Cricotracheostomy for patients with severe COVID-19: A case control study.

Background: Tracheostomy is an important procedure for the treatment of severe coronavirus disease-2019 (COVID-19). Older age and obesity have been reported to be associated with the risk of severe COVID-19 and prolonged intubation, and anticoagulants are often administered in patients with severe COVID-19; these factors are also related to a higher risk of tracheostomy. Cricotracheostomy, a modified procedure for opening the airway through intentional partial cricoid cartilage resection, was recently reported to be useful in cases with low-lying larynx, obesity, stiff neck, and bleeding tendency. Here, we investigated the usefulness and safety of cricotracheostomy for severe COVID-19 patients. Materials and methods: Fifteen patients with severe COVID-19 who underwent cricotracheostomy between January 2021 and April 2022 with a follow-up period of ≥ 14 days were included in this study. Forty patients with respiratory failure not related to COVID-19 who underwent traditional tracheostomy between January 2015 and April 2022 comprised the control group. Data were collected from medical records and comprised age, sex, body mass index, interval from intubation to tracheostomy, use of anticoagulants, complications of tracheostomy, and decannulation. Results: Age, sex, and days from intubation to tracheostomy were not significantly different between the COVID-19/cricotracheostomy and control/traditional tracheostomy groups. Body mass index was significantly higher in the COVID-19 group than that in the control group (P = 0.02). The rate of use of anticoagulants was significantly higher in the COVID-19 group compared with the control group (P < 0.01). Peri-operative bleeding, subcutaneous emphysema, and stomal infection rates were not different between the groups, while stomal granulation was significantly less in the COVID-19 group (P = 0.04). Conclusions: These results suggest that cricotracheostomy is a safe procedure in patients with severe COVID-19.

Laryngeal complications after endotracheal intubation and prone positioning in patients with coronavirus disease 2019.

Objectives: Laryngeal complications have been reported after endotracheal intubation and prone positioning in patients with critical coronavirus disease 2019 (COVID-19), but their association is unclear. In this study, we investigated the rate of laryngeal complications in patients with COVID-19 compared to an alternative condition (control group). Methods: We retrospectively analyzed the data of 40 patients who underwent endotracheal intubation for either COVID-19 or an alternative condition (control group). Data on age, sex, body mass index (BMI), cardiovascular disease (CVD) risk factors, use of prone therapy, duration of endotracheal intubation, and duration from extubation/tracheostomy to laryngeal evaluation were collected from medical records. Results: There were no significant differences in BMI, frequency of CVD risk factors, duration of endotracheal intubation, or duration from extubation/tracheostomy to laryngeal evaluation between the two groups. In the COVID-19 group, all patients adopted the prone position. In comparison, only one patient in the control group adopted the prone position. Significant differences were observed between the two groups regarding the incidence of vocal fold immobility and laryngeal granuloma. Conclusion: Laryngeal complications were more common in the COVID-19 group than in the control group. Prone positioning may be a risk factor for these complications. Level of Evidence: 4.

Suggested organism entry portal of necrotizing fasciitis with complete DNA from fascia, blood, and pharyngeal ulcers: A case report.

Introduction and importance: In approximately 50% of patients with necrotizing fasciitis, infection begins deep in the soft tissues. A history of trauma is often absent. The mechanism of spread has not been elucidated. We report a case of type II necrotizing fasciitis in which the streptococcal strain was identical to isolates from other locations in the same patient. Case presentation: A 42-year-old man presented with left leg pain. Two days prior, he had a non-penetrating injury to the left thigh while playing futsal. Workup revealed swelling of the left gastrocnemius. He was admitted to orthopaedics. On the third hospital day, he was referred to our department for hypotension, impending respiratory failure, and decreased sensorium, and subsequently admitted to the ICU. A biopsy was done on the left gastrocnemius fascia. He was diagnosed with necrotizing fasciitis. On the seventh hospital day, left hip amputation and extensive debridement of the trunk were done. Patient improved and eventually recovered. Clinical discussion: Group A streptococcus was isolated in from the fascia, blood, and pharyngeal ulcer. Pulsed field gel electrophoresis showed all isolates to be genetically identical. An oral route of infection was considered. Conclusions: This is the first report in which etiologic agent of necrotizing fasciitis is genetically identical with isolates from other parts in the absence of trauma.

Hemorrhagic shock due to colonic arteriovenous malformation in late pregnancy: a case report.

