Ultrasound-guided genitofemoral nerve block for femoral arterial access gain and closure: a randomized controlled trial.

OBJECTIVES: This study aimed to compare the analgesic efficacy and safety of the femoral branch block of the genitofemoral nerve (FBB) versus local infiltration anesthesia (LIA) for femoral arterial access gain and closure. METHODS: Eighty-two patients (age, 64.8 ± 10.9 years; female, 30.5%) undergoing endovascular procedures using 5-Fr femoral sheath were assigned to either FBB (n = 41) or LIA (n = 41). In both groups, 2% lidocaine HCL with 1:100,000 epinephrine was used as an anesthetic solution. Pain scores during access gain and closure were evaluated using a visual analog scale (score 0-10), patient satisfaction levels with the quality of anesthesia were scored on a 7-point Likert scale, and adverse events were recorded. RESULTS: The primary endpoint, pain scores during access closure, was significantly lower in the FBB group than in the LIA group (0.1 ± 0.37 vs 1.73 ± 0.92; p < 0.001). The FBB group also had significantly lower pain scores during access gain compared to the LIA group (0.83 ± 0.83 vs 2.78 ± 1.26; p < 0.001). There was an inverse relationship between pain scores and FBB after adjustment for age, gender, and body mass index (p < 0.001). FBB group reported significantly higher satisfaction with anesthesia quality compared to the LIA group (6.49 ± 0.64 vs 4.05 ± 1.05; p < 0.001). No complications were recognized in either group. CONCLUSIONS: Ultrasound-guided genitofemoral nerve blocks offered better acute pain relief and higher patient satisfaction than LIA during femoral arterial access gain and closure. CLINICAL RELEVANCE STATEMENT: In this prospective randomized controlled trial, ultrasound-guided genitofemoral nerve blocks offered better acute pain relief than local infiltration anesthesia, resulting in enhanced patient satisfaction. KEY POINTS: • FBB provided better pain relief during access gain and closure than LIA. • FBB offered higher patient satisfaction with the quality of anesthesia than LIA. • No anesthesia-related or access site complications were recognized in either treatment group.

Early versus delayed bronchial artery embolization for non-massive hemoptysis.

OBJECTIVES: The aims of this study were to compare clinical outcomes of early versus delayed bronchial artery embolization (BAE) for non-massive hemoptysis and to investigate predictors of recurrent hemoptysis. METHODS: From March 2018 to February 2021, 138 consecutive patients (age, 65.5 ± 12.4 years; male, 67.4%) with non-massive hemoptysis underwent BAE. The enrolled patients were divided into an early embolization (EE) group (within the first 24 h, n = 79) and a delayed embolization (DE) group (n = 59). RESULTS: The time to embolization ranged between 0 and 15 days and was shorter in the EE group (0.47 ± 0.5 days) than in the DE group (4.02 ± 2.8 days, p < 0.001). The in-hospital clinical outcomes were not different between the two groups, except for hospital stay and post-embolization hospital stay. The recurrence-free survival in the EE group was significantly better than that in the DE group (p = 0.018). The time to embolization (hazard ratio (HR), 1.21; 95% confidence interval (CI), 1.04-1.42; p = 0.015) and aspergilloma (HR, 6.89; 95% CI, 2.08-22.86; p = 0.002) were predictive factors for recurrent hemoptysis. CONCLUSIONS: BAE is an effective and safe treatment modality for non-massive hemoptysis. An early interventional strategy should be considered in patients presenting with non-massive hemoptysis to reduce the length of hospital stay and early recurrence. A delayed time to embolization and the presence of aspergilloma were independent risk factors for recurrent hemoptysis. KEY POINTS: • Bronchial artery embolization afforded good clinical improvement for treating non-massive hemoptysis without significant complications. • An early interventional strategy should be considered in patients presenting with non-massive hemoptysis to reduce the length of hospital stay and early recurrence. • A delayed time to embolization and the presence of aspergilloma were independent risk factors for recurrent hemoptysis.

Value of multiphase computed tomography for gastrointestinal bleeding before endovascular treatment in hemodynamically unstable patients.

