Catastrophic Hemorrhage Research Articles

Mini review on Artificial Blood Substitutes: Future perspective of Perfluorocarbon based oxygen carriers

The primary cause of death in the battle field and in civilian trauma is haemorrhagic shock. Around 50% combat deaths occur due to haemorrhage, depending on the severity of bleeding medical supervision can be provided like in catastrophic haemorrhage individual death occurs before providing the medical care and it is not a prehospital combat medical management problem during warfare scenario, even to transport wounded personnel to causality centre often takes 45 minutes to one hours. The hazardous nature of the forward combat areas and hostile operational environment frequently prevents medical personnel from quickly reaching the wounded even if the transport distances are small. Moreover, injuries with penetrating battlefield trauma often have only a "platinum 5 minutes." It is very important for military medical personnel to understand their options for treating haemorrhage quickly and efficiently during combat. Early intervention and definitive treatment could save up to 30% of soldier’s who die of action or of wounds. In view of this there is a requirement for the development of synthetic blood substitutes or oxygen therapeutic agents (OTA) in order to maintain the tissue oxygenation. Blood substitutes are the substances which mimic one of the physiological functions of the blood that is transportation of oxygen and carbon dioxide throughout the body. Blood substitutes or OTAs are being clinically tested as artificial oxygen carriers to improve tissue oxygenation and also to reduce allogenic blood transfusions. Two types of blood substitutes are reported so far: 1. Haemoglobin based oxygen carriers (HBOCs) and 2. Perfluorocarbon based oxygen carriers (PFOCs). PFOCs has huge advantages like universal compatibility, no requirement of cold storage, longer shelf life and no risk of infection transmission. These products have their own limitations and they have been withdrawn from international market for clinical use because of their side effects. It is a challenging task to the scientists to develop a safe, stable and biocompatible blood substitute for combat scenarios and also for civilian applications.

ACQUIRED HAEMOPHILIA A

Acquired haemophilia A (AHA) is a rare disease believed to be caused by spontaneous inhibition of clotting Factor VIII by autoantibodies. This is in contrast to the more common congenital haemophilias which are largely due to an absolute deficiency in coagulation factors. It has a prevalence of approximately one per million per year. However, this figure may be underestimated because there are many undocumented cases due to a lack of recognition. Patients who develop this disease may present with catastrophic bleeding despite having no previous bleeding history. In this study, we report a case of acquired Haemophilia A presenting with spontaneous unprovoked bruising and discuss the approach to diagnosis and how to alert the clinician to suspect this potentially rare but devastating disease.

How to avoid early mortality in acute promyelocytic leukemia.

Acute promyelocytic leukemia (APL), a phenotypically and genotypically unique subtype of acute myeloid leukemia, has seen unprecedented advances in its management since the introduction of all-trans retinoic acid (ATRA) and arsenic trioxide. However, the phenomenal pharmacologic conversion of this once highly fatal disease to one with a long-term survival exceeding 90% among patients who survive induction remains impaired by the significant incidence of early death (ED) reaching 30% in some real-world studies. The key driver for ED in APL is catastrophic hemorrhage with a proclivity for cranial sites. Most EDs in APL are currently considered preventable. Here, we discuss the concept of early death in APL and its characteristics. Importantly, we outline implementable strategies to reduce the incidence of ED. Early recognition of APL underpins these preventive measures as significant delays in the diagnosis increase the likelihood of ED. While early administration of ATRA is often taught to all hematology trainees, this lifesaving intervention is only possible if providers, including those in emergency departments and urgent/immediate care settings, are trained to have a high index of suspicion and competence to recognize the morphologic and clinical characteristics of the disease. Other proposed strategies tackle the complications that can be present at diagnosis or arise during induction therapy and address the issues of expert consultation and protocol adherence in the management of these patients. While some of these measures appear intuitive and others aspirational, widespread adoption could bring about an era of cure for almost every patient with APL.

