Carbon dioxide-enhanced angiography for detection of colonic diverticular bleeding and clinical outcomes.

PURPOSE: To determine the ability of CO2-enhanced angiography to detect active diverticular bleeding that is not detected by iodinated contrast medium (ICM)-enhanced angiography and its impact on clinical outcomes when used to confirm embolization, particularly the risks of rebleeding and ischemic complications. MATERIALS AND METHODS: We retrospectively identified a cohort of patients with colonic diverticular bleeding who underwent catheter angiography between August 2008 and May 2023 at our institution. We divided them according to whether they underwent CO2 angiography following a negative ICM angiography study or to confirm hemostasis post-embolization (the CO2 angiography group) or ICM angiography alone in the absence of active bleeding or for confirmation of hemostasis post-embolization (the ICM angiography group). The ability to detect active colonic diverticular bleeding and clinical outcomes were compared between the two groups. RESULTS: There were 31 patients in the ICM angiography group and 29 in the CO2 angiography group. The rate of detection of active bleeding by CO2 angiography that was not identified by ICM angiography was 48%. The rebleeding rate was 23% in the ICM angiography group and 6.9% in the CO2 angiography group. Among the patients who underwent TAE, the ischemic complications rate was 7.1% in the ICM angiography group and 4.5% in the CO2 angiography group. CONCLUSIONS: CO2 angiography may detect active diverticular bleeding that is not detectable by ICM angiography and appears to be associated with a lower rebleeding rate. LEVEL OF EVIDENCE: IV.

Severe liver injury successfully treated with transarterial embolization using carbon dioxide angiography: A case report.

Angiography using carbon dioxide (CO2) has gained attention as a method of inducing active bleeding in patients for whom bleeding cannot be detected with iodine contrast medium (ICM). We experienced a case in which CO2 angiography was performed during transarterial embolization (TAE) for severe liver injury with active bleeding. A woman in her 40s was struck by a minitruck while crossing the road and rushed to our hospital. Upon admission, she was in shock vital with blood pressure of 75/38 mmHg and pulse rate of 130 bpm. Blood transfusion was promptly started after arrival and her blood pressure increased. Abdominal ultrasonography showed echo free space in Morrison's pouch. Contrast-enhanced CT showed deep liver laceration in the right lobe and intra-abdominal hemorrhage with active bleeding. We selected TAE for hemostasis. ICM angiography showed extravasation of contrast medium from the anterior and posterior segmental branches, which was embolized with a gelatin sponge. After embolization, CO2 angiography revealed new extravasation that could not be detected by ICM, which was additionally embolized. There was no rebleeding or pseudoaneurysm after embolization. In TAE for deep liver injury, ICM alone may underestimate active bleeding. CO2 angiography may lead to better outcomes when injured vessels are reliably identified and TAE is performed.

Carbon dioxide angiography during angioembolization for trauma patients increases the detection of active bleeding and leads to reliable hemostasis: a retrospective, observational study.

BACKGROUND: Angiography with carbon dioxide (CO2) has long been used as an alternative when iodine contrast media (ICM) cannot be used due to allergy to iodine or renal dysfunction. Conversely, CO2 angiography is also known as a provocation method for active bleeding. In this study, we examined the efficacy of CO2 angiography in angioembolization (AE) for trauma patients. METHODS: This was a single-center, retrospective, observational study of trauma patients who underwent AE at our facility between January 2012 and April 2023. RESULTS: Within this period, 335 AEs were performed. CO2 angiography was performed in 102 patients (30.4%), and in 113 procedures. CO2angiography was used to provoke active bleeding which went undetected using ICM in 83 procedures, and to confirm hemostasis after embolization in 30 procedures. Of the 80 procedures wherein, active bleeding was not detected on ICM, 35 procedures (43.8%) were detected using CO2. The spleen had the highest detection rate of active bleeding by CO2 angiography among the organs. There were 4/102 (1.9%) patients with CO2 contrast who underwent some form of reintervention. Two patients were re-embolized with n-butyl-2-cyanoacrylate because of recanalization after embolization with gelatin sponge. The other two patients had pseudoaneurysm formation which required reintervention, and CO2 angiography was not used. Vomiting was the most common complication of CO2 angiography in 10 patients (9.8%), whereas all were transient and did not require treatment. CONCLUSIONS: CO2 angiography of trauma patients may have a better detection rate of active bleeding compared with ICM, leading to reliable hemostasis.