BACKGROUND: There has been no practice-based study regarding the multiphase computed tomography (CT) before endovascular treatment in hemodynamically unstable gastrointestinal bleeding (GIB) and concerns exist regarding the time delay. PURPOSE: To evaluate the clinical efficacy of multiphase CT before endovascular treatment in hemodynamically unstable GIB and to investigate the predictors of angiographic localization and recurrent bleeding. MATERIAL AND METHODS: The multicenter retrospective study included 93 consecutive hemodynamically unstable patients who underwent conventional angiography for non-variceal GIB after failed endoscopic localization. Enrolled patients were divided into a CT group (n = 61) and a non-CT group (n = 32). RESULTS: The clinical characteristics did not differ between the two groups except for the time to angiography (CT group, 14.8±15.1 h; non-CT group, 9.2±11.7 h, P = 0.022). The rate of angiographic localization was significantly higher in the CT group than in the non-CT group only for lower GIB (P = 0.049). Indirect sign was significantly more frequent in the CT group than in the non-CT group (P = 0.014). CT localization was positive predictor (odd ratio [OR] = 7.66; 95% confidence interval [CI] = 2.1-27.94; P = 0.002) and prolonged time to angiography was negative predictor (OR = 0.94; 95% CI = 0.9- 0.98; P = 0.001) for angiographic localization. A higher systolic blood pressure until index angiography (OR = 0.95; 95% CI = 0.91-1; P = 0.044) was associated with a reduced risk of recurrent bleeding. CONCLUSION: In hemodynamically unstable patients, multiphase CT is particularly useful for angiographic localization of lower GIB. It should be considered immediately after failed endoscopic hemostasis to reduce time to angiography.

Double-Pigtail Drainage Catheter: A New Design for Efficient Pleural Drainage.

Background and Objectives: The novel double-pigtail catheter (DPC) has an additional pigtail coiling at the mid-shaft with multiple centripetal side holes. The present study aimed to investigate the advantages and efficacy of DPC in overcoming the complications of conventional single-pigtail catheters (SPC) used to drain pleural effusion. Materials and Methods: Between July 2018 and December 2019, 382 pleural effusion drainage procedures were reviewed retrospectively (DPC, n = 156; SPC without multiple side holes, n = 110; SPC with multiple side holes (SPC + M), n = 116). All patients showed shifting pleural effusions in the decubitus view of the chest radiography. All catheters were 10.2 Fr in diameter. One interventional radiologist performed all procedures and used the same anchoring technique. Complications (dysfunctional retraction, complete dislodgement, blockage, and atraumatic pneumothorax) were compared among the catheters using chi-square and Fisher's exact tests. Clinical success was defined as an improvement in pleural effusion within three days without additional procedures. Survival analysis was performed to calculate the indwelling time. Results: The dysfunctional retraction rate of DPC was significantly lower than that of the other catheters (p < 0.001). Complete dislodgement did not occur in any of the DPC cases. The clinical success rate of DPC (90.1%) was the highest. The estimated indwelling times were nine (95% confidence interval (CI): 7.3-10.7), eight (95% CI: 6.6-9.4), and seven (95% CI: 6.3-7.7) days for SPC, SPC + M, and DPC, respectively, with DPC showing a significant difference (p < 0.05). Conclusions: DPC had a lower dysfunctional retraction rate compared to conventional drainage catheters. Furthermore, DPC was efficient for pleural effusion drainage with a shorter indwelling time.

Transcholecystic management of extrahepatic duct stones in poor candidates for endoscopic or transhepatic approaches.