Primary Hepatic Ectopic Pregnancy: Diagnosis and Laparoscopic Management

To demonstrate and discuss a case of primary hepatic ectopic pregnancy and laparoscopic management. Case presentation with demonstration of surgical hepatic wedge resection. Tertiary referral center in Manchester, United Kingdom. A 33-year-old women gravida 13 para 2 with a body mass index of 55 kg/m2 and previous 2 cesarean sections and a laparoscopic cholecystectomy presented to the emergency services after a private ultrasound scan showing a pregnancy of unknown location and a serum human chorionic gonadotropin (hCG) of 18 336 IU/mL. A diagnostic laparoscopy was performed but fallopian tubes were normal with no signs of ectopic pregnancy seen. An abdominal ultrasound scan was performed but did not identify the ectopic pregnancy. Owing to worsening symptoms of pain and rising hCG levels, she underwent a further laparoscopy converted to laparotomy and a left salpingo-oophorectomy for suspected left ovarian pregnancy. However, serum hCG levels continued to rise after the surgery, reaching 36 960 IU/mL. An magnetic resonance imaging scan of her abdomen and pelvis was arranged that showed a 4 cm cystic lesion in the segment V of the liver. Further ultrasound correlation showed a hyperechoic lesion with echogenic components suspicious of an ectopic pregnancy with a fetal pole. Fetal heart action was not visualized. A multidisciplinary team approach was adopted with involvement of the hepatobiliary surgical team, and the option of medical management with methotrexate and surgical excision was considered. A decision was made for surgical excision based on the accessible location of the ectopic pregnancy on segment V and the more controlled and predictable outcome with surgical excision. A preoperative computed tomography scan confirmed the lesion in segment V of liver in keeping with liver capsular implantation of ectopic pregnancy (Video still 1). At laparoscopy the ectopic pregnancy was visualized on the inferior surface of liver close to the inferior margin with a band of overlying omental adhesion (Video still 2). The overlying omental adhesions were sealed and cut with advanced bipolar diathermy, keeping a safe margin from the ectopic pregnancy to minimize any bleeding. The liver capsule was then opened with monopolar diathermy, and the small segment of liver with the ectopic pregnancy was excised using a combination of Bowa-Lotus liver blade (Bowa Medical Ltd). Hemostasis was controlled using Floseal hemostatic matrix and applied pressure laparoscopically. Total operating time was 80 minutes with an estimated blood loss of 500 mL. The patient was discharged on day 3 postoperatively, and follow-up serum hCG excluded residual trophoblastic disease. On review of the clinical case, earlier imaging of the upper abdomen when confronted by a persistent pregnancy of unknown location with high levels of serum hCG would have prevented the second laparoscopy, laparotomy, and salpingo-oophorectomy. In similar cases, it would also help exclude poorly differentiated malignancies as a source of serum hCG. Only 27 cases of ectopic pregnancy on the liver have been identified in English literature since 1952, based on a MEDLINE and Embase enquiry and further review of all case reports by the authors to avoid duplicates. Estimated incidence of hepatic implantation is 1 in 15 000 pregnancies; 4 case reports of laparoscopic liver resection have been identified and another case managed by suction from the liver surface [1,2]. The key principle demonstrated is to resect the ectopic pregnancy with a safe margin of liver tissue and any adhesions to avoid catastrophic bleeding from direct handling of the ectopic pregnancy.

Pseudoaneurysmal Rupture Associated with Pancreatitis Treated with Transarterial Embolization: A Case Series

Pancreatic pseudoaneurysm is a potentially life-threatening complication often associated with pancreatitis or pancreatic surgery. As the rupture of pancreatic pseudoaneurysms can lead to catastrophic bleeding and is associated with high mortality rates, clinical suspicion and early diagnosis are essential to improve patient outcomes. In the management of pseudoaneurysms, transarterial embolization (TAE) could be effective; however, there have been limited local studies on the outcomes of TAE for patients with pseudoaneurysm rupture associated with pancreatitis. Here, we describe patients who were diagnosed with pseudoaneruysm rupture associated with pancreatitis and treated with TAE.