BACKGROUND: Intestinal arteriovenous malformations are difficult to detect because they often present asymptomatically. However, pregnancy increases the hemorrhagic risk of intestinal arteriovenous malformations. This can lead to massive bleeding and hemodynamic instability, threatening the lives of both the mother and fetus. We describe a life-threatening case of hemorrhagic shock due to a colonic intestinal arteriovenous malformation during late pregnancy that was successfully treated through endovascular management. CASE PRESENTATION: A 36-year-old gravida 1, para 1 woman at 35 weeks' gestation presented with hemodynamic instability and painless hematochezia. The patient had hemorrhagic shock and required massive transfusion. A colonoscopy failed to secure a visual field due to bloody fluid, and endoscopic hemostasis was difficult. Before the bleeding could be controlled, the condition of the fetus continued to deteriorate, showing bradycardia dysrhythmia. Therefore, an emergency cesarean section was performed, which was successful. However, the bleeding did not subside, with the patient's hemodynamic instability and hematochezia persisting. An angiogram revealed an ascending colonic intestinal arteriovenous malformation, with extravasation of the contrast medium from a branch of the ileocolic artery. Localized blood flow control and hemodynamic stability were achieved via angioembolization. The patient had an uneventful postoperative recovery and was discharged on postoperative day 12. The newborn was admitted to the neonatal intensive care unit. She successfully recovered and was discharged when she was 22 days old. CONCLUSIONS: We reported a case of colonic intestinal arteriovenous malformation resulting in hemodynamic instability due to hematochezia during late pregnancy, which was successfully treated via angioembolization. Intestinal arteriovenous malformation should be considered as a differential diagnosis in pregnant patients with hemodynamic instability and hematochezia.

Prophylactic placement of external iliac artery balloon catheter in a patient with intrapelvic prosthesis migration after hemiarthroplasty: A case report.

Intrapelvic prosthesis migration is a rare but serious complication of bipolar hemiarthroplasty in femoral neck fractures. The external iliac artery is one of the most frequently damaged arteries during the removal of a migrated implant from the pelvic region. This report describes a case in which prophylactic placement of an external iliac artery balloon catheter was performed to reduce blood loss in the event of vascular injury during implant removal surgery in the pelvic region.

Comparison of patency of single and sequential radial artery grafting in coronary artery bypass.

OBJECTIVES: Sequential radial artery (RA) grafting has the potential to enhance arterial revascularization compared to single grafting. Sequential RA grafting was performed predominantly with a single side-to-side anastomosis. The study aimed to assess if sequential RA grafting improved long-term graft patency compared to single RA grafting. In addition, the anastomotic patencies of side-to-side and end-to-side anastomoses in sequential RA grafting were assessed. METHODS: Two hundred nineteen patients underwent isolated coronary artery bypass grafting with skeletonized RA conduits between 2005 and 2016. Of these, 208 patients underwent radiological graft assessment; thus, 125 and 83 patients underwent single and sequential RA grafting, respectively. The graft and anastomotic patency rates were estimated using the Kaplan-Meier method. RESULTS: The median follow-up period was 9.1 years, and the radiological assessment lasted 5.1 years. The overall RA graft patency rates at 1, 5 and 10 years were 99.4%, 92.7% and 88.1%, respectively. The RA graft patency rate for sequential grafting was similar to that for single grafting (88.7% vs 87.4% at 10 years; P = 0.88). In the stratified analysis of anastomotic patency, the patency rate of side-to-side anastomoses of sequential RA grafting was significantly better than that of end-to-side anastomoses (100% vs 88.7% at 10 years; P = 0.01). CONCLUSIONS: The long-term RA graft patencies of sequential and single grafting were equally high. The anastomotic patency of side-to-side anastomoses of sequential RA grafting was remarkably high. Considering these findings, the RA can be effectively used for multiple arterial coronary revascularizations.

A Comparison of Outcomes Based on Vessel Type (Native Artery vs. Bypass Graft) and Artery Location (Below-Knee Artery vs. Non-Below-Knee Artery) Using a Combination of Multiple Endovascular Techniques for Acute Lower Limb Ischemia.

