Long-Term Neurological Outcome of Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest Patients With Nonshockable Rhythms: A Single-Center, Consecutive, Retrospective Observational Study.

BACKGROUND: Data on extracorporeal cardiopulmonary resuscitation (ECPR) in patients with out-of-hospital cardiac arrest (OHCA) and initially nonshockable rhythms are limited. OBJECTIVE: This study aimed to evaluate the long-term neurological outcomes of ECPR for patients with OHCA and initially nonshockable rhythms. METHODS: In this single-center, consecutive, retrospective, observational study, patients with OHCA and initially nonshockable rhythms who underwent ECPR between January 2012 and December 2017 were included. All patients with refractory cardiopulmonary arrest were transported while undergoing conventional CPR and received ECPR on arrival in the emergency department. We retrospectively collected characteristics at admission and neurological outcomes at the last visit or telephone interview. Cerebral performance category (CPC) scales 1 and 2 were defined as good neurological outcomes and CPC scales 3, 4, and 5 were defined as poor neurological outcomes. RESULTS: Of the 39 patients included in this study, 32 died in the hospital and only 7 survived. There were 4, 0, 0, 3, and 32 patients with CPC 1, 2, 3, 4, and 5, respectively. The proportion of good neurological outcomes for all patients was 10.3% (95% CI 2.9-24.2%) and 14.3% (95% CI 4.0-32.7%) for patients with pulseless electrical activity. No patients with asystole had a good neurological outcome. Median follow-up period was 1052 days (interquartile range 116-1589 days) for those who survived to discharge. CONCLUSIONS: Approximately 10% of initially nonshockable patients with OHCA, generally considered to be a poor prognosis, could acquire good neurological outcomes when they underwent ECPR with our indications.

D-dimer predicts bleeding complication in out-of-hospital cardiac arrest resuscitated with ECMO.

PURPOSE: In out-of-hospital cardiac arrest (OHCA) patients resuscitated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO), known as extracorporeal cardiopulmonary resuscitation (ECPR), bleeding is a common complication. The purpose of this study was to assess the risk factors for bleeding complications in ECPR patients. METHODS: We retrospectively analyzed the data for OHCA patients admitted to our hospital and resuscitated with ECPR between October 2009 and December 2016. We compared patients with and without major bleeding (i.e. the Bleeding Academic Research Consortium class≥3 bleeding) within 24h of hospital admission. Patients, whose bleeding complication was not evaluated, were excluded. RESULTS: During the study period, 133 OHCA patients were resuscitated with ECPR, of whom 102 (77%) were included. In total, 71 (70%) patients experienced major bleeding. There were significant differences in age (median 65 vs. 50years, P<0.001), prior antiplatelet therapy (25% vs. 3%, P=0.008), hemoglobin (median 11.6 vs. 12.6g/dL, P=0.003), platelet count (median 125 vs. 155×103/µL, P=0.001), and D-dimer levels on admission (median 18.8 vs. 6.7µg/mL, P<0.001) among patients with and those without major bleeding. Multivariate analysis showed significant associations between major bleeding and D-dimer levels (odds ratio, 1.066; 95% confidence interval, 1.018-1.116). Area under receiver-operating characteristic curve, which describes the accuracy of D-dimer levels in predicting major bleeding, was 0.76 (95% confidence interval, 0.66-0.87). CONCLUSION: D-dimer levels may predict major bleeding in ECPR patients, suggesting that hyperfibrinolysis may be related to bleeding.

Untangling a Knotted Angiographic Catheter Using a Balloon Catheter: A Case Report.

When a 66-year-old man with hepatocellular carcinoma underwent an angiographic examination, a 4-Fr catheter was inserted from the right femoral artery. It became tightly knotted in the descending aorta. To untangle the knotted catheter, a noncompliant balloon catheter was delivered into the knotted loop from the contralateral femoral artery. After the balloon catheter was inflated from the inside of the knotted loop, the knot became loose. Finally, the knotted catheter was untangled. Subsequently, the remainder of the examination was performed as initially planned.

Radioprotective Effects of a Semicircular X-ray Shielding Device for Operators During CT Fluoroscopy-Guided Interventional Procedures: Experimental and Clinical Studies.

