Immediate Cessation Of Bleeding Research Articles

S3609 Dieulafoy’s Lesion: An Unforeseen Catastrophe

Introduction: A Dieulafoy's lesion is a large tortuous arteriole that can cause life-threatening hemorrhagic shock, occurring in 1-2% of cases of upper gastrointestinal bleeding. It is an underdiagnosed cause of obscure massive hematemesis because its small size and location makes it difficult to visualize. Case Description/Methods: An 84-year-old white male with atrial fibrillation, on apixaban, presented for large-volume hematemesis. Physical examination revealed blood pressure of 80/60 mmHg, pulse of 110 beats/minute, orthostasis, temperature of 36.9°C, and an ill-appearing individual with a diffusely tender abdomen. Laboratory examination revealed leukocytes of 19.9 bil/L (normal: 3.5-10.1 bil/L), hemoglobin of 11.2 g/dL (normal: 13.5-17 g/dL) which dropped to 7.5 g/dL in 2 hours. Computed tomography of the abdomen and pelvis without contrast demonstrated diffusely distended stomach with internal debris concerning for blood products. He was intubated for airway protection and transfused 1-unit of packed-erythrocytes. Intravenous pantoprazole and norepinephrine were administered, and he was transferred to the medical intensive care unit. He was also incidentally found to have coronavirus disease (COVID-19). With precautions taken for COVID-19 infection, he underwent emergent esophogastroduodenoscopy revealing a bleeding vessel, Dieulafoy's lesion, proximal to the gastroesophageal (GE) junction (Figure 1) with a huge amount of clotted blood at the gastric fundus and body. The vessel was injected with 3 mL of epinephrine and two clips were placed achieving hemostasis. The next day, the patient's blood pressures improved, his hemoglobin stabilized to 9.2 g/dL and he was extubated. Discussion: A Dieulafoy's lesion is commonly located in the stomach, with majority found proximal to the GE junction however it can be hidden in the gastric mucosal folds. Treatment includes heat probe coagulation, epinephrine injection or banding. Our case demonstrates that rare diagnoses such as a Dieulafoy's lesion should be considered in the differential diagnosis in patients presenting with hematemesis as timely endoscopic treatment can often result in immediate cessation of bleeding. When the bleeding vessel cannot be located, these patients are often referred for angiography.

Traumatic Hemothorax Caused by Thoracic Wall and Intrathoracic Injuries: Clinical Outcomes of Transcatheter Systemic Artery Embolization.

PurposeWe aimed to assess the clinical efficacy of transcatheter arterial embolization (TAE) for treating hemothorax caused by chest trauma.Materials and MethodsBetween 2015 and 2019, 68 patients (56 male; mean age, 58.2 years) were transferred to our interventional unit for selective TAE to treat thoracic bleeding. We retrospectively investigated their demographics, angiographic findings, embolization techniques, technical and clinical success rates, and complications.ResultsBleeding occurred mostly from the intercostal arteries (50%) and the internal mammary arteries (29.5%). Except one patient, TAE achieved technical success, defined as the immediate cessation of bleeding, in all the other patients. Four patients successfully underwent repeated TAE for delayed bleeding or increasing hematoma after the initial TAE. The clinical success rate, defined as no need for thoracotomy for hemostasis after TAE, was 92.6%. Five patients underwent post-embolization thoracotomy for hemostasis. No patient developed major TAE-related complications, such as cerebral infarction or quadriplegia.ConclusionTAE is a safe, effective and minimally invasive method for controlling thoracic wall and intrathoracic systemic arterial hemorrhage after thoracic trauma. TAE may be considered for patients with hemothorax without other concomitant injuries which require emergency surgery, or those who undergoing emergency TAE for abdominal or pelvic hemostasis.

