Intravascular guide wire aspiration in a patient on extracorporeal membrane oxygenation: A case report.

RATIONALE: Guide wire aspiration during central venous catheter (CVC) insertion in a patient on extracorporeal membrane oxygenation (ECMO) is a very rare but dangerous complication. A guide wire aspirated inside the ECMO can cause thrombosis, the ECMO to break down or shut off, and unnecessary ECMO replacement. PATIENT CONCERNS: A 58-year-old man was scheduled for venovenous ECMO for acute respiratory distress syndrome. After his vital signs stabilized, we inserted a CVC. During CVC insertion, the guide wire was aspirated into the ECMO venous line. INTERVENTION: After confirming the guide wire inside the ECMO venous line, we replaced the entire ECMO circuit. OUTCOMES: ECMO was maintained for 57 days, and weaning was successful but the patient died 5 days afterward. LESSONS: Care must be taken when inserting a CVC using a guide wire in ECMO patients: the guide wire should not be inserted deeply, it should be secured during insertion, the ECMO venous cannula tip requires proper positioning, and ECMO flow should be temporarily reduced.

Surgical Management of an Isolated Huge Innominate Artery Aneurysm Causing Tracheal Compression: A Case Report.

The innominate artery is an uncommon site for an aneurysm, and tracheal compression caused by an innominate artery aneurysm is a very rare occurrence. An innominate artery aneurysm can cause catastrophic complications, such as rupture or thromboembolism. The most common surgical approach for open repair is median sternotomy with cardiopulmonary bypass, but cerebral ischemic injury and thromboembolism can occur during surgery. We present the case of a male patient who had an isolated giant innominate artery aneurysm causing tracheal compression, which was successfully managed by surgical repair.

Diagnostic Value of Bone SPECT/CT Using 99mTc-Methylene Diphosphonate in Patients with Unspecified Chest Wall Pain.

PURPOSE: We investigated the diagnostic performance of single photon emission computed tomography (SPECT)/computed tomography (CT) as a combination of functional and anatomic imaging, in patients with unspecified chest wall pain. METHODS: Fifty-two patients with unspecified chest wall pain and no history of recent major traumatic events or cardiac disease were included. The number and location of radioactive chest wall lesions were evaluated on both planar images and SPECT/CT. The clinical diagnosis was made based on all of the clinical and imaging data and follow-up information. RESULTS: Chest wall diseases were diagnosed in 42 patients (80.8 %). SPECT/CT showed abnormal findings in 35 (67.3 %) patients with positive predictive value (PPV) of 97.1 %. SPECT/CT revealed 56 % more lesions than planar bone scan (P = 0.002) and most of the abnormal radioactive lesions (94.6 %) showed combined morphological changes on the matched CT component. When comparing between age subgroups (< 60 y vs. ≥ 60 y), the prevalence of chest wall disease and diagnosis rate of fracture was significantly higher in the older age group. On SPECT/CT, the older age group showed higher frequency of having abnormal finding (95.8 % vs. 42.9 %, P < 0.001) and significantly more lesions were detected (a total of 189 vs. 32, P = 0.003). CONCLUSION: SPECT/CT showed good diagnostic performance and proved to have higher sensitivity, detecting 56 % more lesions than planar bone scan. A negative result could be helpful for excluding pathologic chest wall disease. SPECT/CT might be recommended for integration in to the diagnostic workup in patients with unspecified chest wall pain, especially in patients ≥ 60 y of age, considering the high disease prevalence and the high frequency of positive results.

Mid-Term Results of Thoracic Endovascular Aortic Repair for Complicated Acute Type B Aortic Dissection at a Single Center.

BACKGROUND: Complicated acute type B aortic dissection is a life-threatening condition with high morbidity and mortality. The aim of this study was to report a single-center experience with endovascular stent-graft repair of acute type B dissection of the thoracic aorta and to evaluate the mid-term outcomes. METHODS: We reviewed 18 patients treated for complicated acute type B aortic dissection by thoracic endovascular aortic repair (TEVAR) from September 2011 to July 2017. The indications for surgery included rupture, impending rupture, limb ischemia, visceral malperfusion, and paraplegia. The median follow-up was 34.50 months (range, 12-80 months). RESULTS: The median interval from aortic dissection to TEVAR was 5.50 days (range, 0-32 days). There was no in-hospital mortality. All cases of malperfusion improved except for 1 patient. The morbidities included endoleak in 2 patients (11.1%), stroke in 3 patients (16.7%), pneumonia in 2 patients (11.1%), transient ischemia of the left arm in 1 patient (5.6%), and temporary visceral ischemia in 1 patient (5.6%). Postoperative computed tomography angiography at 1 year showed complete thrombosis of the false lumen in 15 patients (83.3%). CONCLUSION: TEVAR of complicated type B aortic dissection with a stent-graft was effective, with a low morbidity and mortality rate.

Role and Prognosis of Extracorporeal Life Support in Patients Who Develop Cardiac Arrest during or after Office-Based Cosmetic Surgery.