Transarterial embolization to treat a massive hemothorax during mechanical circulatory support via puncturing of the extracorporeal membrane oxygenation circuit.

BACKGROUND: Current guidelines recommend the use of mechanical circulatory support (MCS) for patients with cardiogenic shock that is refractory to medical therapy. Bleeding is the most common complication of MCS. Transarterial embolization (TAE) is often performed to treat this complication, because it is a less invasive hemostatic procedure. However, the TAE option needs to be carefully considered during MCS, as the access route may be limited during MCS. CASE PRESENTATION: A man in his 70 s was diagnosed with acute myocardial infarction and underwent percutaneous coronary intervention via venoarterial extracorporeal membrane oxygenation (VA-ECMO) and Impella. During treatment in the intensive care unit, he suffered damage to a branch of the internal thoracic artery during a cardiac drainage procedure, which was subsequently treated via emergency TAE. An ECMO return cannula and an Impella sheath were inserted into the patient's right and left femoral arteries, respectively. An approach from the left brachial artery was selected, and the left internal thoracic artery was embolized. Subsequently, the patient required re-intervention to treat re-bleeding from another artery. Because it was difficult to target the target artery from the brachial one, owing to interference from the Impella catheter, the ECMO circuit near the return cannula was punctured and a guiding sheath was inserted. The ECMO flow and the patient's blood pressure decreased following placement of this guiding sheath. We were thus able to maintain the patient's blood pressure by increasing the infusion fluids and Impella flow, and embolize the target artery using a gelatin sponge to achieve hemostasis. CONCLUSION: When TAE is difficult to perform during MCS using an approach from the upper extremities, a lower extremity approach with a sheath inserted into the ECMO circuit may represent a viable alternative.

In vitro comparison of the leakage of carbon dioxide and iodine contrast media in a bleeding model.

BACKGROUND: We aimed to compare the hydrodynamic values of carbon dioxide (CO2) and iodine contrast media for bleeding detection using an in vitro model. MATERIALS AND METHODS: We created a bleeding model with large and small wounds in simulated blood vessels. We connected a syringe to the bleeding model and the blood pressure transducer, filling the circuit with CO2 and iodine contrast media. The syringe's piston was pressed, and the flow rate and intravascular pressure of the CO2 and iodine contrast media leaking from the bleeding model were measured. We compared each leaked contrast medium's volume, sphere-equivalent diameter, and sphere-equivalent area. These values were analyzed to compare the visibility of the leakage objectively. RESULTS: At a constant flow rate, the intravascular pressure required for the model to leak was lower for the CO2 than that for the iodine contrast medium. The CO2 contrast medium leakage volume, equivalent circle diameter, and equivalent circle area were greater than those of the iodine one. These values indicate higher CO2 visibility during fluoroscopy. CONCLUSIONS: In the bleeding model, a CO2 contrast medium may be more prone to leakage than the iodine one in large and small wounds. Regarding visibility, a CO2 contrast medium may be more likely to detect leakage than an iodine one.

Elevated Plasma Tryptophan in Patients with Anorexia Nervosa Compared with Hypotrophic Controls.