Tu1512 ASSESSING THE UTILIZATION AND EFFICACY OF HEMOSTATIC POWDER IN TREATING NON-VARICEAL GASTROINTESTINAL HEMORRHAGES

In 2018, the FDA approved hemostatic powder as a therapeutic instrument to treat non-variceal gastrointestinal bleeding. Since this treatment modality has now been in use for approximately 12 months in the US we evaluated several aspects of its application, such as pattern of utilization, efficacy, trends in hemostasis techniques and patient outcomes. To assess the last 12 months of hemostatic powder utilization, and determine its efficacy of treating non-variceal gastrointestinal hemorrhages as compared to the current hemostatic modalities used in endoscopic procedures at a tertiary medical center. In a retrospective review of our endoscopic procedural database we identified 251 cases of suspected upper gastro-intestinal bleeding (UGIB) between 11/2018 and 11/2019. Cases with confirmed malignancies and those with low risk lesions that did not require endoscopic intervention were excluded. We collected data on immediate cessation of bleeding, as well as re-bleed rates at 24 hours and 7 days after procedure. Etiology was also noted, with Forrest classifications being attributed to peptic ulcers. We identified 74 patients with UGIB requiring endotherapy. Of those cases, hemostatic powder was applied in 23 (31%); in 17 (73%) as an upfront intervention prior to other therapies or as a single modality, and 6 (27%) in combination following other hemostatic interventions (epinephrine injection, hemostatic clips, thermal probe, and over-the-scope clips). Cases in which hemostatic powder was used had a 95.6% success rate of immediate hemostasis. This was not significantly different then in those when hemostatic powder was not used (95% success rate; N.S). There was a significant decrease in 7 day rebleed rates in the hemostatic powder group (26 vs 33%; p<0.05). Peptic ulcers accounted for 52.7% of the UGIB cases seen with intervention. Within that group, hemostatic powder application carried an immediate success rate of 90.9%, and a within 7-day rebleed rate of 18.1%; whereas UGIB cases without hemostatic powder intervention carried rates of 96.4% and 28.5% respectively (p<0.05). Our study shows that hemostatic powder is being used in close to 1/3 of high risk GI bleeding cases. Although in cases when hemostatic powder was used the immediate hemostasis was not different than in other cases, we did demonstrate a lower rebleed rate in benign non-variceal upper GI bleeds.

Abstract No. 667 Transcatheter arterial embolization for traumatic thoracic bleeding: 4-year experiences in a single trauma center

We aimed to assess the safety and efficacy of transcatheter arterial embolization (TAE) for thoracic arterial hemorrhage following chest trauma. From November 2013 to May 2017, 35 patients were referred to our interventional unit for thoracic arterial bleeding following chest trauma, based on clinical decisions and computed tomography (CT) images. A total of 35 patients (male:female ratio, 26:9; mean age, 52.9 years) who underwent selective TAE of thoracic hemorrhage-culprit arteries were included in this study. Technical and clinical success, complications, and 30-day mortality rate were analyzed. In 35 patients who underwent TAE, the main bleeding arteries were intercostal artery (n=23), internal mammary artery (n=11) superior and/or lateral thoracic artery (n=3), and bronchial artery (n=3). N-butyl-2-cyanoacrylate (NBCA) (n=21), gelatin sponge particles (n=7), microcoils (n=2), and combinations of NBCA, microcoils, or gelatin sponge particles (n=10) were used as embolic agents. Initial technical success was achieved in all 27 patients, with immediate cessation of bleeding. Eight patients showed rebleeding 1-2 days later and underwent repeated TAE with successful result. Clinical success rate was 85.7% (30/35), and five patients underwent thoracotomy for controlling residual bleed. There were no TAE-related major complications such as infarction or quadriplegia. The 30-day mortality rate was 5.7% (2/35). Our clinical experience suggests that TAE used to control thoracic arterial bleeding following chest trauma is safe and effective as a minimally invasive treatment alternative to surgery.

Use of self-expanding metal stents for difficult variceal bleed.