Treatment of Ruptured Wide-Necked Aneurysms using a Microcatheter Injectable Biomaterial.

Ruptured wide-neck aneurysms (WNAs), especially in a setting of coagulopathy, are associated with significant morbidity and mortality. It is shown that by trapping a sub-millimeter clinical catheter inside the aneurysm sac using a flow diverter stent (FDS), instant hemostasis can be achieved by filling the aneurysm sac using a novel biomaterial, rescuing catastrophic bleeding in large-animal models. Multiple formulations of a biomaterial comprising gelatin, nanoclay (NC), and iohexol are developed, optimized, and extensively tested in vitro to select the lead candidate for further testing in vivo in murine, porcine, and canine models of WNAs, including in a subset with aneurysm rupture. The catheter-injectable and X-ray visible versions of the gel embolic agent (GEA) with the optimized mechanical properties outperform control groups, including a subset that receive a clinically used liquid embolic (Onyx, Medtronic), with and without aneurysm rupture. A combinatorial approach to ruptured WNAs with GEA and FDS may change the standard of medical practice and save lives.

S3039 Catastrophic Cystic Artery Bleeding With Ruptured Gallbladder in a Patient With Decompensated Alcohol-Related Cirrhosis and Asymptomatic Cholelithiasis

S3039 Catastrophic Cystic Artery Bleeding With Ruptured Gallbladder in a Patient With Decompensated Alcohol-Related Cirrhosis and Asymptomatic Cholelithiasis

Multidisciplinary management of invasive vertebral hemangioma: the role of different neurointervention modalities—a retrospective study

BackgroundCatastrophic intraoperative bleeding is a major complication of surgical removal of invasive vertebral hemangioma. Interventional neuroradiology techniques could be more useful tools to manage such hemorrhagic lesions.ResultsRetrospective analysis of cases of invasive vertebral hemangioma revealed 17 cases treated at the Alexandria University School of Medicine from 2006 to 2020. The study included 52.9% of males with a mean age of 38.4 ± 18.6 years old. All patients reported local and sometimes radicular pain; 64.7% exhibited progressive neurological deficits. Imaging revealed thoracic spine affection in 11 cases, lumbar vertebral in four cases, and cervical vertebra in two cases. Vertebral involvement occurred in 10 cases and paravertebral extension in 13 cases. Neurointervention modalities included transarterial embolization followed by corpectomy and fixation (one case with C4 lesion), direct surgery with corpectomy and anterior fixation (one case with C7 lesion), vertebroplasty alone (four cases), vertebroplasty with fixation (seven cases), and direct transpedicular alcohol injection with immediate devascularization and necrosis of the vascular channels inside the lesions (six cases). The alcohol injection use ranged from 4 to 10 ml in each pedicle. All patients did well during the follow-period post-intervention. The neurological deficits improved over six months. All patients showed improved Nurick grade regardless of the intervention (preoperative mean 2.7 ± 1.9 vs. postoperative mean 1.1 ± 1.3, p value 0.0001). Two patients were completely paraplegic, but with intact deep sensation, they improved dramatically and can walk unsupported post-intervention.ConclusionsVertebral hemangioma can present in an invasive manner that necessitates intervention. Preoperative embolization, alcohol injection, or vertebroplasty are helpful methods to decrease intraoperative catastrophic hemorrhage. Alcohol injection is cost-effective with immediate devascularization of the lesion. The extensive 360 surgery utilization can be decreased with the use of alcohol and vertebroplasty. More cases are needed to validate these conclusions.