Introduction: We hypothesized that anorexia nervosa (AN) is associated with pathological amino acid metabolism. This study aimed to identify amino acids exhibiting abnormal metabolism in patients with AN compared with those in low-nutrient controls. Methods: This was a single-center, retrospective, observational study that compared patients with AN with a low-nutrient control group. All participants were admitted to the Kitasato University Hospital Emergency Center between January 1, 2018, and January 31, 2021. Both the AN and low-nutrient control groups had five patients each. Plasma amino acid category testing was conducted at the same institution for both groups. Patient sex, age, height, weight, and comorbidities were retrospectively extracted. Plasma amino acid fractions, total amino acids, total essential amino acids, total nonessential amino acids, branched-chain amino acids (sum of valine, isoleucine, and leucine), and amino acid concentrations and ratios were compared between the two groups. Data were analyzed using the Mann-Whitney U test. Results: Body mass index was lower in the AN group (p = 0.00794). Tryptophan levels were significantly higher in the AN group (p = 0.00794). Other amino acid values, the sum of amino acid values, and amino acid ratios were not significantly different between both groups. Conclusions: Serum tryptophan levels were higher in the AN group than in the low-nutrient group, and AN may be associated with abnormal amino acid metabolism.

Multiple trauma complicated by traumatic vertebral artery injury without cervical vertebral injury: A case report.

Background: Blunt traumatic vertebral artery injury is commonly associated with head and cervical spinal trauma. However, those associated with chest or upper extremity injuries without cervical spine-related trauma are rare. Case presentation: A 94-year-old woman was injured in a motor vehicle crash. She was diagnosed with traumatic subarachnoid hemorrhage, bilateral subdural hematomas, right vertebral artery injury, and right clavicle fracture. No cervical spine injuries were observed. It was possible that the fracture fragment of the right clavicle may have directly injured the right vertebral artery. Coil embolization was performed for the vertebral artery injury. The patient had a good postoperative course and was transferred to the hospital for rehabilitation on day 65. Conclusion: Regarding the high-risk injury mechanism, blunt traumatic vertebral artery injuries in the V1-2 segment may occur in cases with clavicle fractures.

Evaluation of a new insertion site for arterial pressure line in intensive care unit management: a prospective study.

The arterial pressure line (A-line) is primarily inserted through the radial artery. However, accidental removal due to joint movement can be problematic in the intensive care unit (ICU). This study aimed to evaluate the safety and effectiveness of A-line insertion in the ICU through the distal radial approach (DRA), which is used in cardiac catheterization. This single-center, prospective, comparative study included 200 patients (≥ 20 years) who were brought to our hospital for emergency care and required A-line insertion. Patients were quasi-randomized to the traditional radial approach (TRA) or DRA. Data were recorded at the time of A-line insertion, administration, and removal. We evaluated the vessel diameter, number of punctures, success of the procedure, presence of complications, such as infection during management, and time taken for hemostasis after catheter removal. The primary endpoint was the accidental removal rate. Due to incomplete information, data were collected for 193 patients (96 TRA and 97 DRA). Successful procedures were observed in 95 of the 96 patients with TRA and 94 of the 97 patients with DRA. Guidewire use during insertion was significantly more common in the DRA group (P < 0.01) and post-puncture splint fixation was significantly more common in the TRA group (P < 0.01). Accidental removal, the primary endpoint, was observed in 10 patients with TRAs and 11 patients with DRAs, with no significant difference between the two groups (P > 0.99). DRA is as safe and effective as the TRA, suggesting that it is useful as a new A-line insertion site.

Hybrid surgery for blunt aortic injury with rupture: a case report.

BACKGROUND: Blunt thoracic aortic injury is one of the most lethal traumatic injuries. Ruptured cases often result in cardiac arrest before arrival at the hospital, and survival is rare. CASE PRESENTATION: A female patient in her 30 s was struck by an automobile while she was walking across an intersection. She was in a state of shock when emergency services arrived and was in cardiac arrest shortly after arriving at the hospital. A left anterolateral thoracotomy revealed a massive hemothorax secondary to thoracic aortic rupture. In addition, the patient had multiple traumas, including maxillary, pelvic, and lumbar burst fractures. We attempted to directly suture the aortic lesion; however, the increasing blood pressure caused the suture to break. We used a thoracic stent graft while ensuring permissive hypotension. Her postoperative prognosis was positive, and she was transferred to another hospital 85 days later. CONCLUSIONS: We successfully performed a hybrid surgery combining thoracotomy and endovascular repair for this emergency case of blunt thoracic aortic injury with rupture.