Patients with variceal band ligation (VBL)-induced ulcer bleeding and those with persisting bleeding in spite of VBL carry a high mortality. Balloon tamponade and transjugular intrahepatic portosystemic shunt have limitations in terms of complications, cost, and availability. The aim was to evaluate the efficacy of Sx-Ella Danis stent in persistent or complicated variceal bleeding. Twelve patients with either persistent variceal bleeding or VBL-induced ulcer bleeding were treated with the placement of Sx-Ella Danis stents. The patients were followed up for mortality, complications, and efficacy to control bleeding. Stents were inserted successfully in all 12 patients (with immediate hemostasis). There was an immediate cessation of bleeding in all 12 patients with no stent-related complication. Five out of 12 patients died during 30days post-procedure due to worsening encephalopathy or sepsis. Enteral feeding could be started in all 12 patients 6h after stent placement. One patient had bleeding 10days after stent removal and was re-stented but expired 7days later. Stents were removed in eight patients at a mean duration of 17.5days. (range 7 to 30days). Sx-Ella Danis stent is a useful modality to control persistent variceal bleeding as well VBL-related ulcer bleeding.

Transcatheter arterial embolization for traumatic mesenteric bleeding: a 15-year, single-center experience.

We aimed to assess the safety and effectiveness of transcatheter arterial embolization (TAE) for mesenteric bleeding following trauma. From 2001 to 2015, 12 patients were referred to our interventional unit for mesenteric bleeding following trauma, based on clinical decisions and computed tomography (CT) images. After excluding one patient with no bleeding focus and one patient who underwent emergency surgery, a total of 10 patients (male:female ratio, 9:1; mean age, 52.1 years) who underwent super selective TAE of visceral arteries were included in this study. Technical and clinical success, complications, and 30-day mortality rate were analyzed. In 10 patients who underwent TAE, the types of trauma were motor vehicle collision (n=6), fall (n=2), assault (n=1), and penetrating injury (n=1), and the bleeding arteries were in the pancreaticoduodenal arterial arcade (n=4), jejunal artery (n=3), colic artery (n=2), and sigmoid artery (n=1). N-butyl-2-cyanoacrylate (NBCA) (n=2), microcoils (n=2), and combinations of NBCA, microcoils, or gelatin sponge particles (n=6) were used as embolic agents. Technical success was achieved in all 10 patients, with immediate cessation of bleeding. Clinical success rate was 90% (9/10), and all patients were discharged with no further treatment required for mesenteric bleeding. However, one patient showed rebleeding 10 days later and underwent repeated TAE with successful result. There were no TAE-related ischemic complications such as bowel infarction. The 30-day mortality rate was 0%. Our clinical experience suggests that TAE used to control mesenteric bleeding following trauma is safe and effective as a minimally invasive alternative to surgery.

Tactile Electrosurgical Ablation: A Technique for the Treatment of Intractable Heavy and Prolonged Menstrual Bleeding

Objective. To study the efficacy and safety of tactile electrosurgical ablation (TEA) in stopping a persistent attack of abnormal uterine bleeding not responding to medical and hormonal therapy. Methods. This is a case series of 19 cases with intractable abnormal uterine bleeding, who underwent TEA at the Women's Health Center of Assiut University. The outcomes measured were; patient's acceptability, operative time, complications, menstrual outcomes, and reintervention. Results. None of the 19 counseled cases refused the TEA procedure which took 6–10 minutes without intraoperative complications. The procedure was successful in the immediate cessation of bleeding in 18 out of 19 cases. During the 24-month follow-up period, 9 cases developed amenorrhea, 5 had scanty menstrual bleeding, 3 were regularly menstruating, 1 case underwent repeat TEA ablation, and one underwent a hysterectomy. Conclusions. TEA represents a safe, inexpensive, and successful method for management of uterine bleeding emergencies with additional long-term beneficial effects. However, more studies with more cases and longer follow-up periods are warranted.

Review of in vivo studies of dimethyl sulfoxide cryopreserved platelets.