BACKGROUND: Cardiac arrest during or after office-based cosmetic surgery is rare, and little is known about its prognosis. We assessed the clinical outcomes of patients who developed cardiac arrest during or after cosmetic surgery at office-based clinics. METHODS: Between May 2009 and May 2016, 32 patients who developed cardiac arrest during or after treatment at cosmetic surgery clinics were consecutively enrolled. We compared clinical outcomes, including complications, between survivors (n=19) and non-survivors (n=13) and attempted to determine the prognostic factors of mortality. RESULTS: All 32 of the patients were female, with a mean age of 30.40±11.87 years. Of the 32 patients, 13 (41%) died. Extracorporeal life support (ECLS) was applied in a greater percentage of non-survivors than survivors (92.3% vs. 47.4%, respectively; p=0.009). The mean duration of in-hospital cardiopulmonary resuscitation (CPR) was longer for the non-survivors than the survivors (31.55±33 minutes vs. 7.59±9.07 minutes, respectively; p=0.01). The mean Acute Physiology and Chronic Health Evaluation score was also higher among non-survivors than survivors (23.85±6.68 vs. 16.79±7.44, respectively; p=0.01). No predictor of death was identified in the patients for whom ECLS was applied. Of the 19 survivors, 10 (52.6%) had hypoxic brain damage, and 1 (5.3%) had permanent lower leg ischemia. Logistic regression analyses revealed that the estimated glomerular filtration rate was a predictor of mortality. CONCLUSION: Patients who developed cardiac arrest during or after cosmetic surgery at office-based clinics experienced poor prognoses, even though ECLS was applied in most cases. The survivors suffered serious complications. Careful monitoring of subjects and active CPR (when necessary) in cosmetic surgery clinics may be essential.

Early Administration of Venovenous Extracorporeal Life Support for Status Asthmaticus during Anaesthetic Induction: Case Report and Literature Review.

Here we report a case of a 40-year-old man who visited the emergency room with severe chest pain. He showed a Stanford type B aortic dissection on chest-computed tomography. Despite medical treatment and malperfusion of lower extremities, acute renal failure developed; hence thoracic endovascular aortic repair (TEVAR) was considered under general anaesthesia. After endotracheal intubation, ventilation with low tidal volume required high inspiratory airway pressure. An arterial blood gas analysis showed PaCO2 of 61.8mmHg and PaO2 of 26.4mmHg, indicating a status asthmaticus of hypoxaemia and hypercarbia, which did not respond to bronchodilator or mechanical ventilation. Impending cardiac arrest was treated using venovenous extracorporeal life support, which was administered by percutaneous femoral cannulation. Surgical procedure was completed without any complications. Extracorporeal life support was weaned at one day after the operation. The patient was discharged without any complications.

Short stature is associated with the development of lower limb ischaemia during extracorporeal life support.

BACKGROUND: Percutaneous cannulation of femoral vessels has been widely used for the rapid deployment of extracorporeal life support (ECLS). Limb ischaemia is a devastating complication in patients receiving ECLS. Our aim was to evaluate the predictors of limb ischaemia during ECLS and to determine the role of preventative distal perfusion. METHODS: Two hundred and fifty-five consecutive patients who received veno-arterial ECLS due to cardiac and/or respiratory failure were enrolled from January 2009 to December 2015. All patients received ECLS for more than 6 hours and the data was reviewed retrospectively. Distal perfusion to minimise lower limb ischaemia was performed at the discretion of the physician. Predictors for lower limb ischaemia during ECLS were analysed using multivariate regression analysis. RESULTS: For the 255 patients, the mean age was 58 and 177 (69.4%) were male. Limb ischaemia developed in 24 patients (9.4%); 178 patients (69.8%) died within 30 days. Among the 24 patients, one patient (4.2%) developed limb ischaemia with preventative distal perfusion. Fourteen patients (58.3%) received therapeutic distal perfusion. After distal perfusion, two patients (8.3%) still required surgical intervention. Limb ischaemia was more frequent in female patients (54.2% in the ischaemia group versus 28.1% in the non-ischaemia group, p=0.008) and shorter patients (162.0 ± 9.5 cm in the ischaemia group versus 166.3 ± 9.1 cm in the non-ischaemia group, p=0.027). Patients shorter than 165 cm were more commonly diagnosed with ischaemia compared to those who were taller than 165 cm (79.2% versus 40.7%, p<0.001). In a multivariate regression analysis, height under 165 cm was the only predictor for limb ischaemia (Odds ratio (OR) [95% confidence interval (CI)] = 12.645 [3.190-50.118]). CONCLUSION: Smaller female patients are more prone to developing limb ischaemia from femoral ECLS. Our findings might support preventative distal perfusion and more careful observation of these patients.

Complete spontaneous resolution of a giant bulla without rupture or infection: a case report and literature review.

