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.

Carnitine Deficiency in Intensive Care Unit Patients Undergoing Continuous Renal Replacement Therapy: A Single-center Retrospective Study.

Introduction: Carnitine deficiency is common in patients undergoing intermittent hemodialysis and may also occur during continuous renal replacement therapy (CRRT). We evaluated intensive care unit (ICU) patients undergoing CRRT for carnitine deficiency and its associated risk factors. Methods: This was a single-center, retrospective, observational study performed between June 2019 and March 2020. The primary outcome was the incidence of carnitine deficiency in ICU patients undergoing CRRT. Results: Eighty-eight patients underwent 103 blood carnitine concentration measurements. The median age was 68 years (interquartile range: 55-80), Acute Physiology and Chronic Health Evaluation II score was 28 (24-33), Sequential Organ Failure score was 8.5 (5-11), Nutrition Risk in Critically Ill score was 6 (5-7), and blood carnitine concentration was 66.1 µmol/L (51.8-83.3). In total, 34 of 88 patients (38.6%) were found to have carnitine deficiency; however, there was no significant difference in the proportions of patients with carnitine deficiency characterized by disease. CRRT was performed in 44 (50%) patients, and the median blood total carnitine concentration measured after 24 h of CRRT without changing the settings was 65.5 µmol/L (48.6-83.3). The purification volume of CRRT and blood carnitine concentration were negatively correlated (R = -0.63; P = 0.02). Conclusions: Carnitine deficiency is seen in patients receiving CRRT and may increase in incidence as the purification volume increases, requiring regular monitoring.

Efficacy of the bleeding risk scoring system for optimal prophylactic anticoagulation therapy of venous thromboembolism in trauma patients: a single-center, retrospective, observational cohort study.

BACKGROUND: We developed a bleeding risk scoring system (BRSS) using prophylactic anticoagulation therapy to comprehensively assess the risk of venous thromboembolism (VTE) in trauma patients. This study evaluated the usefulness of this system in trauma patients, with a focus on minimizing the rate of bleeding events associated with prophylactic anticoagulation therapy. METHODS: We retrospectively evaluated the efficacy of BRSS in trauma patients who received prophylactic anticoagulation therapy for VTE at the Kitasato University Hospital Emergency and Critical Care Center between April 1, 2015, and August 31, 2020. To compare the incidence of bleeding events, patients were divided into two groups: one group using the BRSS (BRSS group) and another group not using the BRSS (non-BRSS group). RESULTS: A total of 94 patients were enrolled in this study, with 70 and 24 patients assigned to the non-BRSS and BRSS groups, respectively. The major bleeding event rates were not significantly different between the two groups (BRSS group, 4.2%; non-BRSS group, 5.7%; p = 1.000). However, minor bleeding events were significantly reduced in the BRSS group (4.2% vs.27.1%; p = 0.020). Multivariate logistic regression analysis showed that BRSS was not an independent influencing factor of major bleeding events (odds ratio, 0.660; 95% confidence interval: 0.067-6.47; p = 0.721). Multivariate logistic regression analysis showed that BRSS was an independent influencing factor of minor bleeding events (odds ratio, 0.119; 95% confidence interval: 0.015-0.97; p = 0.047). The incidence of VTE did not differ significantly between groups (BRSS group, 4.2%; non-BRSS group, 8.6%; p = 0.674). CONCLUSIONS: BRSS may be a useful tool for reducing the incidence of minor bleeding events during the initial prophylactic anticoagulation therapy in trauma patients. There are several limitations of this study that need to be addressed in future research.

Distal radial approach for arterial pressure monitoring with a long catheter provides safe and stable monitoring in the intensive care unit: A single-center retrospective study.

BACKGROUND: To compare the distal radial artery approach (DRA) with a longer catheter to DRA with a shorter catheter in arterial catheter (AC) placement in the intensive care unit (ICU). METHODS: This was a single-center retrospective cohort study of DRA with a long catheter (60 mm) for arterial catheterization in the ICU. DRA with a short catheter (25-30 mm) was used in the control group, and the groups were compared using multivariate regression analysis. The primary study endpoint was the incidence of unplanned AC removal. The secondary endpoint was the incidence of other inappropriate events, namely loss of arterial pressure waveforms, bleeding, catheter-related infection, pressure ulcer, and other complications associated with the AC. RESULTS: In this study, the DRA with a long catheter was used in 50 patients. No unplanned AC removals or other inappropriate events occurred, and there were no complications associated with the DRA. The DRA procedural success rate was 100%. There was no significant difference in hemostasis times between the groups. Loss of arterial waveforms was an early predictor of unplanned AC removal. CONCLUSIONS: The DRA with a long catheter provided stable monitoring and was associated with a low unplanned removal rate. This method has the advantages of fewer complications and shorter hemostasis time compared with the DRA with a short catheter, and may become a new AC option in the ICU.

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.

Relationship between subarachnoid hemorrhage and nonocclusive mesenteric ischemia as a fatal complication: patient series.