A literature review was conducted to assess the efficacy and safety of dimethyl sulfoxide (DMSO) cryopreserved platelets for potential military use. In vivo DMSO cryopreserved platelet studies published between 1972 and June of 2013 were reviewed. Assessed were the methods of cryopreservation, posttransfusion platelet responses, prevention or control of bleeding, and adverse events. Using the Department of Defense's preferred 6% DMSO cryopreservation method with centrifugation to remove the DMSO plasma before freezing at -65°C and no postthaw wash, mean radiolabeled platelet recoveries in 32 normal subjects were 33% ± 10% (52% ± 12% of the same subject's fresh platelet recoveries), and survivals were 7.5 ± 1.2 days (89% ± 15% of fresh platelet survivals). Using a variety of methods to freeze autologous platelets from 178 normal subjects, mean radiolabeled platelet recoveries were consistently 39% ± 9%, and survivals, 7.4 ± 1.4 days. More than 3000 cryopreserved platelet transfusions were given to 1334 patients. There were 19 hematology/oncology patient studies, and, in 9, mean 1-hour corrected count increments were 11 100 ± 3600 (range, 5700-15 800) after cryopreserved autologous platelet transfusions. In 5 studies, bleeding times improved after transfusion; in 3, there was either no improvement or a variable response. In 4 studies, there was immediate cessation of bleeding after transfusion; in 3 studies, patients being supported only with cryopreserved platelets had no bleeding. In 1 cardiopulmonary bypass study, cryopreserved platelets resulted in significantly less bleeding vs standard platelets. In 3 trauma studies, cryopreserved platelets were hemostatically effective. No significant adverse events were reported in any study. In summary, cryopreserved platelets have platelet recoveries that are about half of fresh platelets, but survivals are only minimally reduced. The platelets appear hemostatically effective and have no significant adverse events.

The efficacy of selective arterial embolization in the management of colonic bleeding

The aim of the present study was to determine the efficacy of mesenteric embolization in the management of acute haemorrhage from the colon. A retrospective review was performed of a consecutive series of patients who underwent selective arterial embolization between 2002 and 2010 at two Australian institutions. An analysis was performed of each patient's present and past medical history, procedural details and subsequent post-procedural recovery. Seventy-one patients were reviewed in the study. Sixty-one patients (86%) had immediate cessation of bleeding following embolization. In total, 20% had some form of morbidity due to mesenteric embolization being performed, the three most common being worsening renal function, groin haematoma and contrast allergy (11, 9 and 7%, respectively). Only one patient developed superficial bowel ischaemia. Overall, 11 patients (18%) had recurrent bleeding. Of these patients, five had repeat embolization. Of the patients who underwent re-embolization, three stopped bleeding. Surgery was required in 5 patients 2 of whom died postoperatively of systemic complications. Colonic bleeding can be treated successfully in most patients by embolization, without causing ischaemia. Eighteen per cent of patients rebleed during the first hospital admission, and 20% patients experienced a procedure-related complication. In those patients that proceed to surgery, the morbidity, mortality and length of hospital stay increase dramatically.

Complementary effect of fibrinogen and rFVIIa on clotting ex vivo in Bernard-Soulier syndrome and combined use during three deliveries

Women with Bernard-Soulier syndrome (BSS) are considered to be at high risk of serious bleeding during childbirth. Due to the frequently occurring platelet transfusion refractoriness, alternative prophylactic therapy is required. Using rotational thromboelastometry, we evaluated the whole blood coagulation profile of a pregnant woman with BSS before and after spiking ex vivo with different concentrations of recombinant activated factor VII (rFVIIa) and fibrinogen. As experiments suggested improved clotting with clinically applicable concentrations of both agents in a complementary manner, the findings were confirmed on blood from a non-pregnant woman and three men suffering from BSS. During delivery, bleeding refractory to platelets occurred and immediately following delivery she received both rFVIIa and fibrinogen intravenously. Immediate cessation of bleeding occurred, and no postpartum hemorrhage was seen. Another woman with BSS later also received the same rFVIIa and fibrinogen treatment prophylactically after delivery without any postpartum bleeding. Eventually, the first woman during her second delivery received the same treatment again prophylactically without any bleeding. No side effects were observed during these three deliveries. Our observations suggest that rFVIIa combined with fibrinogen may provide a beneficial clinical hemostatic effect partly by separate but complementary mechanisms.