OBJECTIVES: To investigate transcholecystic management of extrahepatic duct (EHD) stones using balloon ampulloplasty in patients who are poor candidates for endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) and assess its efficacy and safety. METHODS: Forty-one patients who were unable to undergo ERCP or had failed ERCP with non-dilated intrahepatic ducts (IHD) between February 2019 and October 2020 were retrospectively enrolled. After clinical improvement with percutaneous cholecystostomy (PC), EHD stones were managed through cystic duct passage, guidewire unwinding, sheath insertion, and EHD stone removal using balloon ampulloplasty. If the transcholecystic route failed, a transhepatic approach was used according to the pre-existing cholangiogram obtained via PC. We evaluated the technical success rate and complications of each step. RESULTS: The technical success rate for the transcholecystic-only approach was 80.5%. The remaining cases were successfully managed with transhepatic conversion. Multiple stone removal sessions were required in 22% of the cases. One patient with combined IHD stones was initially converted to a transhepatic approach without any transcholecystic removal trial. The technical success rates for each step were as follows: cystic duct passage (38/40, 95%), guidewire unwinding (36/38, 94.7%), sheath insertion (36/36, 100%), and stone removal using balloon ampulloplasty (33/36, 91.7%). The overall clinical success was 97.6% (40/41) without major procedure-related complications. Thereafter, cholecystectomy was successfully performed in patients with concomitant gallstones (n = 20). No postprocedural complications occurred during the follow-up (1-70 days). CONCLUSIONS: Percutaneous EHD stone removal through transcholecystic and transhepatic routes after PC is effective and safe in poor candidates for PTBD or ERCP. KEY POINTS: • This study shows the safety and efficacy of extrahepatic duct (EHD) stones in patients who are poor candidates for initial percutaneous transhepatic biliary drainage and endoscopic retrograde cholangiopancreatography. • The overall technical success for the transcholecystic-only approach was 80.5% (33/41). Including transhepatic conversions, it was 100% (41/41). Stone removal was successful in one session in 78% (32/41) of the patients and in multiple sessions in 28.1% (9/41) of the patients. • Balloon ampulloplasty with stone expulsion using an occlusion balloon catheter is also a safe and effective method for removing EHD stones.

Imaging-Guided Deployment of a Balloon-Based Vascular Closure Device in Routine Clinical Practice.

This study evaluated the feasibility and safety of imaging-guided deployment of a Mynx Control device (Cordis, Miami Lakes, Florida) at the femoral access. A total of 201 Mynx devices were used under imaging guidance in 137 patients (mean age, 64.18 years ± 13.8; male, 68.6%) between June 2020 and February 2022. A 5-F sheath was used in 176 (87.6%) procedures, a 6-F sheath was used in 17 (8.5%) procedures, and a 7-F sheath was used in 8 (4%) procedures. Indicator errors occurred in 9 (4.5%) procedures. However, technical success was achieved via manipulation under imaging guidance in all procedures. The mean time to hemostasis was 3.3 minutes ± 0.5, and the clinical success rate was 100%. The mean length of hospital stay was 7 days ± 7.5. After 4 (2%) procedures, small hematomas reabsorbed spontaneously. Imaging-guided deployment of a Mynx Control device is a feasible and safe option for access site closure. Even after an indicator error, successful hemostasis was achieved via real-time interaction.

Transcatheter arterial embolization for hemorrhage after gynecologic hysterectomy: a multicenter study.

BACKGROUND: Transcatheter arterial embolization (TAE) is not common for hemorrhagic complications after gynecologic hysterectomy. PURPOSE: To evaluate the effectiveness and safety of TAE for hemorrhage after hysterectomy for gynecologic diseases. MATERIAL AND METHODS: This is a retrospective, multicenter study, which investigated 11 patients (median age = 45 years) who underwent TAE for hemorrhage after gynecologic hysterectomy between 2004 and 2020. RESULTS: The median interval between surgery and angiography was one day (range = 0-82 days). Hemodynamic instability and massive transfusion were present in 6 (54.5%) and 4 (36.4%) patients, respectively. CT scans (n = 7) showed contrast extravasation (n = 5), pseudoaneurysm (n = 1), or both (n = 1). On angiography, the bleeding arteries were the anterior division branches of the internal iliac artery (IIA) (n = 6), posterior division branch (lateral sacral artery, n = 1), and inferior epigastric artery (n = 1) in eight patients with active bleeding. In the remaining three patients, angiographic staining without active bleeding foci was observed at the vaginal stump, and the feeders for staining were all anterior division branches of the IIA. Technical and clinical success rates were 100% and 90.9% (10/11), respectively. In one patient, active bleeding focus was successfully embolized on angiography, but surgical hemostasis was performed for suspected bleeding on exploratory laparotomy. Postembolization syndrome occurred in one patient. CONCLUSIONS: TAE is effective and safe for hemorrhage after hysterectomy for gynecologic diseases. Angiographic findings are primarily active bleeding, but angiographic staining is not uncommon. A bleeding focus is possible in any branch of the IIA, as well as the arteries supplying the abdominal wall.

SUPERA stent placement for salvaging early recurrent arteriovenous graft thrombosis after percutaneous transluminal angioplasty: A single-center study.