Preeclampsia complicated with hypofibrinogenemia: 2 case reports and review of the literature

BackgroundPreeclampsia complicated with hypofibrinogenemia is a rare disorder. We report two cases of severe preeclampsia complicated with hypofibrinogenemia followed by postpartum haemorrhage (PPH).CaseTwo women diagnosed as preeclampsia and hypofibrinogenemia developed severe PPH after undergoing Cesarean sections. Besides supplement with fibrinogen concentrate and supportive treatment, the second patient got administration of heparin after delivery and bleeding was stopped. The haemorrhage in case 1 didn’t disappear until an hysterectomy. The two patients both recovered and were discharged soon.ConclusionsSevere preeclampsia patients with hypofibrinogenemia could suffer PPH. It’s necessary to detect and master coagulation function. Heparin could be considered to balance hypercoagulation and hypocoagulation to avoid catastrophic haemorrhage and hysterectomy.

O04 Segmental congenital haemangioma: a novel subtype of a rare vascular tumour

Abstract Congenital haemangiomas (CH) are rare vascular tumours present at birth. These high-flow vascular lesions can lead to significant morbidity secondary to high-output cardiac failure (HOCF) and Kasabach–Merritt phenomenon (KMP). They are classically round/oval lesions and present anywhere on the body. The majority involute spontaneously in the first 2 years of life. We describe three patients who presented with an unusual segmental pattern CH of the head/scalp: the first with a segmental CH of the left forehead, extending over the left eye with associated ipsilateral heterochromia and anisocoria; the second with a segmental ulcerated CH of the right scalp – catastrophic haemorrhage from the CH sadly resulted in death at age 6 weeks; the third with a left forehead segmental CH. None of the CH in this series developed HOCF or KMP. All lesions were consistent with CH on sonography and histology where available. Patients 1 and 3 exhibited spontaneous involution in the first 2 years of life. Segmental CH have been reported once before in a series of three patients, although involving the arm/trunk rather than the head. Two of the three patients developed KMP/HOCF. The genetic basis in this cohort was identical to that of classic nonsegmental CH, activating somatic mutations in GNAQ/11. The striking segmental pattern in our cohort is likely attributable to the timing of the somatic hit during development. Identification of this pattern in CH gives important insights into vascular tumorigenesis. Further cohort studies are needed to determine if this group has differing clinical outcomes from classical CH.

Use of super resolution reconstruction MRI for surgical planning in Placenta accreta spectrum disorder: Case series

IntroductionComprehensive imaging using ultrasound and MRI of placenta accreta spectrum (PAS) aims to prevent catastrophic haemorrhage and maternal death. Standard MRI of the placenta is limited by between-slice motion which can be mitigated by super-resolution reconstruction (SRR) MRI. We applied SRR in suspected PAS cases to determine its ability to enhance anatomical placental assessment and predict adverse maternal outcome. MethodsSuspected PAS patients (n = 22) underwent MRI at a gestational age (weeks + days) of (32+3±3+2, range (27+1-38+6)). SRR of the placental-myometrial-bladder interface involving rigid motion correction of acquired MRI slices combined with robust outlier detection to reconstruct an isotropic high-resolution volume, was achieved in twelve. 2D MRI or SRR images alone, and paired data were assessed by four radiologists in three review rounds. All radiologists were blinded to results of the ultrasound, original MR image reports, case outcomes, and PAS diagnosis. A Random Forest Classification model was used to highlight the most predictive pathological MRI markers for major obstetric haemorrhage (MOH), bladder adherence (BA), and placental attachment depth (PAD). ResultsAt delivery, four patients had placenta praevia with no abnormal attachment, two were clinically diagnosed with PAS, and six had histopathological PAS confirmation. Pathological MRI markers (T2-dark intraplacental bands, and loss of retroplacental T2-hypointense line) predicting MOH were more visible using SRR imaging (accuracy 0.73), in comparison to 2D MRI or paired imaging. Bladder wall interruption, predicting BA, was only easily detected by paired imaging (accuracy 0.72). Better detection of certain pathological markers predicting PAD was found using 2D MRI (placental bulge and myometrial thinning (accuracy 0.81)), and SRR (loss of retroplacental T2-hypointense line (accuracy 0.82)). DiscussionThe addition of SRR to 2D MRI potentially improved anatomical assessment of certain pathological MRI markers of abnormal placentation that predict maternal morbidity which may benefit surgical planning.