Endovascular thrombectomy using a stent retriever catheter for massive pulmonary thromboembolism.

Acute massive pulmonary thromboembolism (PE) has a high mortality rate of 18%-65%. Along with anticoagulation and thrombolytic therapy, treatment may require a catheter-based thrombectomy or surgical thrombectomy. We report a case of pulmonary thromboembolism treated with a Stent Retriever (Trevo® NXT ProVue Retriever, Stryker, Kalamazoo, MI, USA), which is commonly used to treat stroke. An 81-year-old woman complained of back pain and was transported to our hospital after she became unconscious. Cardiopulmonary resuscitation was initiated before her arrival at the hospital; she returned to spontaneous circulation after arrival. After undergoing computed tomography (CT) scanning, she went into cardiac arrest again, and we established veno-arterial extracorporeal membrane oxygenation and performed catheter thrombectomy using a stent retriever. The left basilar pulmonary artery and the right middle pulmonary artery trunk were retrieved after the stent's deployment, and bilateral pulmonary arteries were confirmed to be reopened. A residual thrombus was present, and Monteplase was administered. A contrast-enhanced CT scan taken on day 15 following admission revealed that the thrombus had disappeared, and echocardiography revealed improved right ventricular dysfunction. The patient was transferred to another hospital on day 64 for rehabilitation. We report the first case of pulmonary artery thrombosis that was successfully recanalized by endovascular treatment with a stent retriever. The stent retriever may be useful as an endovascular treatment device for PE because it is easier to achieve recanalization using this method compared to conventional treatment methods.

Safety of arterial catheterization using the distal radial approach in intensive care unit management: A pilot study.

BACKGROUND: Arterial catheter (A-line) is essential for managing severely ill patients, and the radial artery is the most common insertion site in the intensive care unit (ICU). However, many accidental removals occur because the insertion site of A-line in the traditional radial approach (TRA) overlaps with the joint flexion. Recent reports have shown no significant difference in the complication rates between coronarography using the distal radial approach (DRA) and that using TRA. However, to date, no report has examined accidental removals of DRA in the ICU. This study aimed to retrospectively evaluate the safety of the DRA A-line in ICU management. METHODS: This retrospective, descriptive, and observational study enrolled patients who underwent A-line insertion using the DRA at the authors' facility, which is a university hospital with approximately 1100 beds, from January 1, 2019 to August 31, 2019. The participants' clinical data were extracted from their medical records. The primary outcome was the number of accidental removals. RESULTS: The study included 20 patients with a median age of 70 (interquartile range (IQR): 58.5-77) years: 10 patients with traumas, 6 with cerebral hemorrhages, 2 with gastrointestinal perforations, and 2 with other diagnoses. The number of punctures was 1 in 15 patients, 2 in 4 patients, and 3 in 1 patient. Only 1 patient required ultrasound guidance, whereas 12 patients required the use of guidewires. The median duration after insertion was 3 (IQR 2.5-5.5) days. Accidental removal was noted in only one patient. No other complications were observed during the period from insertion to removal. CONCLUSIONS: DRA may be a safe option for insertion of a new A-line in the ICU.

Efficacy of median sacral artery embolization for treating severe pelvic fractures: a retrospective study.