BACKGROUND: The aim of this study was to evaluate the patency of the helical interwoven SUPERA stent for salvaging prosthetic arteriovenous (AV) grafts with rapidly recurrent thrombotic occlusion developed within a short time period after successful percutaneous transluminal angioplasty. METHODS: From December 2019 to September 2021, the data of 20 patients with AV graft who had the SUPERA stent inserted satisfying the following conditions were consecutively collected. (1) More than 1 year has passed since the AV access operation; (2) Thrombotic re-occlusion of AV graft occurred within 3 months after previous successful endovascular treatment; (3) Residual stenosis is greater than 30% after full effacement of balloon angioplasty in the primary lesion. Post-interventional target lesion primary patency (TLPP), access circuit primary patency (ACPP), and secondary patency (SP) were calculated. RESULTS: Primary lesions of early recurrent arteriovenous graft thrombosis were found in 13 patients with graft-vein anastomosis, six patients with intra-graft stenosis, and one patient with outflow vein complications. The lesions showed residual stenosis in 47.4% (interquartile range: 44.1%-55.3%) of patients despite full-effacement balloon angioplasty. Clinical success was achieved in all patients with full-expansion of the stents at the 1-month follow-up. The TLPP was 70.7% and 32% at 6 and 12 months, respectively, and ACPP was 47.5% and 6.8% at 6 and 12 months, respectively. The SP was 76.1% and 57.1% at 6 and 12 months, respectively. No cannulation complications occurred in the six patients with installation inside the graft. No hemodialysis or stent fracture occurred in any patient during the follow-up period. CONCLUSIONS: The SUPERA stent may have a role in salvaging AV grafts with early recurrent thrombosis due to its greater radial force and its conformability and can be useful in treating stenosis involving the elbow or axilla, with fair patency and low complication rates.

Single-Session Percutaneous Mechanical Thrombectomy for Acute and Subacute Deep Vein Thrombosis: Clinical Outcomes and Predictive Factors of Recurrence.

Objectives: To evaluate the efficacy and safety of single-session percutaneous mechanical thrombectomy (PMT) for deep vein thrombosis (DVT), to compare clinical outcomes and recurrences between acute and subacute DVT, and to identify factors predicting recurrence. Materials and Methods: From January 2018 to March 2021, 100 consecutive patients (age: 64.64 ± 17.28 years; male, 42%) with symptomatic DVT who underwent single-session PMT were enrolled for this study. These patients were divided into an acute DVT group (< 14 days, n = 75) and a subacute DVT group (15-28 days, n = 25). Results: A large-bore aspiration thrombectomy was used in 80 (80%) cases, Angiojet (Boston Scientific, Marlborough, MA, USA) device in one (1%) case, and a combination of both techniques in 19 (19%) cases. The anatomic success rate was 97% and the clinical success rate was 95%. There were no major complications. Clinical outcomes were not different between the two groups. The recurrence-free survival rate in the acute DVT group was significantly (p = 0.015) better than that in the subacute DVT group. The anatomic success (HR, 52.3; 95% CI, 3.82-715.21; p = 0.003) and symptom duration (HR, 17.58; 95% CI, 1.89-163.34; p = 0.012) were predictive factors associated with recurrence. Conclusions: Single-session PMT is safe and effective for immediate symptom relief in acute and subacute DVT patients. However, recurrence occurred more frequently in patients with subacute DVT than in those with acute DVT. Anatomic success of the procedure and duration of symptoms were independent predictors of DVT recurrence.

Efficacy and Technical Feasibility of Plug-Assisted Retrograde Transvenous Obliteration of Gastric Varices via Pathways Other than the Gastrorenal Shunt.

PURPOSE: To evaluate the efficacy and technical feasibility of plug-assisted retrograde transvenous obliteration of gastric varices via pathways different from the typical gastrorenal shunt. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 130 patients who underwent plug-assisted retrograde transvenous obliteration for gastric varices between 2013 and 2022. Eight patients underwent plug-assisted retrograde transvenous obliteration via different pathways. We evaluated the types of portosystemic shunts in these patients, the procedure technical and clinical success rates, and clinical outcomes. RESULTS: In these eight patients (6 males, 2 females; mean age = 60 ± 6 years), the most common type of portosystemic shunt was a gastrocaval shunt (n = 7). Five patients had a gastrocaval shunt only; two had coexisting gastrocaval and gastrorenal shunts. One patient had a pericardiacophrenic shunt without a gastrorenal or gastrocaval shunt. The mean procedure time was 55 min. For patients with a gastrocaval shunt alone (n = 5), the mean procedure time was 40.8 min. The technical and clinical success rates were 100%. No major complication related to the procedure occurred. An initial follow-up computed tomography was performed within 2-3 weeks in all patients and revealed complete thrombosis of the gastric varices. Subsequent follow-up computed tomography (interval: 2-6 months) was performed in seven patients and showed complete disappearance of the gastric varices in all patients. During the follow-up period (range: 42 days-6.25 years), no patients experienced rebleeding or recurrence of gastric varices. CONCLUSION: Plug-assisted retrograde transvenous obliteration via alternative portosystemic shunts is effective and technically feasible in the treatment of gastric varices.