BACKGROUND: To evaluate outcomes of endovascular treatment (EVT) using a combination of multiple endovascular techniques for acute lower limb ischemia (ALLI) and to compare outcomes based on vessel type and artery location. METHODS: A total of 95 consecutive patients with ALLI (mean age, 72.0 years; 65 males; 104 lower limbs) who received emergency EVT using a combination of multiple endovascular techniques including thrombolysis, aspiration thrombectomy, stenting, and balloon angioplasty with or without surgical thromboembolectomy, between January 2005 and December 2017 were included. Vessel type was classified into native artery occlusion (native occlusion) and bypass graft occlusion (graft occlusion), including prosthetic and vein graft. Additionally, native arteries were categorized into below-knee occlusion and non-below-knee occlusion. Technical success, perioperative death (POD), ALLI-related death, amputation, amputation-free survival (AFS), and complications were compared according to vessel type (native occlusion vs. graft occlusion) and artery location (below-knee occlusion vs. non-below-knee occlusion). RESULTS: Of all patients with ALLI, 16.8% underwent a single endovascular technique, whereas 83.2% underwent a combination of multiple endovascular techniques. The technicalsuccess, POD, and ALLI-related death rates in the total number of patients were 94.7%, 11.6%, and 4.2%, respectively. A total of 67 patients (75 limbs) and 28 patients (29 limbs) were classified as having native occlusion and graft occlusion (prosthetic, 24 limbs; vein, 5 limbs), respectively. No significant differences in technical success (native occlusion: 92.5% vs. graft occlusion: 100%), POD (14.9% vs. 3.6%), and ALLI-related death (6.0% vs. 0%) were noted between native occlusion and graft occlusion. However, the 30-day AFS rate of native occlusion was significantly lower than that of graft occlusion (75.2% vs. 96.3%, P=0.01). The amputation rate (P=0.03) and AFS rate (P=0.03) of below-knee occlusion were significantly worse for below-knee occlusion patients than for non-below-knee occlusion patients. CONCLUSIONS: EVT using multiple endovascular techniques for ALLI is effective and safe. A combination of multiple endovascular techniques is crucial for successful treatment. However, native occlusion may have a lower AFS rate than graft occlusion, and below-knee occlusion may have a higher risk of amputation than non-below-knee occlusion.

Late clinical outcomes of manual aspiration thrombectomy for a massive acute pulmonary thromboembolism.

PURPOSE: We investigated the late outcomes of patients who underwent manual aspiration thrombectomy for acute massive pulmonary thromboembolism. MATERIALS AND METHODS: Fifteen patients underwent manual aspiration thrombectomy between December 1995 and June 2002. All patients were discharged after the procedure. Patients' statuses were checked by medical record examinations and telephone interviews. The median follow-up was 162 months (116-208 months). RESULTS: Five patients died during follow-up; two for malignancy, one for septic shock, one for cerebral infarction, and in one patient the cause of death was unknown. There were no pulmonary thromboembolism-related deaths during the period and no recurrence. The 1-year survival rate was 100%, the 5-year survival rate was 75.0 ± 12.5%, and the 10-year survival rate was 75.0 ± 12.5%. CONCLUSION: Patients who undergo manual aspiration thrombectomy for acute massive pulmonary thromboembolism show acceptable outcomes.

Pulmonary valve replacement after tetralogy of Fallot repair in a patient with immune thrombocytopenia.

Marked thrombocytopenia causes significant bleeding in cardiovascular surgery. Herein, we describe the case of a 47-year-old woman with immune thrombocytopenia who underwent successful pulmonary valve replacement for pulmonary valve regurgitation and stenosis after complete repair of tetralogy of Fallot. Her platelet count decreased significantly to less than 5 × 109 /L on postoperative day 3, thus multiple platelet transfusions were given. Pulse steroid therapy with dexamethasone was subsequently administered systemically for 4 days. After the treatment, her platelet count started to recover. There were no significant postoperative bleeding events, and red blood cell transfusion was not required. Other than the platelet event, the postoperative course was uneventful and the patient was discharged on postoperative day 15.

Recanalization using direct stenting before bowel resection for acute-on-chronic superior mesenteric artery occlusion: A case report.

INTRODUCTION: Acute-on-chronic mesenteric ischemia (ACMI) refers to acute mesenteric ischemia (AMI) developing in a patient displaying typical symptoms of chronic mesenteric ischemia (CMI). Delayed treatment can cause short bowel syndrome and increased mortality. Intervention involves intestinal revascularization and resection of the necrotic intestine. However, the revascularization procedure must consider the chronic nature of the occlusion. PRESENTATION OF CASE: A 79-year-old man presented with periumbilical pain for 6 h. AMI was diagnosed, together with chronic superior mesenteric artery occlusion and suspected intestinal necrosis. The symptomatic CMI might have insufficient blood flow to intestines. Endovascular recanalization of the superior mesenteric artery using direct stenting was performed before laparotomy to improve blood flow to the intestines. Subsequent laparotomy revealed approximately 60 cm of ischemic small bowel extending from the jejunum (300 cm anal to the ligament of Treitz) to the ileum (30 cm oral to the terminal ileum). The necrotic bowel was resected without anastomosis. At the second-look operation, further resection was not required. DISCUSSION: Making a differential diagnosis between acute and acute-on-chronic occlusions is essential for determining the necessity of recanalization and the method of restoring the intestinal blood flow. Here, the patient with symptomatic CMI might have had insufficient blood flow to the intestines despite establishing collateral supply. We determined that recanalization was needed. Direct stenting without predilation could save time to recanalization and result in less risk of distal embolization. CONCLUSION: This case suggests prompt recanalization using direct stenting can minimize subsequent bowel resection in patients with ACMI.