PURPOSE: To evaluate, experimentally and clinically, the radioprotective effects of a semicircular X-ray shielding device for operators during CT fluoroscopy-guided IR procedures. MATERIALS AND METHODS: During experimentation, the reduction rates of scattered radiation rates from CT fluoroscopy were evaluated using a humanoid phantom. Two shielding device positions were tested: "shielding close to the CT gantry" and "shielding close to the operator". The scattered radiation rate without shielding was also evaluated. The clinical study retrospectively evaluated the operator's radiation exposure during 314 CT-guided IR procedures. With a semicircular X-ray shielding device (with shielding group, n = 119) or without it (no shielding group, n = 195), CT fluoroscopy-guided IR procedures were performed. Radiation dose measurements were taken using a pocket dosimeter placed near the operator's eye. For shielding and no shielding groups, the procedure time, dose length product (DLP), and the operator's radiation exposures were compared. RESULTS: Experimentation revealed the respective mean reduction rates of "shielding close to the CT gantry" and "shielding close to the operator" as 84.3% and 93.5% compared with the no-shielding setting. Although no significant differences were found in the procedure time and the DLP between "no shielding" and "with shielding" groups in the clinical study, the operators' radiation exposure in the "with shielding" group (0.03 ± 0.04 mSv) was significantly lower than in the "no shielding" group (0.14 ± 0.15 mSv; p < .001). CONCLUSION: The semicircular X-ray shielding device provides valuable radioprotective effects for operators during CT fluoroscopy-guided IR.

Radiofrequency Ablation Combined with Hepatic Artery Embolization Using a Tris-acryl Gelatin Microsphere for Colorectal Liver Metastases-Initial Experience.

Purpose: We aim to evaluate retrospectively the feasibility, safety, and initial therapeutic outcomes of radiofrequency ablation combined with hepatic artery embolization using a tris-acryl gelatin microsphere for colorectal liver metastases. Material and Methods: Six consecutive patients (4 men and 2 women) with median age of 68 years (range 57-78 years) underwent computed tomography fluoroscopy-guided radiofrequency ablation immediately after hepatic artery embolization using microspheres. This study evaluated tumor visibility on noncontrast-enhanced computed tomography immediately after hepatic artery embolization; analyzed local tumor progression; defined technical success as the coverage of the tumor by the ablative zone; and assessed adverse events based on Common Terminology Criteria for Adverse Events v5.0. Results: Ten tumors with median maximum diameter of 9 mm (range 5-52 mm) were treated in nine sessions. Eight tumors (80%, 8/10 tumors) were detected as high-attenuation nodules. One tumor was treated in two sessions because follow-up computed tomography revealed an insufficient ablative margin. Therefore, the primary and secondary technical success was 90% (9/10 tumors) and 100% (10/10 tumors), respectively. Grade 2 pneumothorax was observed in one session (11%, 1/9 sessions). No grade 3 or higher adverse event was observed. The local tumor progression rate was 20% (2/10 tumors) during the median follow-up of 14 months. Conclusions: Radiofrequency ablation following microsphere embolization may be a feasible, safe, and useful therapeutic option for controlling small colorectal liver metastases.

Clinical Utility of Bland Embolization Using Microspheres for Painful Malignant Musculoskeletal Tumors.

BACKGROUND/AIM: To evaluate retrospectively whether bland embolization using microspheres is safe and useful for relieving pain in patients with painful malignant musculoskeletal (MSK) tumors. PATIENTS AND METHODS: Bland embolization using microspheres was performed for 20 patients (11 women/9 men) with a median age of 69 years (range=40-89 years) who had 22 painful malignant MSK tumors. The maximum tumor diameters were 2.4-13.8 cm (median, 7.5 cm). Pain was evaluated using the visual analog scale. A decrease of this score by 2 or more after embolization was defined as clinically effective pain relief. Adverse events (AEs) were evaluated using CTCAE v5.0. Objective response, disease control rates, and overall survival were also evaluated. RESULTS: Effective pain relief was achieved in 18 patients (90.0%, 18/20). Grade-3 AEs developed in four patients (20.0%, 4/20): skin ulcer (n=2), skin ulcer and pain (n=1), and muscle weakness with dysesthesia (n=1). No grade-4 or grade-5 AEs developed. Objective response and disease control rates were 26.7% (4/15) and 86.7% (13/15), respectively. The 1-year survival rate was 43.8%, with median survival of 9.2 months (range=0.5-41.0 months). CONCLUSION: Although the survival benefit is equivocal, bland embolization is acceptably safe and useful for relieving pain by controlling tumor growth in patients with painful malignant MSK tumors.