Unscarred uterine rupture with catastrophic hemorrhage immediately after vaginal delivery: diagnosis and management of six consecutive cases

Background To describe and explore the risk factors, clinical presentations, timely diagnostic approaches, and management in patients experiencing unscarred uterine rupture with catastrophic hemorrhage. Methods We retrospectively analyzed clinical and imaging data from women who encountered postpartum hemorrhage (PPH) and were diagnosed with unscarred uterine rupture within a three-year timeframe (2018-2020). The data were extracted from medical records obtained from a multi-hospital 24-hour emergency PPH transfer system. Results Six patients were identified as having unscarred uterine rupture after vaginal delivery. All six women were para 2, with four of them undergoing vacuum-assisted delivery. One patient experienced out-of-hospital cardiac arrest (OHCA), while five patients presented with hypovolemic shock. Abdominopelvic ultrasound revealed a boggy lower uterine segment. Initially, five patients underwent transarterial embolization (TAE) of the internal iliac arteries in an attempt to achieve hemostasis, but this approach proved unsuccessful. Abdominopelvic computed tomography (CT) confirmed the diagnosis of ruptured uterus by demonstrating disrupted myometrium and hemoperitoneum. Immediate exploratory laparotomy followed by life-saving hysterectomy was performed in all cases. The median estimated total blood loss was 2725 mL ± 900 mL (ranging from 1600 mL to 7100 mL). Lower segment lacerations were observed in all patients, with more extensive uterine damage noted in those who underwent vacuum extraction. The length of hospital stay varied between 9 and 38 days. Conclusion Instrument-assisted obstetric delivery is a possible contributing factor to unscarred uterine rupture in our study. In specific cases, the use of abdominopelvic CT prior to initiating transarterial embolization (TAE) offers valuable information to complement ultrasound findings. This comprehensive approach helps in accurately identifying the underlying cause of intractable postpartum hemorrhage (PPH). Immediate conversion to laparotomy is essential to explore the intra-abdominal factors causing PPH that cannot be controlled by TAE. The rational etiologies of uterine rupture must be clarified while generating practical guideline in the future.

Addressing Portal Hypertension: Exploring the Crucial Role of Partial Splenic Embolization in Critical Situations

Background: Esophageal varices are one of the most common symptoms of direct outcomes of portal hypertension besides ascites, hepatorenal syndrome, and hypersplenism. Nonselective beta-blockers or band ligation are currently the effective primary preventive options for variceal hemorrhage. The use of partial splenic arterial embolization for the management of variceal hemorrhage in patients with portal hypertension has been described in a small number of reports. Case Report: A girl, 6 y.o., was hospitalized with hematemesis with hypovolemic shock. Laboratory findings show anemia and thrombocytopenia. Radiology and endoscopy show grade III esophageal varices with hepatosplenomegaly. Because of the high risk of morbidity in surgical procedures, partial splenic embolization was performed to treat portal hypertension. Discussion: The combination of varices and a low platelet count puts these patients at high risk for catastrophic hemorrhage. Partial splenic embolization reduces splenic blood volume, resulting in a decrease in venous drainage and a reduction in portal venous flow and pressure. Conclusion: The use of partial splenic arterial embolization to manage variceal hemorrhage in patients with portal hypertension has been described. Embolization can be used alone or in combination with other therapies, like endoscopic ligation or retrograde transvenous variceal obliteration, to treat a variety of conditions. Keywords: Embolization, esophageal varices, splenomegaly, portal hypertension

A Retrospective, Long-term Follow-up of the Clinical Outcomes and Cost-effectiveness of Single-anesthetic Multiple Total Joint Procedures in Hemophilic Arthropathy.