OBJECTIVE: Transcatheter arterial embolization (TAE) of bilateral internal iliac arteries (IIAs) in patients with a hemodynamically unstable pelvic fracture is associated with a low mortality rate. The persistence of unstable hemodynamics after IIA embolization indicates the involvement of other arteries, such as the median sacral artery (MSA). This study aimed to evaluate the efficacy of MSA embolization. METHODS: In this single-center, retrospective, observational study, medical records of patients who underwent MSA angiography or embolization for pelvic fractures (n = 21) between January 2007 and August 2019 were reviewed. The percentage of patients achieving hemodynamic stabilization by MSA embolization was calculated. RESULTS: Fifteen patients underwent MSA embolization, and the remaining six underwent MSA angiography. The shock index value was significantly higher after MSA embolization than that before MSA embolization in hemodynamically unstable patients who underwent this procedure. The success rate of MSA selection was 100%. One patient presented with urinary retention because of bladder and rectal disorders after MSA embolization. The 30-day survival rate was 85.7%. CONCLUSIONS: Severe pelvic fractures, such as a Dennis Zone III fracture and suicidal jumper's fracture due to trauma from a fall, may require MSA embolization.

Advanced do-not-attempt-resuscitation directives and emergency medical services for out-of-hospital cardiopulmonary arrest patients in Japan: a pilot study.

AIMS: We investigated how do-not-attempt-resuscitation (DNAR) orders are currently used, and we examined the emergency medical team responses for out-of-hospital cardiac arrest (OHCA) cases in Japan. METHODS: The sample for this prospective study comprised all OHCA cases attended to by the Sagamihara Municipal Fire Department emergency medical services between May 30, 2019 and February 15, 2020. Data were recorded by the responding emergency medical team. RESULTS: There were 396 OHCA cases. The mean age was 75 ± 18 years, and individuals aged 65 years or older accounted for 80.6%. Approximately 70% of the patients had an underlying disease. A DNAR order was available in only 45 (11.4%) of the cases, of which 12 (26.7%) were written, 27 (60%) were verbally confirmed, and six (13.3%) were confirmed in some other way or both. The home physician was present and able to confirm the patient's death in only one of the DNAR cases. In 43 (95.6%) of the cases, the emergency medical team carried out cardiopulmonary resuscitation despite a DNAR order; of them, a total of 17 (37.8%) patients were transported to a tertiary emergency hospital. CONCLUSIONS: Our analyses indicate the under-utilization of DNAR advance directives and advance care planning (which are important for better end-of-life care) in Japan. Currently, an emergency medical team could be required to attempt resuscitation against an individuals' clear DNAR order. In the future, legal arrangements regarding the handling of DNAR directives on site may be required to respect patients' wishes.

Transcatheter arterial embolization for severe blunt liver injury in hemodynamically unstable patients: a 15-year retrospective study.

BACKGROUND: Transcatheter arterial embolization (TAE) is the first-line nonsurgical treatment for severe blunt liver injury in patients, whereas operative management (OM) is recommended for hemodynamically unstable patients. This study investigated the comparative efficacy of TAE in hemodynamically unstable patients who responded to initial infusion therapy. METHODS: This retrospective study enrolled patients with severe blunt liver injuries, which were of grades III-V according to the American Association for the Surgery of Trauma Organ Injury Scale (OIS). Patients who responded to initial infusion therapy underwent computed tomography to determine the treatment plan. A shock index > 1, despite undergoing initial infusion therapy, was defined as hemodynamic instability. We compared the clinical outcomes and mortality rates between patients who received OM and those who underwent TAE. RESULTS: Sixty-two patients were included (eight and 54 who underwent OM and TAE, respectively; mean injury severity score, 26.6). The overall in-hospital mortality rate was 6% (13% OM vs. 6% TAE, p = 0.50), and the hemodynamic instability was 35% (88% OM vs. 28% TAE, p < 0.01). Hemodynamically unstable patients who underwent TAE had 7% in-hospital mortality and 7% clinical failure. Logistic regression analysis showed that the treatment choice was not a predictor of outcome, whereas hemodynamic instability was an independent predictor of intensive care unit stay ≥7 days (odds ratio [OR], 3.80; p = 0.05) and massive blood transfusion (OR, 7.25; p = 0.01); OIS grades IV-V were predictors of complications (OR, 6.61; p < 0.01). CONCLUSIONS: TAE in hemodynamically unstable patients who responded to initial infusion therapy to some extent has acceptable in-hospital mortality and clinical failure rates. Hemodynamic instability and OIS, but not treatment choice, affected the clinical outcomes.

