Medical intensivist directed VV ECMO cannulation for the facilitation of tracheostomy in a patient with severe tracheal stenosis: A case report

Objectives: We present a case report of medical intensivist driven ECMO program using ECMO as a pre-procedural tool to maintain oxygenation in a patient with critical tracheal stenosis during tracheostomy placement. Method(s): VV ECMO is primarily used to support patients when mechanical ventilation is unable to provide adequate gas exchange. Alternatively, it has been used pre-procedurally when intubation is required in anticipation of a difficult airway. Described here is the first intensivist preformed awake VV ECMO cannulation to facilitate tracheostomy in a patient with severe tracheal stenosis. Result(s): The patient is a 41-year-old female with the relevant background of COVID19 pneumonia status post tracheostomy and subsequently decannulated after prolonged intubation and ICU stay. As a result, the patient developed symptomatic tracheal stenosis and presented two years after her ICU stay for scheduled bronchoscopy and balloon dilation. However, the patient developed worsening stridor and shortness of breath requiring heliox and BPAP. After multidisciplinary discussion between the critical care team ENT teams, the decision was made to cannulate for VV ECMO as a pre-procedural maneuver to allow for oxygenation during open tracheostomy in the OR. Dexmedetomidine and local anesthesia were used for the procedure with the patient sitting at 30 degrees on non-invasive ventilation and heliox. The patient was cannulated with a 21F right internal jugular return cannula and 25F right common femoral drainage cannula by medical intensivists in the intensive care unit using ultrasound guidance. The patient went for operative tracheostomy the next day and was subsequently decannulated from ECMO the following day without complication. She was discharged home on trach collar. Conclusion(s): Intensivist performed ECMO cannulation has been shown to be safe and effective. We anticipate the indications and use will continue to expand. This case is an example that intensivist driven preprocedural ECMO is a viable extension of that practice.

Management of COVID-19-related post-intubation tracheal stenosis.

Introduction: The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic has affected Italy since the beginning of 2020. Endotracheal intubation, prolonged mechanical ventilation, and tracheostomy are frequently required in patients with severe COVID-19. Tracheal stenosis is a potentially severe condition that can occur as a complication after intubation. The aim of this study was to evaluate the utility and safety of endoscopic and surgical techniques in the treatment of tracheal stenosis related to COVID-19. Materials and Methods: Between June 2020 and May 2022, consecutive patients with tracheal stenosis who were admitted to our surgical department were considered eligible for participation in the study. Results: A total of 13 patients were included in the study. They consisted of nine women (69%) and four men (31%) with a median age of 57.2 years. We included seven patients with post-tracheostomy tracheal stenosis. Bronchoscopy was performed to identify the type, location, and severity of the stenosis. All patients underwent bronchoscopic dilation and surveillance bronchoscopy at 7 and 30 days after the procedure. We repeated endoscopic treatment in eight patients. Three patients underwent tracheal resection anastomosis. Final follow-up bronchoscopy demonstrated no residual stenosis. Conclusions: The incidence of and risk factors associated with tracheal stenosis in critically ill patients with COVID-19 are currently unknown. Our experience confirms the efficacy and safety of endoscopic management followed by surgical procedures in cases of relapsed tracheal stenosis.

Interventional challenges in vasculitis

Background: This case highlights how coronary pathology presents in vasculitis. Case presentation: A 49-year-old male, never-smoker presented to our hospital for a series of Acute Coronary Syndromes (ACS). The first in October 2019;angiogram revealed diffuse aneurysms and clot in the right coronary artery (RCA) and stenosis in the posterolateral branch (PLB). Post aspiration thrombectomy, and drug eluting stent (DES) to the PLB, patient was discharged on standard ACS meds. Coagulopathy workup was unremarkable. Follow up in November 2020, the patient was recommended reducing ticagrelor to 60mg twice daily (bid). The second ACS, one year later, revealed severe in-stent restenosis of the PLB stent. Patient had 2 DES placed in the PLB and was discharged on escalated therapy of rivaroxaban 2.5mg bid, and ticagrelor 90mg bid. Two months later the patient had COVID-19;during that admission he had two ACS events. The first showing mid-RCA stenosis and thrombosis of the same PLB;this was treated with only angioplasty. The next day, he had repeat ACS showing thrombosis of the RCA, but despite multiple attempts RCA recanalization was unsuccessful and discharged on medical therapy only. During clinic follow up, May 2022, the patient revealed that he had Kawasaki's disease as a kid. Conclusion(s): Coronary aneurysms are high risk because of slow flow and endothelial dysfunction that makes balloon dilation, stent sizing, and post interventional medical therapy difficult. Currently no standard guidelines exist to help providers treat this population. It may be beneficial to regularly follow up, monitor inflammatory markers (ESR, CRP correlated well with interleukin 6 and 8), and use CT or PET to follow active vasculitis and changes in aneurysms. Kawasaki's disease is a vasculitis of small and medium-sized vessels and often presents in childhood. Prospective studies show that patients with coronary aneurysms tend to have systemic artery aneurysms, so it is important to screen other arterial beds. Valvular disease has also been found to co-exist in patients with vasculitis, and pre-existing disease should be followed with echocardiography.

