) was 19 hours compared with 7.5 hours for the larger sheaths (P=0.025). Smaller sheaths were more likely to be removed using external manual compression (96% vs 45%, P<0.001). One case of a common femoral artery thrombus (large group) and two cases of amputation (unusual group) were identified. Partial REBOA was carried out in more cases (n=78) and resulted in a better haemodynamic response than complete REBOA (improvement in haemodynamics, 92% vs 70%, P=0.004; achievement of stability, 78% vs 51%, P=0.007) and allowed longer occlusion duration (median 58 vs 33 min, P=0.041). No statistically significant difference in 24-hour or 30-day survival was found between partial and complete REBOA. Conclusion In Japan, EM physicians undertake the majority of REBOA procedures. Smaller sheaths appear to have fewer complications despite relatively prolonged placement and require external compression on removal. Although REBOA is a rarely performed procedure, partial REBOA, which may extend the occlusion duration without a reduction in survival, is used more commonly in Japan.

Case Report: Urgent endovascular treatment of subclavian artery injury after blunt trauma.

Subclavian arterial injury is rare and potentially life-threatening, particularly when it leads to arterial occlusion, causing limb ischemia, retrograde thromboembolization and cerebral infarction within hours after injury. Here we report a blunt trauma case with subclavian arterial injury, upper extremity ischemia, and the need for urgent treatment to salvage the limb and prevent cerebral infarction. A 41-year-old man had a left, open, mid-shaft clavicle fracture and left subclavian artery injury accompanied by a weak pulse in the left radial artery, decreased blood pressure of the left arm compared to the right, and left hand numbness. Urgent debridement and irrigation of the open clavicle fracture was followed by angiography for the subclavian artery injury. The left distal subclavian artery had a segmental dissection with a thrombus. Urgent endovascular treatment using a self-expanding nitinol stent successfully restored the blood flow and blood pressure to the left upper extremity. Endovascular treatment is a viable option for cases of subclavian artery injury where there is a risk of extremity ischemia and cerebral infarction.

Lessons learned from endovascular management of ureteroarterial fistula.

Stent graft placement for ureteroarterial fistula is the preferred treatment. However, some pitfalls may occur during the procedure. Chronic inflammation process will induce longer adhesion area between artery and ureter, which results in unusual fistula site and rigid iliac arteries. This further leads to difficulty in advancing the endograft delivery system, even when access route is large enough. Multiple attempts to pass the iliac artery may result in “incidental” mechanical provocative angiography with subsequent massive bleeding. These suggested us not only to be careful and prepared but also to consider that angiography after inserting the delivery system could give additional information on the exact fistula site.

Duodenal Disruption Diagnosed 5 Days After Blunt Trauma in a 2-Year-Old Child : Report of a Case

Blunt duodenal injury in children is uncommon and diagnosis is often delayed because of its retroperitoneal location. Both diagnosis and treatment are difficult. We report the case of a 2-year-old boy whose trauma injury was not reported for 5 days. His vital signs were stable, but he was vomiting bile-stained fluid and his stools were white. The third portion of the duodenum was completely disrupted, and was repaired by pyloric exclusion with duodenal and bile duct drainage. The child recovered uneventfully. We discuss the diagnostic strategies and therapeutic measures for this type of injury.

Inhibition of Growth in a Rabbit VX2 Thigh Tumor Model with Intraarterial Infusion of Carbon Dioxide–Saturated Solution

PURPOSE To evaluate the efficacy of intraarterial infusion of CO2-saturated solution in rabbit VX2 thigh tumors. MATERIALS AND METHODS Fourteen Japanese white rabbits had VX2 tumors implanted in the right femoral muscle 3 weeks before intraarterial infusion. Rabbits were divided into control and CO2 groups (n = 7 each). Fifty milliliters of solution (saline solution and CO2-saturated solution for the control and CO2 groups, respectively) was administered via a 24-gauge catheter in the ipsilateral iliac artery close to the feeding artery of the VX2 tumor. All rabbits were killed for tumor harvest on day 3 after the procedure. Tumor volume was evaluated with in vivo direct caliper measurement and contrast-enhanced computed tomography (CT). Tumor apoptotic changes were examined by DNA fragmentation assay and immunoblot analysis. The tumor growth ratio and apoptotic cell rate were analyzed. RESULTS Body weight was equally increased in both groups, but the mean tumor growth ratio was significantly decreased in the CO2 group compared with the control group (-9.5% ± 7.9 vs 27.2% ± 6.6 and 4.1% ± 4.4 vs 35.7% ± 4.5 measured by calipers and contrast-enhanced CT, respectively; P < .01). Apoptotic activity in the CO2 group was higher than in the control group (number of apoptotic cells per area, 215.0 ± 58.7 vs 21.8 ± 5.4; adjusted relative density of cleaved caspase-3, 0.23 ± 0.07 vs 0.04 ± 0.01; P < .01). CONCLUSIONS Intraarterial infusion of CO2-saturated solution inhibits rabbit VX2 thigh tumor growth by activation of apoptotic cell death through cleaved caspase-3 upregulation.

Endovascular Treatment of Blunt Traumatic Abdominal Aortic Occlusion With Kissing Stent Placement

Blunt traumatic abdominal aortic dissection is extremely rare and potentially deadly. We present the case of a 62-year-old man involved in a frontal car crash. After emergency undergoing laparotomy for bowel injuries, he was referred to our hospital due to acute ischemia of bilateral lower extremities on day 3 after the trauma. Computed tomography and aortography showed an aortobiiliac dissection with complete occlusion. This injury was successfully treated by endovascular treatment with “kissing”-technique stent placement, which appears to be a safe, effective, and minimally invasive treatment.

Fibromuscular dysplasia presenting as hemorrhagic shock due to spontaneous rupture of a right gastroepiploic artery aneurysm.

Intraabdominal bleeding from a ruptured artery aneurysm in a young adult is rare. This report describes a patient who presented to the emergency department with hemorrhagic shock caused by a ruptured aneurysm in an omental branch of the right gastroepiploic artery. The gastroepiploic artery aneurysm was successfully treated with a superselective transcatheter arterial embolization. In addition, the angiography of the superior mesenteric artery revealed multifocal stenosis, which has a typical “string-of-beads“ appearance, characteristic of fibromuscular dysplasia (FMD) in the jejunal artery. Fibromuscular dysplasia is a rare disease that can cause stenosis, occlusion, aneurysm, or dissection in a medium-sized artery and is more common in women than men. The natural history, causative genes, and pathogenesis of FMD have not been fully elucidated; however, delayed diagnosis of FMD has been reported. In a young female patient with intraabdominal bleeding, clinicians should consider the possibility of a ruptured aneurysm due to FMD. Examinationwith early-phase angiography and endovascular treatment may reduce the need for laparotomy for hemostasis. Awareness of FMD among emergency physicians could potentially shorten diagnostic delays and increase the chances of effective examination and treatment of this condition.

Successful n-butyl cyanoacrylate embolization of a spontaneous rupture of the internal mammary artery in a patient with myelodysplastic syndrome: report of a case

Hemomediastinum and hemothorax due to spontaneous internal mammary artery (IMA) rupture is extremely rare, and can be a life-threatening condition. We herein present, to the best of our knowledge, the first case of spontaneous IMA rupture complicating myelodysplastic syndrome, and the first case that was successfully treated by emergency trans-arterial embolization using n-butyl cyanoacrylate.