BACKGROUND: Nonocclusive mesenteric ischemia (NOMI) causes intestinal necrosis due to irreversible ischemia of the intestinal tract. The authors evaluated the incidence of NOMI in patients with subarachnoid hemorrhage (SAH) due to ruptured aneurysms, and they present the clinical characteristics and describe the outcomes to emphasize the importance of recognizing NOMI. OBSERVATIONS: Overall, 7 of 276 consecutive patients with SAH developed NOMI. Their average age was 71 years, and 5 patients were men. Hunt and Kosnik grades were as follows: grade II, 2 patients; grade III, 3 patients; grade IV, 1 patient; and grade V, 1 patient. Fisher grades were as follows: grade 1, 1 patient; grade 2, 1 patient; and grade 3, 5 patients. Three patients were treated with endovascular coiling, 3 with microsurgical clipping, and 1 with conservative management. Five patients had abdominal symptoms prior to the confirmed diagnosis of NOMI. Four patients fell into shock. Two patients required emergent laparotomy followed by second-look surgery. Four patients could be managed conservatively. The overall mortality of patients with NOMI complication was 29% (2 of 7 cases). LESSONS: NOMI had a high mortality rate. Neurosurgeons should recognize that NOMI can occur as a fatal complication after SAH.

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.

Difference in postcourse knowledge and confidence between Web-based and on-site training courses on resuscitative endovascular balloon occlusion of the aorta.

AIM: Effective courses are essential for highly invasive procedures such as resuscitative endovascular balloon occlusion of the aorta. However, the coronavirus disease pandemic has forced the postponement of on-site educational courses due to transmission concerns. Few studies have examined the effectiveness of Web-based education in highly invasive procedures. To address this knowledge gap, this study aimed to investigate whether knowledge acquisition and confidence after the Web-based course are different from those acquired after the on-site course, using pre- and postcourse test scores. METHODS: The increase in scores before and after the course was compared between the on-site and Web-based courses. The questions reflected knowledge about seven different topics in the course modules. In addition, participants were asked about their self-rated confidence about three topics before and after the course. RESULTS: Thirty learners completed the on-site course, and 21 learners completed the Web-based course. Forty-seven learners completed both the precourse and postcourse tests. In both courses, the difference between the precourse and postcourse test scores showed a statistically significant increase in knowledge (on-site course: increased score, 1.8; 95% confidence interval, 0.8 to 2.8; Web-based course: increased score, 1.6, 95% confidence interval, 0.5 to 2.5). However, the difference was not statistically significant in the self-rated confidence scores about "sheath and catheter removal" among learners of the Web-based course. CONCLUSION: Knowledge increased significantly in both the on-site and Web-based courses. However, the Web-based course might not be sufficient to give learners confidence in the procedures.

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.

Factors for unsuccessful endoscopic hemostasis in patients with severe peptic ulcer bleeding.

OBJECTIVES: Although the first approach for peptic ulcer bleeding is endoscopic hemostasis, quick determination of a hemostatic strategy is important in patients with vitals indicating shock. However, the unsuccessful factors for endoscopic treatment have yet to be sufficiently examined. We aimed to investigate the factors for unsuccessful endoscopic hemostasis in severe peptic ulcer bleeding. MATERIALS AND METHODS: Unsuccessful factors were retrospectively investigated in 150 eligible patients who underwent endoscopic hemostasis for shock-presenting peptic ulcer bleeding at our critical care center between April 2007 and March 2021. RESULTS: There were 123 and 27 cases of successful and unsuccessful endoscopic hemostasis, respectively. Causative diseases included gastric ulcer bleeding in 124 patients (82.7%) and duodenal ulcer bleeding in 26 patients (17.3%). Shock index (SI) (1.46 vs. 1.60) (p = .013), exposed blood vessel diameter (1.4 mm vs. 3.1 mm) (p < .001) identified on contrast-enhanced computed tomography (CE-CT), duodenal ulcer bleeding (p = .012), and Forrest classification Ia (p = .004) were extracted as independent factors for unsuccessful endoscopic hemostasis. In receiving operating curve analysis, when the cut-off value for the SI was set at 1.53, the sensitivity and specificity were 70.4% and 63.4%, respectively. When the cut-off value for the exposed blood vessel diameter was set at 1.9 mm, these were 88.9% and 83.7%, respectively. CONCLUSIONS: When these factors (SI ≥ 1.53, exposed blood vessel diameter ≥1.9 mm identified on CE-CT, duodenal ulcer bleeding, and Forrest Ia) are present in patients with severe peptic ulcer bleeding, non-endoscopic hemostasis, such as interventional radiology (IVR) and surgery, should be considered.

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.

Clinical Utility of the Candy-Plug Technique Using an Excluder Aortic Extender.

Objective: To describe the clinical utility and technical aspects of the candy-plug technique using an Excluder aortic extender (Ex-cuff) for false lumen (FL) occlusion in chronic aortic dissection. Materials and Methods: This is a retrospective study analyzing seven consecutive patients (mean age, 63 years; range, 44-78 years; 6 men) with aneurysmal dilatation or rupture in chronic aortic dissection. All patients had undergone thoracic endovascular aortic repair with FL occlusion using this technique. We assessed technical (deployment accuracy) and clinical (no FL backflow on the latest contrast-enhanced computed tomography) success. Results: Technical success was obtained in six patients (86%). Technical failure was caused by the malposition of the candy-plug. The mean follow-up period was 593 days (range, 222-1225 days). Clinical success was obtained in four (57%), and incomplete Amplatzer Vascular Plug (AVP) embolization was seen in two. There was no enlarged FL after the procedure, and all patients are alive during the follow-up periods. Conclusion: The candy-plug technique using an Ex-cuff may be a feasible option; however, it takes time to achieve complete AVP embolization. Therefore, using additional embolic materials should be considered when we use it for the rupture case. (This is a translation of Jpn J Endovasc Interv 2018; 19: 29-35.).

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.