Scrubs (QUB Surgical Society) Medical Students' Academic Medicine Conference and Research Symposium

The proceedings contain 6 papers. The topics discussed include: endoscopic balloon dilatation for pediatric subglottic stenosis: systematic review and meta-analysis;a review of literature on anatomical variation of the extra-hepatic biliary tree;impact of the COVID-19 pandemic on patients with pediatric cancer in low-income, middle-income, and high-income countries: a multicenter, international, observational cohort study;preoperative mediastinal staging in resectable non-small cell lung cancer in a single surgical center;thoracotomy vs video-assisted thoracoscopic surgery in the treatment of vascular rings;and application of photogrammetry in medical education.

Esophageal Strictures in Children, a Six Year Case Series Experience in a Tertiary Center in Mexico City

Introduction: Esophageal strictures in children are in most cases associated with a benign etiology. There are multiple conditions that are associated with esophageal strictures including congenital stenosis, secondary to surgical repair of esophageal atresia, caustic burns following ingestion of acids or alcalis, radiation therapy and secondary to some pathologies as gastroesophageal reflux disease, eosinophilic esophagitis, scleroderma, epidermolysis bulllosa and idiopathic. Esophageal dilation can be performed with different techniques that include endoscope dilators, dilations performed over the wire and using the endoscope itself. Some cases require other adjunctive techniques that improve the results after failed progressive dilation. This therapies includes medical treatment and surgical derivations, with some cases known as recalcitrant. Also, esophageal strictures and its management could produce motility disorders. There is no consensus in the literature regarding the management process, especially in frequency of interventions, use of adjunctive therapies and alternatives for conservative management. This problem is more evident in developing countries. Objective(s): The objective of this study was to describe the cases of esophageal strictures and its management in children between 2016 and 2022 in the Instituto Nacional de Pediatria in Mexico City. Method(s): This was a six year retrospective study involving pediatric patients with esophageal stricture. We retrospectively reviewed the medical records of 23 pediatric patients who underwent endoscopic treatments for esophageal strictures, between January 2016 and May 2022 in the Comprehensive Pediatric Gastroenterology Diagnostic Unit in the Instituto Nacional de Pediatria in Mexico City. Result(s): The mean age at diagnosis was 24 months (Q1 15, Q3 35), 12 patients were male (52%) and 11 patients were female (48%). The most prevalent etiology was caustic strictures in 10 patients (43%). Six patients (26%) had esophageal atresia (4 type III, 1 type I and 1 type V), all whose received surgical management in the first days of life. All required repeated pneumatic dilation (between 1 and 11) for the management of postsurgical stenosis. Other etiologies that were found include Schatzki Ring, congenital stenosis, esophageal fibrosis associated with congenital dyskeratosis, epidermolysis bullosa, graft-versus-host disease and gastroesophageal reflux disease (one patient for each cause). In one patient the etiology remains unknown. Seventeen patients had one stricture, 5 patients had two strictures and 1 had 3 strictures. Ten patients had esophageal pseudodiverticula and two had mucosal fold. Six patients underwent dilation with Savary-Guilliard dilators combined with pneumatic balloon dilation. Four patients received mitomycin- C as an adjuvant therapy during dilations. The average diameter of stenosis was increased from 7 mm (range 4-15 mm) to 13,5 mm (range 8-18mm). Two patients had severe complications, one had a esophageal perforation associated with dilation. The other one had a pneumothorax related with anesthetic management. In the outcome 6 patients are asymptomatic, 1 patient persist with dysphagia after completed treatment, 9 patients are under treatment, 1 patient died secondary to its underlying disease and 6 patients lost follow up. Conclusion(s): Post-corrosive esophagitis and post-esophageal atresia anastomotic strictures were the most frequent types of cicatricial esophageal strictures. The conservative treatment was the first management strategy in the majority of patients, being the endoscopic balloon dilation the first choice. The SARS-COV-2 sanitary emergency limited the progressive intervention rate and appropriate clinical follow up of patients, reason why there is an important loss of follow up in the described group. A number of patients are currently on management, reason why their outcomes will be assessed in the future.