We report a case of complete spontaneous resolution of a giant bulla without ipsilateral pneumothorax or overt infection accompanied by contralateral recurrent pneumothorax. A 67-year-old man visited the emergency room with dyspnea. Chest computed tomography revealed spontaneous pneumothorax on the right side and a giant bulla in the left anterior lung. Closed thoracostomy was performed and the patient was discharged. Two years later, right pneumothorax recurred. Bullectomy in the right lung and pleurodesis were performed. On monthly follow up, the giant bulla in the left lung had abruptly disappeared without any episode of pneumothorax or infection at one year after the operation.

Delayed Surgery for Aortic Dissection after Intravenous Thrombolysis in Acute Ischemic Stroke.

We report a case of aortic dissection masquerading as acute ischemic stroke followed by intravenous thrombolysis. A 59-year-old man presented with dizziness. After examination, the patient had a seizure with bilateral Babinski signs. Soon after identifying multiple acute infarctions in both hemispheres on diffusion-weighted brain magnetic resonance (MR) imaging, tissue plasminogen activator (t-PA) was administered. Both common carotid arteries were invisible on MR angiography, and subsequent chest computed tomography revealed an aortic dissection. The emergency operation was delayed for 13 hours due to t-PA administration. The patient died of massive bleeding.

Pulse pressure as a prognostic marker in patients receiving extracorporeal life support.

BACKGROUND: It is not easy to predict the prognosis of patients receiving extracorporeal life support (ECLS) because of the highly variable situation around its implementation. We evaluated the role of pulse pressure (PP), which is available on real-time basis, as a hemodynamic prognostic marker during ECLS. METHODS: From January 2009 to August 2011, data from 69 patients who were treated with ECLS for at least 6h in a single center for any cause was collected. We calculated the mean PP over the first 6h after ECLS implantation and examined if there was any correlation between mean PP and the study endpoints, in-hospital death and ECLS weaning failure. RESULTS: The causes of ECLS were of cardiac origin in 36 patients (52%). 27 patients (39.1%) weaned off ELCS and 13 patients (18.8%) survived to discharge. In Cox regression analysis (with age, Killip class ≥3, ECLS implementation during cardiopulmonary resuscitation (CPR), CPR duration, out-of-hospital arrest, initial laboratory results including blood gas analysis, initial systolic blood pressure (SBP), mean SBP over the first 6h after ECLS implantation, mean PP over the first 6h after ECLS implantation as independent variables), mean PP over the first 6h after ECLS implantation (hazard ratio [95% confidence interval]=0.96[0.94-0.98], P<0.001) and out-of-hospital arrest (HR[95%CI]=2.04[1.14-3.62], P=0.02) were independent predictors of in-hospital mortality and mean PP over the first 6h after ECLS implantation (HR[95% CI]=0.95[0.93-0.98], P<0.001) was the sole independent predictor of weaning failure. CONCLUSION: Higher mean PP over the initial 6h after ECLS implementation independently predicted successful weaning and survival. Our findings may help better predict and analyze prognosis in patients receiving ECLS.

Extracorporeal Life Support After Prolonged Resuscitation for In-Hospital Cardiac Arrest due to Refractory Ventricular Fibrillation: Two Cases Resulting in a Full Recovery.

Extracorporeal life support (ECLS) has well demonstrated its efficacy in treating in-hospital cardiac arrest and is being used for broader indications. However, ECLS after prolonged cardiopulmonary resuscitation (CPR) has been traditionally contraindicated and is now challenging. Here, we introduce two cases of successful ECLS after prolonged CPR, resulting in a immediate and full recovery. Both these acute ST elevation myocardial infarction patients waiting for primary percutaneous coronary intervention (PCI) suddenly collapsed due to ventricular fibrillation (VF), which was refractory to conventional treatment. After 2 hours of conventional CPR, the ECLS had been implemented and primary PCI could be performed. Subsequent to successful revascularization, the VF was stopped with a single electric shock. In our second case, normal sinus rhythm was spontaneously restored after ECLS implementation, which was completed after 45 minutes of conventional resuscitation. Both patients made a full neurological recovery on the day of the event and were discharged with only minor complications.

Acute diffuse phlegmonous esophagogastritis: a case report.

Acute phlegmonous infection of the gastrointestinal tract is characterized by purulent inflammation of the submucosa and muscular layer with sparing of the mucosa. The authors report a rare case of acute diffuse phlegmonous esophagogastritis, which was well diagnosed based on the typical chest computed tomographic (CT) findings and was successfully treated. A 48-yr-old man presented with left chest pain and dyspnea for three days. Chest radiograph on admission showed mediastinal widening and bilateral pleural effusion. The patient became febrile and the amount of left pleural effusion is increased on follow-up chest radiograph. Left closed thoracostomy was performed with pus drainage. A CT diagnosis of acute phlegmonous esophagogastritis was suggested and a surgery was decided due to worsening of clinical condition of the patient and radiologic findings. Esophageal myotomies were performed and the submucosal layer was filled with thick, cheesy materials. The patient was successfully discharged with no postoperative complication.