Although total joint replacement (TJR) procedures are efficacious, perioperative high-dose factors replacement therapy (FRT) to avoid catastrophic bleeding represents a significant hurdle, particularly for patients with multiple joint affection. Double simultaneous bilateral TJRs were reported as safe and cost-effective. However, little is known about multiple TJRs. The feasibility and effects remain debatable. Surgeons need to weigh the high cost of FRT against safety. Accordingly, we aimed to evaluate the clinical outcomes and cost-effectiveness of single-anesthetic multiple-joint procedures of lower limbs in end-stage hemophilic arthropathy. Our retrospective cohort study retrieved data from an inpatient database of patients with hemophilia who underwent total knee arthroplasty (TKA), total hip arthroplasty (THA), and/or ankle arthrodesis from January 2000 to April 2016. Complications, hospital stays, transfusion, doses of clotting factor, medical costs, range of motion (ROM), Harris hip scores (HHSs) and Hospital for special surgery knee scores (HSSs) were recorded. A P value < 0.05 was considered significant. A total number of 81 patients were included in this study, among which 89 TKAs and 52 THAs were performed. Compared to the single TJR group, the simultaneous multiple TJR group showed a significantly higher rate of blood transfusions (P < 0.05). But no significant differences were found in the length of hospital stays, factor consumption, hospitalization costs excluding prosthesis expenses, and total complication rates. Finally, similar postoperative ROM, HHS, and HSS were witnessed in two groups (P value > 0.05). Our data indicated that simultaneous multiple TJRs are a safe and cost-effective choice for treating hemophilic patients with multiple HA-affected lower limb joints.

Endoscopic Repair of Internal Carotid Artery Injury with a Lateral Tongue Muscle Patch Graft: Novel Technique and Literature Review.

Objectives Iatrogenic injury to the internal carotid artery (ICA) is one of the most catastrophic complications of endoscopic sinus and skull base surgery. Previous research has shown that packing with a crushed muscle graft at the injury site can be an effective management technique to control bleeding and prevent the need for ICA sacrifice. Here, we describe a novel and readily available repair donor site-an autologous lateral tongue muscle patch. Design Three representative cases of a successful repair of ICA injuries using a lateral tongue muscle patch are included in this study. The graft measured approximately 2 × 3 cm and was taken from the lateral intrinsic tongue musculature. We describe the harvest of the graft, its advantages, and the details of operative repair. Results The lateral tongue provides a large and readily accessible source of muscle within the surgical field that can be quickly harvested during an endoscopic procedure. For the first case, an expanding parasellar ICA pseudoaneurysm was managed with a tongue muscle patch and nasal packing. In the second case, a cavernous ICA injury was sustained during craniopharyngioma resection. Case three involved an ICA injury during endonasal debridement of invasive fungal rhinosinusitis. None of the patients required embolization or neurovascular stenting. Postoperative angiograms and serial computed tomography angiograms showed complete resolution of the pseudoaneurysm, and the patients continued to do well at least 1 year after repair. Conclusion Lateral tongue muscle graft is an effective and efficient method to manage ICA injuries during endoscopic endonasal surgery. Advantages include the speed of harvest, donor site being readily accessible in the surgical field, and low donor site morbidity. It should be added to the repertoire of possible donor sites for addressing catastrophic sinonasal bleeding.

An Unexpected Cause of Catastrophic Bleeding During Juvenile Nasopahryngeal Angiofibroma Excision.

We describe the first case of juvenile nasopharyngeal angiofibroma receiving blood supply from caroticotympanic artery which resulted in catastrophic bleeding intraoperatively. The patient was an 12-year-old boy with a Radkowski stage 3B JNA. We utilized preoperative embolization of feeders from external carotid artery though the surgeon failed to excise the tumor completely due to uncontrollable bleeding from the tumor. On retrospective analysis of angiography only the culprit feeder found. Tumor was excised in the second surgery conducted a week later. Although selective embolization of ICA branches are described in literature the data are sparse and so is the management of such cases.