Metastasis of Hepatocellular Carcinoma in the Pouch of Douglas Successfully Treated by Radiation Therapy: A Case Report.

Metastasis of hepatocellular carcinoma (HCC) in the pouch of Douglas is relatively rare. A 65-year-old man with liver cirrhosis was admitted for detailed examination of a pelvic tumor. He had a previous history of ruptured HCC, and received emergent hemostasis with transcatheter arterial embolization followed by curative ablation. His blood tests showed an increase in des-gamma-carboxy prothrombin (DCP). Contrast-enhanced computed tomography (CE-CT) revealed a heterogeneously enhanced large pelvic tumor, but no additional tumorous lesions were detected in other organs, including the lungs, liver and abdominal lymph nodes. The colonoscopy showed compression by an extra-luminal/submucosal tumor, and computed tomography-guided percutaneous needle biopsy revealed that the pelvic tumor was metastasis of HCC. Because of the poor liver function, the solitary pelvic tumor was treated with three-dimensional conformal radiation therapy (3D-CRT). The tumor size and the DCP value were markedly decreased after radiation therapy. Nine months later, occasional mild bloody stool due to radiation proctitis was observed; however, no serious side effects occurred. Our case suggests that radiation therapy may be a therapeutic option for a solitary metastatic lesion of HCC in the pouch of Douglas.

Clinical Experience of Percutaneous Radiofrequency Ablation Using an arfa RF ABLATION SYSTEMⓇ in Various Organs.

Purpose: To evaluate the feasibility, safety, and efficacy of radiofrequency (RF) ablation using an ablation system (arfa RF ABLATION SYSTEMⓇ; Japan Lifeline Co. Ltd.) for treating solid tumors in various organs. Material and Methods: Between October 2019 and August 2021, 80 patients (29 women, 51 men; median age, 70.0 yr) underwent 107 RF ablation sessions using the ablation system to treat 151 tumors in the liver (n = 86), lung (n = 51), adrenal gland (n = 4), pleura (n = 4), bone (n = 3), lymph node (n = 2), and kidney (n = 1). The maximum tumor diameter was 2-40 mm (median, 11 mm). This study evaluated technical success (defined as the completion of planned RF ablation), technique efficacy (defined as the complete tumor ablation on follow-up images), and adverse events. Local tumor progression in 146 curatively treated malignant tumors was evaluated. Results: The technical success rate was 100% (107/107). Ablation zones in two tumors were insufficient. Therefore, the primary technique efficacy rate was 98.1% (105/107). Grade 3 hepatic infarction (1.6%, 1/64) and grade 4 pleuritis (3.4%, 1/29) occurred respectively after liver and lung RF ablation. During the median follow-up period of 10.2 months (Interquartile range, 4.2 and 16.4 months), local tumor progression developed in two tumors (1.4%, 2/146). Conclusions: The arfa RF ABLATION SYSTEMⓇ is a feasible, safe, and effective RF ablation device for managing solid tumors in various organs.

Low-flow time is associated with a favorable neurological outcome in out-of-hospital cardiac arrest patients resuscitated with extracorporeal cardiopulmonary resuscitation.

PROPOSE: The aim of this retrospective study was to investigate the prognostic factors in extracorporeal cardiopulmonary resuscitation (ECPR) patients and to assess their accuracy as predictors of a favorable neurological outcome. MATERIALS AND METHODS: Between October 2009 and December 2017, we retrospectively analyzed witnessed out-of-hospital cardiac arrest patients who were admitted to our hospital and resuscitated with ECPR. We compared the baseline characteristics, pre-hospital clinical course, arrest causes, and blood samples on admission for the favorable and unfavorable outcome groups. RESULTS: Among the 135 patients included, 22 (16%) had a favorable neurological outcome. Low-flow time was shorter (median 38 vs. 48 min, p < 0.001) in the favorable neurological outcome group; in multiple logistic analyses, low-flow time was significantly associated with a favorable neurological outcome (odds ratio, 0.88; 95% confidence interval, 0.82-0.94). The area under the receiver-operating characteristic curve of low-flow time was 0.80 (95% confidence interval, 0.70-0.89), and the cut-off value of 58 min corresponded to a sensitivity of 0.25 and a specificity of 1.0. CONCLUSIONS: In ECPR patients, low-flow time was significantly associated with a favorable neurological outcome, and ECPR should be performed within 58 min of the low-flow time.