Effectiveness of use of local hemostatic agents for external bleeding by visiting ambulance teams

The alternative use of local hemostatic agents based on chitosan is the gentlest method of stopping bleeding, with minimal damaging effect on tissues, in comparison with the imposition of a hemostatic tourniquet or a pressure bandage.Goal. To evaluate the effectiveness of temporary stopping of external bleeding with the help of local hemostatic agents based on chitosan in powder and bandage forms and to determine the expediency of their use by visiting ambulance teams.Materials and methods. Specialists of the field teams of Ambulance and Medical Emergency Care Station n. a. A. S. Puchkov (Moscow, Russia) used local hemostatic agents based on chitosan in the form of a powder, a bandage in comparison with traditional hemostatic agents (a hemostatic tourniquet to stop arterial bleeding and a pressure bandage). The criteria for hemostasis were the absence of wetting of the pressure bandage and the absence of the need for a hemostatic tourniquet.Results. 103 patients were included in the main group, and 106 patients with arterial and venous bleeding from wounds of various localization were included in the control group. The age of patients in the compared groups ranged from 18 to 94 years. When using hemostatic powder and bandage, primary hemostasis was achieved in 99 patients in 96.1 % of cases, compared with the control group in 76 patients in 67.9 % of cases.Conclusions. Simplicity and ease of use, the speed of stopping bleeding and achieving results, as well as the absence of the need for special skills among specialists in the use of hemostatic agents, improved the quality of emergency medical care for patients with bleeding and allowed them to be recommended as a dressing for emergency medical care.

Supraceliac aortic cross-clamping to control bleeding from the celiac axis during pancreatic surgery: a case report

Background Intraoperative bleeding from the celiac axis (CA) can occur during pancreatic surgery, and appropriate management is essential to avoid critical complications. Here, we have reported a case that was managed with supraceliac aortic cross-clamping (SAC) for arterial bleeding from the CA during pancreatic surgery. Case presentation A 70-year-old man was diagnosed with pancreatic cancer located in the pancreatic head and body. Preoperative computed tomography showed a stricture at the root of the CA, which may have been caused by a median arcuate ligament. Pancreaticoduodenectomy with division of the median arcuate ligament was scheduled. Uncontrollable bleeding from the root of the CA was observed during surgery. The bleeding was controlled by performing SAC, and a defect in the CA was confirmed. Arterial wall repair was successfully performed under temporal blood control using SAC. The aortic clamp time was 2 min and 51 s, and the intraoperative blood loss was 480 ml. Conclusions Although SAC is primarily a procedure for ruptured abdominal aortic aneurysm, it can be useful for the management of CA injuries during pancreatic surgery.

Emergency endovascular treatment using a Viabahn stent graft for upper and lower extremity arterial bleeding: a retrospective study

Background A Viabahn stent graft (SG) is a heparin-coated self-expandable SG for lower extremity arterial disease that exhibits high flexibility and accuracy in the delivery system. This study aimed to evaluate the short-term efficacy and safety of emergency endovascular treatment (EVT) using a Viabahn SG for upper and lower extremity arterial bleeding (ULEAB). Methods Consecutive patients with ULEAB who underwent emergency EVT using the Viabahn SG between January 2017 and August 2021 were retrospectively reviewed. The indications for EVT, location of artery, technical success, clinical success, limb ischemia, periprocedural complications, bleeding-related mortality, 30-day mortality, diameter of the target artery, diameter of the SG, neck length, rebleeding, endoleaks, and patency of the SGs at 1, 3, 6, and 12 months were evaluated. Results EVT using the Viabahn SG was performed in 22 patients (mean age, 72.0 ± 13.0 years; 11 men) and 23 arteries (upper, 6; lower, 17). The indications for EVT were pseudoaneurysm (n = 13, 59.1%), extravasation (n = 9, 39.1%), and inadvertent arterial cannulation (n = 1, 4.3%). The anatomical locations of the 23 ULEAB injuries were the brachiocephalic (1 [4.3%]), subclavian (3 [13.0%]), axillary (1 [4.3%]), brachial (1 [4.3%]), common iliac (4 [17.4%]), external iliac (8 [34.8%]), common femoral (2 [8.7%]), superficial femoral (2 [8.7%]), and popliteal (1 [4.3%]) arteries. The technical and clinical success rates were 100%. The rates of limb ischemia, periprocedural complications, and bleeding-related mortality were 0%, whereas the 30-day mortality rate was 22.7%. The mean diameters of the arteries and SGs were 7.7 ± 2.2 and 8.9 ± 2.3 mm, respectively. The mean neck length was 20.4 ± 11.3 mm. No endoleaks or rebleeding occurred during the follow-up period (mean, 169 ± 177 days). Two SG occlusions without limb ischemia occurred in the external iliac and brachial arteries after 1 and 4 months, respectively. Subsequently, cumulative SG patency was confirmed after 1, 3, 6, and 12 months in 91.7%, 91.7%, 81.5%, and 81.5% of patients, respectively. Conclusions Emergency EVT using the Viabahn SG for ULEAB was effective and safe according to short-term outcomes. Appropriate size selection and neck length are important for successful treatment. SG patency was good after 1, 3, 6, and 12 months.