Diagnosis of skin and soft tissue infections using near-infrared spectroscopy.

AIM: Skin and soft tissue infections are classified into cellulitis and necrotizing fasciitis, which are difficult to distinguish. Necrotizing fasciitis has a poor prognosis and requires immediate intensive care. The diagnostic gold standard is to incise the lesion to determine whether necrosis has reached the fascia. We aimed to show that these infections can be differentiated using near-infrared spectroscopy. METHODS: We describe two cases in an observational study about the utility of near-infrared spectroscopy. Case 1 involved a 77-year-old man with a chief complaint of pain, redness, and swelling in the right lower leg for 1 week. Computed tomography of his legs showed no gas formation. Case 2 involved an 82-year-old man. He visited another hospital because of pain, redness, and swelling in the right thigh. Based on the X-ray examination, necrotizing fasciitis was suspected, and he was transferred to our hospital. RESULTS: In Case 1, the regional oxygen saturation value was lower on the lesion side (41%) than on the healthy side (55%). We confirmed the depth of invasion by incision, leading to a diagnosis of necrotizing fasciitis. In Case 2, the thigh's regional oxygen saturation was higher on the affected side (76%) than on the healthy side (61%). An incision was made for diagnosis, but the fascia was not necrotized. Thus, we diagnosed cellulitis and provided conservative treatment using antibiotics. CONCLUSION: Near-infrared spectroscopy can be utilized to measure tissue blood flow, and it could be useful as a non-invasive diagnostic tool for skin and soft tissue infections.

Life-threatening traumatic epistaxis due to massive bleeding into the maxillary sinus.

A 77-year-old woman with no medical history fell, and her face was strongly impacted on the ground. On arrival at our hospital, her initial vital signs were stable. She underwent an endoscopy to stop the bleeding. However, identification of the origin of the bleeding failed, and her injury resulted in hemorrhagic shock during the procedure. Head to face contrast computed tomography showed extravasation of contrast media into the maxillary sinus. Transcatheter arterial embolization was performed for the ruptured infraorbital artery branching from the maxillary artery. She recovered from the "shock" state after transcatheter arterial embolization and was admitted to the intensive care unit. There were no complications associated with transcatheter arterial embolization during hospitalization. For this case, early recognition of an active hemorrhage was challenging because the hemorrhage was pooled in the sinuses. Although epistaxis is sometimes fatal, transcatheter arterial embolization can be the first choice for the treatment of life-threatening epistaxis, owing to its safety and effectiveness.

Pancreatitis in a Patient with Severe Coronavirus Disease Pneumonia Treated with Veno-venous Extracorporeal Membrane Oxygenation.

Severe coronavirus disease (COVID-19) can induce serious complications, including acute respiratory distress syndrome, septic shock, and acute kidney injury. However, few reports have associated COVID-19 with pancreatitis. We herein report the case of a 55-year-old patient who developed acute pancreatitis associated with severe COVID-19 pneumonia and was successfully treated with veno-venous extracorporeal membrane oxygenation (ECMO). Elevated pancreatic enzymes levels and computed tomography findings led to the diagnosis of acute pancreatitis due to COVID-19. Although we found that severe COVID-19 pneumonia can lead to pancreatitis, the underlying pathophysiology remains unknown.

Intravascular treatment for ruptured facial artery aneurysm via percutaneous cardiopulmonary support device: A case report.

Even in cases of cardiac arrest caused by hemorrhagic shock, when reliable control of the bleeding source is possible, ECPR may be an effective treatment option if anticoagulant therapy is well-managed and is withdrawn early.