Isolated Gastric Varix Bleeding Caused by Splenic Vein Obstruction: Two Case Reports.

Isolated left-sided portal hypertension is a rare clinical syndrome caused by splenic veno-occlusive disease. Splenic vein thrombosis and extrinsic compression causes proximal splenic vein hypertension, and the splenic blood flows into the superior mesenteric or portal vein through the upper stomach's collateral vessels, such as the short gastric, coronary, and gastroepiploic veins. Open splenectomy is recommended to treat gastrointestinal bleeding caused by isolated left-sided portal hypertension. Interventional management could be a clinically useful option for selected patients who want to avoid surgical corrections. The report presents two cases of left-sided portal hypertension with gastric variceal bleeding.

Development and validation of an updated PICC length prediction formula based on anteroposterior chest radiographs for the ultrasound-guided bedside placement.

Bedside peripherally inserted central catheter (PICC) placement is sometimes required when the patient's intrahospital transport is restricted, and the ideal catheter length prediction is needed. This study aimed to develop an updated formula that predicts the optimal length of a PICC based on anteroposterior chest radiographs (AP-CXRs). This retrospective study collected PICC procedure data as the training and validation sets in three hospitals, including cubital crease-puncture point distance (CP), the actual PICC length (aCL), and the approach side. Horizontal and vertical measurement variables were set on the AP-CXRs. Two dependent variables were ipsilateral upper arm length (AL) and ideal truncal catheter length (iTCL). Simple and multiple regression analyses were used for formula development, and it was applied to the test set to evaluate the length prediction performance. The study included 309 patients in the training and validation sets and 91 intensive care patients in the test set. The final derived formula was: (AL + iTCL = CP + estimated PICC length, cm) = 19.831 - 0.062 × (contralateral clavicle length, cm) + 0.255 × (2nd ribs horizontal distance, cm) + 0.720 × (humero-vertebral distance, cm) + 0.761 × (thoraco-carinal distance, cm) + 1.024 × (the vertical distance of two vertebral body units, cm). (If approaching from the left, add 2.843cm, and if female, subtract 0.821cm.) In the test set, there was no case of length prediction failure. Moreover, the catheter tip position was evaluated as optimal in 82 cases (90.1%). This study's results suggest an updated formula to predict the ideal PICC length using only AP-CXRs for bedside placement.

Brachial plexus block using only 1% lidocaine to reduce pain during the endovascular treatment of dysfunctional arteriovenous access.

BACKGROUND: Interventional endovascular treatments of dysfunctional arteriovenous (AV) access for hemodialysis can cause pain and discomfort to the patients. Ultrasound-guided brachial plexus block (BPB) is an alternative regional anesthesia method, but conventional BPB using ropivacaine or bupivacaine may cause long-lasting motor power loss, significantly reducing patient satisfaction. This study aimed to introduce BPB using only 1% lidocaine, which induces sensory loss while minimizing motor block, and evaluate the efficacy and safety of this procedure. METHODS: This retrospective study was conducted on 277 consecutive patients with dysfunctional AV access requiring percutaneous transluminal angioplasty (PTA). Of these, 174 patients underwent the BPB procedure using 1% lidocaine. Time data were recorded, and the motor strength grade (MRC scale, grade 0-5) was evaluated. Numeric rating pain score (NRPS, grade 0-10) was asked during every PTA, and overall NRPS and satisfaction scores (scale 1-3) were asked after the procedure was completed. RESULTS: Of the 174 patients who received BPB, the success rate was 100%, and there were no significant complications related to BPB. The MRC scale measured at the time when the complete sensory loss was achieved was 1.99 ± 0.63, and that at the point of sensory recovery when the block effect expired was 3.93 ± 0.62, indicating a good grade of motor strength. The average NRPS during PTA in the BPB group was significantly lower than that of the control group without BPB (1.04 ± 2.04vs 6.30 ± 2.71, p < 0.001). The overall satisfaction score was significantly higher in the BPB group than in the control group (2.79 ± 0.50vs 2.00 ± 0.81, p < 0.001). CONCLUSIONS: BPB using only 1% lidocaine can induce a sensory block while minimizing the effect on motor function. It can be applied safely in an outpatient clinic setting with relatively higher satisfaction.