Late Clinical Outcomes of Hybrid Catheter Intervention for Acute Massive Pulmonary Thromboembolism.

PURPOSE: We aimed to investigate the long-term outcomes of patients undergoing hybrid catheter intervention for acute massive pulmonary thromboembolism. MATERIAL AND METHODS: Twenty-five patients with hemodynamic impairment were treated with mechanical thrombus fragmentation, an intrapulmonary injection of mt-PA, and manual clot aspiration between August 1999 and June 2002. All patients were discharged after the procedure. Patients' statuses were checked by medical record examinations and telephone interviews. The median follow-up was 141 months (115-168 months). RESULTS: Ten patients died during follow-up, five for malignancy, three for septic shock, one for cerebral infarction, and one for heart failure. One patient had recurrence of pulmonary thromboembolism because of drug withdrawal by self-judgment. No chronic pulmonary thromboembolism was observed. The 1-year, 5-year, and 10-year survival rates were 87.5 ±6.8%, 83.3±7.6%, and 74.5±9.0%, respectively. CONCLUSION: Patients who undergo hybrid catheter intervention for acute massive pulmonary thromboembolism show good long-term outcomes.

An Extremely Rare Complication: Abdominal Aortic Aneurysm Rupture Caused by Migration of a Zenith Main Body Years After Repair of the Suprarenal Stent Separation.

PURPOSE: To report an unusual case of an abdominal aortic aneurysm (AAA) rupture caused by migration of a Zenith stent-graft main body years after its separation from the suprarenal stent. CASE REPORT: A 72-year-old man underwent endovascular aneurysm repair with a Zenith stent-graft for an infrarenal AAA in year 2000. At that time, a femorofemoral bypass was performed because the left external iliac and common femoral arteries were dissected during treatment. In 2013, follow-up computed tomography (CT) showed disconnection of the uncovered proximal stent, which led to a type Ia endoleak. An additional Zenith main body and Large Palmaz XL balloon-expandable stent were deployed; the endoleak disappeared. In 2016, the patient had abdominal pain, and emergency CT showed AAA rupture caused by migration of the first main body deployed in 2000 under the distal edge of the contralateral (left) leg of the additional main body from 2013, which led to a type IIIa endoleak between the 2 main bodies. A converter and iliac legs were deployed to successfully seal the type IIIa endoleak. The patient remains well 18 months after the second repair; CT scans document stable stent-grafts and no endoleak. CONCLUSION: Physicians should be aware of the potential risk for AAA rupture caused by late main body migration after treatment for suprarenal stent separation from a Zenith stent-graft.

Early Transcatheter Arterial Embolization for the American Association for the Surgery of Trauma Grade 4 Blunt Renal Trauma in Two Institutions.

OBJECTIVES: To evaluate the efficacy of early transcatheter arterial embolization for hemodynamically stable patients with The American Association for the Surgery of Trauma (AAST) grade 4 blunt renal trauma. MATERIALS AND METHODS: The medical records of consecutive patients with grade 4 blunt renal trauma who were transported to our two critical care centers in Japan and treated with early transcatheter arterial embolization (TAE) between 2001 and 2013 were retrospectively reviewed. Treatment failure was defined as the need for further surgical intervention or re-embolization after initial embolization. We divided these cases into two groups, a group who survived and a group who died, investigating the factors that led to death. RESULTS: Seventeen patients underwent early TAE, with an average time between presentation and embolization for renal trauma of 125 minutes (66-214 minutes). There was no case of treatment failure. Three of the patients died, but none solely because of renal injury. Significant factors associated with patient death were the number of concomitant injured organs (p=0.04), the presence of pelvic fractures (p<0.01), and the presence of visceral injuries (p<0.01). The presence of lumber fractures (p=0.09) also tended to be associated with patient death. CONCLUSIONS: Early TAE is an effective treatment and should be actively performed for hemodynamically stable patients with grade 4 blunt renal injuries without multiple concomitant organ injuries.