Sectioning of C2 nerve roots during C1–2 fusion: report of aberrant vertebral artery during C2 nerve root sectioning. Illustrative case

BACKGROUND Sectioning the C2 nerve root is increasingly utilized during posterior C1–2 fusion, as the nerve overlies the entry point for C1 lateral mass screws and the C1–2 joint. Nerve sectioning improves visualization for screw placement and enables joint decortication for arthrodesis. While rare, vascular injury is a devastating complication of atlantoaxial fusion. Anomalous vascular anatomy at C1–2 greatly increases risk of iatrogenic injury. OBSERVATIONS A 78-year-old female with rheumatoid arthritis and prior C2–7 fusion presented with myelopathy from a compressive pannus at C1–2. She underwent C1 laminectomy and C1–2 posterior instrumented fusion. Intraoperatively, arterial bleeding occurred as the right C2 nerve root was sectioned. Vertebral artery injury was suspected, and tamponade was performed while vascular control was established. The artery passed aberrantly beneath the nerve root in the C1–2 foramen. It was repaired microsurgically, and patency was confirmed using indocyanine green. The remainder of the fusion was aborted. The patient wore a cervical collar and was treated with aspirin for 6 weeks before undergoing instrumented fusion. The patient suffered no deficits. LESSONS Although rare, anomalous vertebral artery anatomy increases risk of injury at time of C2 nerve root sectioning. Preoperative assessment of the vasculature is vital.

Emergency endovascular treatment using a Viabahn stent graft for upper and lower extremity arterial bleeding: a retrospective study

BackgroundA Viabahn stent graft (SG) is a heparin-coated self-expandable SG for lower extremity arterial disease that exhibits high flexibility and accuracy in the delivery system. This study aimed to evaluate the short-term efficacy and safety of emergency endovascular treatment (EVT) using a Viabahn SG for upper and lower extremity arterial bleeding (ULEAB).MethodsConsecutive patients with ULEAB who underwent emergency EVT using the Viabahn SG between January 2017 and August 2021 were retrospectively reviewed. The indications for EVT, location of artery, technical success, clinical success, limb ischemia, periprocedural complications, bleeding-related mortality, 30-day mortality, diameter of the target artery, diameter of the SG, neck length, re-bleeding, endoleaks, and patency of the SGs at 1, 3, 6, and 12 months were evaluated.ResultsEVT using Viabahn SG was performed in 22 patients (mean age: 72.0 years; 11 males) and 23 arteries (upper: 6, lower: 17). The indications for EVT were pseudoaneurysm (n=13, 59.1%), extravasation (n=9, 39.1%), and inadvertent arterial cannulation (n=1, 4.3%). The anatomical locations of the 23 ULEAB injuries were the brachiocephalic (1 [4.3%]), subclavian (3 [13.0%]), axillary (1 [4.3%]), brachial (1 [4.3%]), common iliac (4 [17.4%]), external iliac (8 [34.8%]), common femoral (2 [8.7%]), superficial femoral (2 [8.7%]), and popliteal (1 [4.3%]) arteries. The technical and clinical success rates were 100%. The rates of limb ischemia, periprocedural complications, and bleeding-related mortality were 0%, whereas the 30-day mortality rate was 22.7%. The mean diameters of the arteries and SGs were 7.7 and 8.9 mm, respectively. The mean neck length was 20.4 mm. No endoleaks or re-bleeding occurred during the follow-up period (mean: 169 days). Two SG occlusions without limb ischemia occurred in the external iliac artery and brachial artery after 1 and 4 months, respectively. Subsequently, cumulative SG patency was confirmed after 1, 3, 6, and 12 months in 91.7%, 91.7%, 81.5%, and 81.5% of patients, respectively.ConclusionsEmergency EVT using the Viabahn SG for ULEAB was effective and safe according to short-term outcomes. Appropriate size selection and neck length are important for successful treatment. SG patency was good after 1, 3, 6, and 12 months.