Plug-assisted retrograde transvenous obliteration for the treatment of gastric variceal bleeding in absence of gastrorenal or gastrocaval shunt: A case report.

RATINALE: Plug-assisted retrograde tansvenous obliteration (PARTO) is commonly used to treat gastric variceal bleeding. PARTO is typically performed via the gastrorenal shunt or gastrocaval shunt and there have been no reports of PARTO performed through the pericardial vein in cases of gastric varices in which there is no gastrorenal or gastrocaval shunt. Herein, we report a case of PARTO was performed to treat gastric variceal bleeding in a patient with a gastric varix without a gastrorenal or gastrocaval shunt. PATIENT CONCERNS: A 54-year-old man with alcoholic liver cirrhosis presented to the emergency room with hematemesis and melena. At presentation, the patient's blood pressure was 130/70 mm Hg and hemoglobin level was 10.1 g/dL. DIAGNOSES: Computed tomography (CT) scan and endoscopic examination revealed a gastric varix at the gastric fundus. INTERVENTIONS: PARTO was performed to treatment of gastric variceal bleeding via the pericardial vein. OUTCOMES: The patient did not show any signs of variceal bleeding after the procedure, and follow-up CT at 3 weeks showed complete resolution of the gastric varix. LESSONS: Although PARTO is technically difficult to perform through pathways other than the gastrorenal or gastrocaval shunt, it can be a beneficial alternative in cases in which other treatments fail or are not feasible.

Gastrointestinal bleeding after failed endoscopic hemostasis: diagnostic efficacy of angiography compared with computed tomography and treatment outcomes of transcatheter arterial embolization.

PURPOSE: This study compared the detection sensitivity of catheter angiography to that of contrast-enhanced multi-detector computed tomography (MDCT) for detecting acute non-variceal gastrointestinal bleeding (GIB) to elucidate the diagnostic efficacy of catheter angiography. We also determined GIB outcomes of transcatheter arterial embolization after failed endoscopic hemostasis. MATERIALS AND METHODS: Data were collected retrospectively from 63 patients managed at four institutions who met the following criteria during a 3-year period: (1) ongoing non-variceal GIB confirmed during endoscopy; (2) failed endoscopic hemostasis; and (3) endoscopy, MDCT, and catheter angiography performed within 24 h. The diagnostic efficacies of MDCT, selective angiography with a 5-Fr catheter (5Fr-angiography), and super-selective angiography with a microcatheter (micro-angiography) were compared using endoscopic diagnosis as the reference method. The rates of technical success, clinical success, and complications were analyzed when arterial embolization was performed. RESULTS: All transcatheter angiographies were performed after MDCT. Micro-angiography had a significantly higher GIB detection rate (73.0%) than MDCT (57.1%) and 5Fr-angiography (39.7%) (micro-angiography vs. MDCT, P = 0.021; MDCT vs. 5Fr-angiography, P = 0.043). Arterial embolization was attempted in 55 of 63 patients, with technical success achieved in 53 of 55 patients (96.4%) and clinical success in 38 of 42 patients (90.5%). Eleven patients were lost to follow-up. Three patients experienced complications, including bowel infarction (two patients) and common bile duct stricture (one patient). CONCLUSION: In cases of endoscopic hemostasis failure, angiography can be performed even if MDCT yields negative results but should include micro-angiography; moreover, embolization can be performed safely and effectively. TRIAL REGISTRATION: None.

Uterine Artery Embolization as an Effective Management and Diagnostic Tool for Puerperal Uterine Inversion with Severe Postpartum Bleeding: A Case Report.

Acute puerperal uterine inversion is a rare postpartum obstetric complication; however, without rapid diagnosis and appropriate management, it is life-threatening. Substantial bleeding hinders the verification of a partially inverted uterus, possibly delaying the treatment. Herein, we present the report of a 32-year-old female presenting with massive postpartum bleeding managed by uterine artery embolization. The peculiar course of the uterine artery bowing inferiorly along the inverted fundus during embolization could uncover the uterine inversion, which was not diagnosed by physical examination and CT. In conclusion, uterine artery embolization is not only an effective therapeutic strategy for postpartum hemorrhage but also a valuable tool for diagnosing uterine inversion.

