Comparative effectiveness of angioembolization versus open surgery in patients with blunt splenic injury.

The effectiveness and safety of transcatheter splenic artery embolization (SAE) compared to those of open surgery in patients with blunt splenic injury (BSI) remain unclear. This retrospective cohort-matched study utilized data from the Japan Trauma Data Bank recorded between 2004 and 2019. Patients with BSI who underwent SAE or open surgery were selected. A propensity score matching analysis was used to balance the baseline covariates and compare outcomes, including all-cause in-hospital mortality and spleen salvage. From 361,706 patients recorded in the data source, this study included 2,192 patients with BSI who underwent SAE or open surgery. A propensity score matching analysis was used to extract 377 matched pairs of patients. The in-hospital mortality rates (SAE, 11.6% vs. open surgery, 11.2%, adjusted relative risk (aRR): 0.64; 95% confidence interval [CI]: 0.38-1.09, p = 0.10) were similar in both the groups. However, spleen salvage was significantly less achieved in the open surgery group than in the SAE group (SAE, 87.1% vs. open surgery, 32.1%; aRR: 2.84, 95%CI: 2.29-3.51, p < 0.001). Survival rates did not significantly differ between BSI patients undergoing SAE and those undergoing open surgery. Nonetheless, SAE was notably associated with a higher likelihood of successful spleen salvage.

Pancreatic serous cystic neoplasms with spontaneous hemorrhage in a young woman: A case report.

INTRODUCTION: Pancreatic serous cystic neoplasm (SCN) is usually benign and is often managed using imaging surveillance if asymptomatic. It has a higher incidence in females but is rare in younger age groups. Acute hemorrhagic complications associated with SCN are infrequent. Whether asymptomatic SCN can cause acute hemorrhage, especially in women of childbearing age, is not well-established. PRESENTATION OF CASE: A 30-year-old Japanese female, who was six months postpartum and under surveillance for asymptomatic pancreatic SCN, presented to the emergency department with gradually worsening left lateral abdominal pain. Regular ultrasound revealed no change in SCN size; however, no imaging surveillance had been conducted over the past two years. She had pain in the entire abdomen, which intensified around the navel and elicited guarding. Abdominal contrast-enhanced computed tomography revealed a cystic mass in the pancreatic tail with a contrast blush within the cyst and an adjacent retroperitoneal hematoma. Endovascular embolization was performed to control the hemorrhage. The patient had an uneventful medical recovery and was discharged five days after embolization. Five months after discharge, she underwent laparoscopic distal pancreatectomy and splenectomy as an elective surgery and was discharged uneventfully. DISCUSSION: Even with periodic imaging surveillance, pancreatic SCN can suddenly cause spontaneous hemorrhage. Clinicians should be aware that pancreatic SCN can potentially cause life-threatening complications, including spontaneous hemorrhage. CONCLUSION: We report a case of an unexpected complication with spontaneous hemorrhage in a young woman who was under imaging surveillance for pancreatic SCN. The patient was successfully treated with angioembolization and planned laparoscopic surgery.

Postpartum hemorrhage with associated placenta previa in a kidney transplant recipient: A case report.

INTRODUCTION: The efficacy and safety of uterine artery embolization (UAE) and prophylactic resuscitative endovascular balloon occlusion of the aorta (REBOA) against postpartum hemorrhage (PPH) in pregnant women after kidney transplantation have not been reported. Here, we describe a case of PPH associated with placenta previa in pregnancy following kidney transplantation, which was managed with UAE and prophylactic REBOA. CASE PRESENTATION: A 35-year-old, gravida 2, para 1 woman with total placenta previa presented with vaginal bleeding (460 mL) at 33 weeks and 3 days of gestation. Previously, she underwent a living-donor kidney transplantation for IgA nephropathy, and the renal artery of the transplanted kidney was anastomosed with the right internal iliac artery. An emergency cesarean section with prophylactic REBOA was performed under general anesthesia. A balloon catheter was introduced via the left femoral artery and positioned above the aortic bifurcation (Aortic zone 3). Upon confirming fetal delivery, the balloon was immediately inflated, and the total aortic occlusion time was 20 min. However, following aortic balloon deflation, atonic bleeding continued despite Bakri balloon usage and uterotonic drug administration. Subsequently, UAE was performed for the refractory PPH, the left uterine artery was embolized using a gelatin sponge, and hemostasis was successfully achieved. The patient recovered uneventfully and was discharged on postoperative day 7. DISCUSSION AND CONCLUSION: In pregnancies following kidney transplantation, prophylactic REBOA controls bleeding; however, it decreases blood flow to the transplanted kidney. Furthermore, uterine nutrient vasculature alterations are observed, necessitating a thorough understanding of the uterine artery supply pathways during UAE.

Spontaneous Tension Hemothorax in a Patient with Asbestosis.

CASE PRESENTATION: A 75-year-old man with a history of asbestosis presented to the emergency department with sudden-onset dyspnea and hemoptysis, triggered by coughing. The patient was hemodynamically unstable and in respiratory distress. Computed tomography revealed a massive hemothorax on the left side and compression of the descending thoracic aorta. He underwent emergency surgical exploration after decompression by chest tube insertion. The hemothorax was caused by tears in the pleural adhesions due to asbestosis and induced by coughing. DISCUSSION: Spontaneous hemothorax is a rare subtype of hemothorax. There have been only a few case reports of spontaneous tension hemothorax. In addition to its typical findings, compression of the thoracic descending aorta was observed in our patient. We hypothesize that severely diminished pulmonary compliance contributed to the extremely high intrathoracic pressure, which led to this unusual finding.

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

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

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

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

Traumatic Pneumothorax Associated With Penetrating Neck Injury Caused by a Stingray: A Case Report.

We describe a patient with missed traumatic pneumothorax due to penetrating neck injury that was presumably caused by a stingray while diving. The barb can result in significant injuries to deep structures and organs despite a deceptively small entrance wound. This case underscores the importance of performing a thorough examination and having a high suspicion of distant injury in patients with penetrating neck injuries.