EP.FRI.680 “Avulsion of the Corona Mortis following low energy pubic rami fracture: a rare but life-threatening injury.”

We describe the case of an 81 year old gentleman who presented after a trivial fall with haemodynamic instability and worsening abdominal pain and swelling. An initial trauma CT identified superior and inferior pubic rami fractures associated with a large intra-pelvic collection. A subsequent CT angiogram confirmed a large pelvic haematoma with an active arterial bleeding from a ruptured vessel adjacent to the superior pubic rami fracture. This was managed by resuscitating him with fluids and blood transfusions followed by fluoroscopic guided Internal Iliac artery embolisation. The “Corona Mortis” is an aberrant arterial connection between the inferior epigastric artery and obturator artery and is prevalent in the hemipelvis of more than 49.3% of the population. Very rarely it can be damaged during low energy pubic rami fractures leading to haemodynamic compromise and potential death. For this reason and the fact there is a high chance that it could be missed, we wish to highlight this case, and management and emphasise the need to consider this life-threatening complication even in cases when the mechanism of injury may seem trivial.

The Efficacy of Chitosan Hemostatic Pad on Hemostatic Function in Patients Undergoing Cardiac Catheterization: A Systematic Review and Meta-Analysis

Background: Chitin is a nitrogen-containing polysaccharide that can promote wound healing and stop bleeding. This paper investigates the effects of the addition of a chitin hemostatic patch on the time to arterial hemostasis, bleeding time, and reduction of the risk of bleeding and hematoma in patients undergoing cardiac catheterization. Methods: Databases were searched for published clinical studies. The subjects were patients who received cardiac catheterization and had a chitin hemostatic patch added at the site of arterial puncture, while the control group received routine hemostatic treatment. The research quality was evaluated using the Cochrane risk-of-bias tool, version 2.0, and the meta-analysis was carried out using RevMan software. Results: After searching literature databases, five randomized controlled trials were retrieved and included in the meta-analysis. The results showed that adding a chitin hemostatic patch could shorten the time to arterial hemostasis in patients, who received cardiac catheterization (Std. Mean Difference, -0.58; P < .001). In the subgroup analysis, the grouped effect of the chitin hemostatic patch on the bleeding time showed that the bleeding time was not significantly shortened after adding a chitin hemostatic patch in patients in the experimental group (RR, 0.78). At the same time, this measure did not significantly reduce the risk of arterial bleeding (RR, 0.49) or hematoma (RR, 0.73). Conclusions: The results of the meta-analysis showed that adding a chitin hemostatic patch at the site of arterial puncture in patients undergoing cardiac catheterization significantly reduced the time to hemostasis, but did not significantly reduce the incidence of bleeding and hematoma.

Acute haemoperitoneum caused by endometriosis infiltrating the uterine artery - Two case reports and a literature review

Objective: We report 2 cases of haemoperitoneum due to a bleeding of the uterine artery caused by infiltrating endometriosis. We have also conducted a literature review on endometriosis-related intra-abdominal haemorrhage and wrote a practical guideline on how this entity can be recognized and handled. Patients: Case 1: A 49-year-old multiparous woman presented with intense stabbing pain in the lower abdomen during her menstruation. CT angiography showed a bleeding from a side branch of the internal iliac artery. Laparoscopy was performed and an active bleeding from the right uterine artery was confirmed, clearly caused by infiltrating endometriosis lesions. Haemostasis was achieved by bipolar coagulation. Case 2: A 29-year-old nulliparous woman was admitted for observation because of heavy stabbing pain in the right lower quadrant and presence of free fluid on CT abdomen. The day after the admission, laparoscopy was performed because of a decreasing haemoglobin level. An arterial bleeding from the right parametrium was observed, probably originating from the right uterine artery. Histopathological examination of a biopsy of the right parametrium proved the presence of endometriosis. Haemostasis was achieved by bipolar coagulation. Conclusion: Although endometriosis-related haemoperitoneum is a rare entity, this diagnosis should be considered when a patient presents with an intra-abdominal haemorrhage during menstruation or withdrawal bleeding - especially in case of a history or suspicion of endometriosis. Laparoscopy is the cornerstone of the treatment.