Prevalence and clinical significance of anatomic variant in cephalic arch on preoperative mapping venography.

The aim of the current study was to determine the prevalence of anatomic variant in cephalic arch on preoperative mapping venography and evaluate patency rates and predictors of patency in patients with brachiocephalic fistulas. The prevalence of anatomic variant in cephalic arch was retrospectively evaluated in 1004 consecutive patients who underwent bilateral preoperative mapping venography from July 2006 to December 2018 in a single center. The overall prevalence of anatomic variant in cephalic arch was 17.2% (173/1004). For patency analysis, 128 patients with brachiocephalic fistulas were divided into two groups: a standard anatomy (SA) group (n = 97) and a variant anatomy (VA) group (n = 31). There were no significant differences in clinical characteristics between the two groups. The primary patency rate did not differ significantly between the two groups. The secondary patency rate was significantly (p = 0.009) lower in the VA group than in the SA group. Older age (HR 1.03; 95% CI 1.01-1.05; p = 0.007) was a negative predictor of primary patency, and antiplatelet agent (HR 0.53; 95% CI 0.33-0.84; p = 0.007) and large-diameter cephalic vein (HR 0.52; 95% CI 0.31-0.86; p = 0.012) were positive predictors of primary patency. Older age (HR 1.04; 95% CI 1.01-1.07; p = 0.011) and anatomic variant in cephalic arch (HR 2.9; 95% CI 1.19-7.06; p = 0.019) were negative predictors of secondary patency. The current study provides insight into the clinical significance of anatomic variant in cephalic arch. Anatomic variant in cephalic arch should be considered as a potential risk factor for decreased patency of brachiocephalic fistula during preoperative planning.

Validation of the PICC length prediction formula based on anteroposterior chest radiographs for bedside ultrasound-guided placement.

This study aimed to validate the accuracy of the peripherally inserted central catheter (PICC) length prediction formula using only anteroposterior chest radiographs (AP-CXR) and the technical feasibility of bedside ultrasound-guided PICC placement. This study included 156 Asian adult patients who underwent bedside PICC placement at three hospitals from September 2021 to March 2022. The shortest straight-line distance from the cubital crease to the puncture point (CP) was measured first. Using the formula of a previous study, the CP + estimated PICC length (eCL) was calculated with the parameters measured on AP-CXR. The formula was as follows: 19.409 + 0.424 × (MHTD, maximal horizontal thoracic diameter) + 0.287 × (CL, clavicle length) + 0.203 × (DTV, distance of thoracic vertebrae) + (2VBUs, two vertebral body units below the carina inferior border) (if from the left, 3.063cm was added; if female, 0.997cm was subtracted). Catheters were pretrimmed according to calculated eCL prior to the procedure. Technical success was evaluated, and the validation success of catheter length prediction was classified according to the catheter tip position as follows: optimal position or suboptimal position. Technical success was achieved in 153 cases (98.1%). Evaluation of validation success revealed that the position was "optimal" in 108 cases (70.6%) and "suboptimal" in 45 cases (29.4%). There was no validation failure. There was no case where the catheter was inserted too deep as to wedge into the right atrial wall. In conclusion, the PICC could be positioned accurately using the formula based on only AP-CXR. Furthermore, this bedside procedure was technically feasible.

Epipericardial Fat Necrosis in a Pediatric Patient Diagnosed Using Contrast-Enhanced MRI Findings: A Case Report and Literature Review.

Epipericardial fat necrosis (EPFN) is a relatively rare cause of acute chest pain, with only five pediatric cases having been reported in the English-language medical literature to date. EPFN can be diagnosed based on the clinical symptoms of acute pleuritic chest pain and classic CT features of typically ovoid fatty lesions surrounded by a rim or capsule in the mediastinal or pericardial areas. Previous studies have reported that contrast-enhanced MRI can detect typical fat signal changes in adults with EPFN. We report a pediatric EPFN case diagnosed using gadolinium-enhanced MRI. Thus, contrast-enhanced MRI may be used to confirm EPFN in the differential diagnoses of the causes of acute chest pain.