EXCIMER LASER CORONARY ATHERECTOMY: USED IN A STAGED APPROACH TO REDUCING THROMBUS BURDEN IN A 34 YEAR OLD WITH ACS

Background: Excimer Laser Coronary Atherectomy (ELCA) is a well-established adjunctive treatment modality that can be effectively used to reduce thrombus burden during percutaneous coronary intervention of coronary thrombosis. Case: A 34-year-old male with history of COVID-19 pneumonia one month prior, presented with non-ST elevation myocardial infarction. Coronary angiography revealed large thrombus burden involving the distal left main (LM) and ostial left anterior descending artery (LAD), as well as a distal LAD thrombotic occlusion (Figure 1A). Intravascular ultrasound showed distal LM plaque rupture with overlying thrombus (Figure 1C). Decision-making: Given the large thrombus burden and elevated risk of distal embolization, we proceeded with lesion passivation using adjunctive antiplatelet and antithrombotic treatment for 48 hours. ELCA was then used for thrombus debulking with a 1.7-mm catheter under distal embolic protection placed in mid LAD (Figure 1B). This was followed by aspiration thrombectomy, balloon dilation, and placement of a drug eluting stent in the distal LM and ostial LAD (Figure 1D). Conclusion: A strategy of using ELCA followed by stent implantation can be useful in selected patients with high intracoronary thrombus burden. ELCA can achieve effective thrombus removal, promotion of fibrinolysis, and platelet-stunning effects allowing plaque debulking and reduction of distal embolization. This case combines traditional tools to achieve the best possible outcome. [Formula presented]

Coronary angioplasty and stenting in acute coronary syndromes with very low contrast volume using Cordis 6F diagnostic catheters and improved cardiovascular and renal outcomes

Background: To perform safely angioplasties in acute coronary syndromes with very low contrast volume using Cordis 6F diagnostic catheters, and thereby improve the cardiovascular and renal outcomes. Methods: In 1652 patients (2138 lesions/2447 stents) with acute coronary syndromes, angioplasty was performed with Cordis 6F diagnostic catheters. Primary angioplasty was performed in 525 cases. In 75% of cases, iodixanol was used. A regular follow-up of the patients was performed 30 days after the procedure. All the procedures were performed through the femoral route. Tirofiban was used in 99% cases with adjusted dosages based on the creatinine values. Covid19 was positive in 23 cases by RT PCR. Results: The mean contrast volume used per patient was 28 ml (±6 ml) including the angiogram prior to the angioplasty. 103 patients had crea-tinine more than 2mg/dl before the angioplasty procedures. Left main angioplasty was performed in 41 patients using single stents. 87 patients had cardiogenic shock at presentation. 77% of the cases had diabetes. IVUS was used in only two patients. Mild reversible nephropathy (CIN) was observed in six patients. Six patients were already on dialysis, and dialysis was continued thereafter. Switch-over of angioplasty to the radial route was performed in six cases. 32 deaths in total were observed in this series;19 of these patients had cardiogenic shock (10 late presenters), and three patients expired after discharge due to possible acute stent thrombosis. Groin haematoma was seen in seven cases requiring one unit of blood transfusion. Proximal mild edge dissection in the deployed stent was seen in 3 cases. Acute in-hospital stent thrombosis was seen in 7 cases, which were managed with balloon dilatations and stents. Conclusions: Angioplasty and stenting can be performed safely in patients with acute coronary syndromes using Cordis diagnostic catheters and a very low volume of contrast with improved clinical outcomes.