Sinus pericranii in the setting of a posterior fossa pilocytic astrocytoma: illustrative case.

Sinus pericranii (SP) is a rare vascular anomaly, with an uncertain etiology. Often discovered as superficial lesions, they can be primary or secondary in nature. Herein, we report a rare case of SP in the setting of a large posterior fossa pilocytic astrocytoma associated with a significant venous network. A 12-year-old male presented with acute clinical deterioration in extremis with a 2-month history of lethargy and headaches. Outside plain computed tomography imaging revealed a large posterior fossa cystic lesion, probably a tumor, with severe hydrocephalus. There was also a midline small skull defect at the opisthocranion, without visible vascular anomalies. An external ventricular drain was placed with rapid recovery. Contrast imaging revealed a large midline SP emanating from occipital bone with a large intraosseous, and subcutaneous venous plexus in the midline draining inferiorly into venous plexus around the craniocervical junction. A posterior fossa craniotomy without contrast imaging could have resulted in catastrophic hemorrhage. A small modified off-center craniotomy provided access to the tumor with a gross total excision. SP is a rare but significant phenomenon. Its presence does not necessarily preclude resection of underlying tumors, provided that a careful preoperative assessment of the venous anomaly is undertaken.

Laparoscopic Hepatectomy for Giant Hepatic Hemangioma Using the Involved Intrahepatic Anatomic Markers Approach

BackgroundHepatic hemangioma has been one of the absolute indications of laparoscopic hepatectomy (LH).1 However, the risk of catastrophic intraoperative bleeding and the difficulty to control it make the laparoscopic treatment of giant hepatic hemangioma (GHH) a technical challenge for hepatobiliary surgeons.2 Herein, we presented a video of LH for GHH using the involved intrahepatic anatomic markers approach. MethodsA 22-year-old female was referred for treatment of an intractable GHH (18 cm), which involved the left hepatic pedicle, left hepatic vein (LHV), and middle hepatic vein (MHV), resulting in the invisibility of the above intrahepatic anatomic markers on CT. The procedure was performed according to the following steps: (1) dissecting and ligating the left hepatic artery (LHA) and left portal vein (LPV) via intrafascial approach, respectively; (2) cutting the accessory LHA; (3) transecting parenchymal along the demarcation line in a caudal-to-cranial direction and exposing the involved caudal middle hepatic vein (MHV); (4) isolating and transecting the involved left hepatic duct; (5) preserving the integrity of involved MHV; (6) isolating and transecting the left hepatic vein (LHV) and splenic vein (SV); (7) mincing and extracting the specimen. This study was approved by the West China Hospital Ethics Committee and was conducted in accordance with the ethical guidelines of the Declaration of Helsinki. All treatments were performed after obtaining written informed consent from the patients. ResultsThe operative time was 286 min, and blood loss during operation was 160 ml. This procedure ensured the integrity of MHV and maximized the residual functional hepatic volume. The histopathologic examination confirmed the hepatic cavernous hemangioma. The patient had an uneventful postoperative recovery and was discharged on the fifth day after operation. ConclusionLH using the involved intrahepatic anatomic markers approach is feasible and effective for intractable GHH. Its advantages lie in decreasing the risk of disastrous hemorrhage or open conversion rate while maximizing the postoperative functional hepatic reserve.3

Interstitial Ectopic Pregnancy: Laparoscopic Cornuostomy

To demonstrate and discuss the technique of cornuostomy for surgical management of interstitial ectopic pregnancy. Stepwise demonstration of the technique with narrated video footage. Tertiary referral center in Manchester, United Kingdom. Interstitial ectopic pregnancies are rare but are associated with a higher mortality rate than other ectopic pregnancies [1,2]. It occurs when the fertilized embryo implants in the interstitial portion of the fallopian tube traversing the vascularized myometrium. When undiagnosed they present late in the second trimester associated with rupture and catastrophic bleeding, with a mortality rate of 2% to 2.5%.2 Diagnosis requires a degree of vigilance from the ultrasound operator because it is commonly misdiagnosed as intrauterine pregnancies. Surgical management options include laparoscopic cornual resection or cornuostomy. There is no consensus on the optimal surgical technique but cornuostomy is a more conservative approach associated with less disruption to uterine anatomy and loss of myometrium [3,4]. A 22-year-old gravida 4 woman presented at 7 weeks' gestation with right iliac fossa pain. Initial serum human chorionic gonadotropin was 18136 IU/L. Transvaginal ultrasound scan showed an empty endometrial cavity and an echogenic "donut"-shaped mass within the right interstitial space, within the uterine serosa but outside the endometrial cavity (Supplemental Video 1). At laparoscopy the diagnosis of a right interstitial ectopic pregnancy was confirmed (Supplemental Video 2). Vasopressin 20 IU diluted in 80 mL of normal saline was injected around the base of the ectopic pregnancy. Monopolar diathermy was used to incise the overlying serosa followed by hydrodissection to separate the ectopic gestational sac from the myometrial attachment. The resulting defect was inspected and closed in 2 layers. Total operating time was 46 minutes. Although there is no clear evidence to guide the management of all interstitial ectopic pregnancies, an individualized approach taking into account the woman's previous history and future fertility plans and wishes is essential. In this case, given the woman's previous contralateral salpingectomy and her wishes for a conservative approach, a laparoscopic cornuostomy was likely the best option.

Abstract Number ‐ 121: Flow Diversion Jet: A Dangerous Mechanism in the Flow Diversion Treatment of Giant Intracranial Aneurysms

Introduction We present a patient with a giant vertebrobasilar system aneurysm. This case provides an in‐depth analysis of the pathologic mechanism resulting in catastrophic distal hemorrhage following stent deployment due to the shared effects of normal perfusion pressure breakthrough (NPPB) and the Windkessel phenomenon. The Windkessel phenomenon and NPPB occur before and after treatment of various vascular malformations, respectively. These phenomena are hypothesized to contribute to the loss of cerebrovascular autoregulation. High flow lesions and giant aneurysms reduce blood flow in downstream vessels, causing chronic distal vasodilation to protect against ischemia. Sudden restoration of normal pulsatile flow, following treatment, compromises the integrity of distal vessels leading to potential catastrophic intracerebral hemorrhage. Methods A retrospective review of the patient’s medical record was performed. Results A 60‐year‐old female initially presenting with pulsatile neck mass was found to have dolichoectasia of the right cervical internal carotid artery and two large, irregular, vertebrobasilar aneurysms. Managed conservatively for 10 years before developing gait ataxia, new imaging revealed growth of the now giant, more distal aneurysm. Flow diversion with partial coiling of the aneurysms was pursued. Following deployment, DynaCT demonstrated catastrophic thalamic and midbrain hemorrhage with intraventricular extension. A review of intra‐aneurysmal pressure measurements, angiography, MRI, and neuromonitoring data strongly suggests rupture of multiple deep perforators following the conversion to laminar flow when the flow diverting chain was finalized. This suggests giant aneurysms chronically depress the distal pulse pressure by acting as a Windkessel reservoir. Flow diversion bypasses the reservoir increasing pulse pressure distal to the aneurysm, exceeding autoregulatory capacity, leading to hemorrhage. Conclusions This is the first case in the literature to describe NPPB and the Windkessel phenomenon in the attempt to treat giant aneurysms with flow diversion. Flow diversion bypasses the reservoir, suddenly changing turbulent flow to laminar flow. The resultant dramatic rise in pulse pressure distal to the aneurysm can exceed the autoregulatory mechanisms of small distal vessels such as perforating branches. While demonstrating a poor outcome, awareness of these mechanisms and meticulous intra‐operative blood pressure management may reduce or prevent complications. Further modeling of flow dynamics both before and following treatment of these aneurysms may lead to altered guidelines in the temporality of treatment due to potential catastrophic sequelae.