Treatment of Nonvariceal Gastrointestinal Hemorrhage by Transcatheter Embolization

Purpose. To investigate the sensitivity of mesenteric angiography, technical success of hemostasis, clinical success rate, and complications of transcatheter embolization for the treatment of acute nonvariceal gastrointestinal hemorrhage. Material and Methods. A retrospective review of 200 consecutive patients who underwent mesenteric arteriography for acute nonvariceal gastrointestinal hemorrhage between February 2004 and February 2011 was done. Results. Of 200 angiographic studies, 114 correctly revealed the bleeding site with mesenteric angiography. 47 (41%) patients had upper gastrointestinal hemorrhage and 67 (59%) patients had lower gastrointestinal hemorrhage. Out of these 114, in 112 patients (98%) technical success was achieved with immediate cessation of bleeding. 81 patients could be followed for one month. Clinical success was achieved in 72 out of these 81 patients (89%). Seven patients rebled. 2 patients developed bowel ischemia. Four patients underwent surgery for bowel ischemia or rebleeding. Conclusion. The use of therapeutic transcatheter embolization for treatment of acute gastrointestinal hemorrhage is highly successful and relatively safe with 98% technical success and 2.4% postembolization ischemia in our series. In 89% of cases it was definitive without any further intervention.

Hepatic arterial embolization for massive bleeding from an intrahepatic artery pseudoaneurysm using N-butyl-2-cyanoacrylate after living donor liver transplantation

Parenchymal pseudoaneurysm of the hepatic arteries with massive intraperitoneal bleeding is rare but a serious life-threatening complication when it occurs following liver transplantation. We report a case of an adult postliving donor liver transplant recipient who developed massive subcapsular bleeding combined with massive right pleural effusion from ruptured multiple small intrahepatic arteries, which developed from a pseudoaneurysm that was treated by hepatic arterial embolization. Successful embolization was performed via a percutaneous trans-catheter approach by depositing 20-25%N-butyl-2-cyanoacrylate (NBCA) through the multiple small intrahepatic arteries into the pseudoaneurysm. Complete occlusion of the feeding arteries and pseudoaneurysm cavity resulted to immediate cessation of bleeding. There was no re-bleeding; and normal liver graft function was noted postembolization. Hepatic arterial embolization with NBCA can be used as treatment for postliver transplant peripheral intrahepatic artery pseudoaneurysm bleeding.

Mesenteric Embolization for Lower Gastrointestinal Bleeding

Mesenteric embolization is an established treatment for lower gastrointestinal bleeding. The aim of this study was to determine the outcome of angiography and embolization and its influencing factors. A prospective database of all mesenteric angiograms performed for lower gastrointestinal bleeding at a tertiary center between 1998 and 2008 was analyzed in combination with chart review. There were 107 angiograms performed during 83 episodes of lower gastrointestinal bleeding in 78 patients. Active bleeding was identified in 40 episodes (48%), and embolizations were performed in 37 (45%). One patient without active bleeding on angiogram also underwent embolization, making a total of 38 embolizations. Overall mortality was 7% with 4 deaths due to rebleeding and 2 deaths due to a medical comorbidity (respiratory failure, pneumonia). Short-term complications of angiography were false aneurysm (1 patient) and Enterobacter sepsis (1 patient). Long-term complications were groin lymphocele (1 patient) and late rebleed from collateralization (1 patient). In 43 episodes, angiography did not demonstrate active bleeding. Twelve (28%) of these patients continued to bleed, 9 of whom had successful surgery. Of the 38 patients who had embolizations, all had immediate cessation of bleeding. Nine patients (24%) later rebled; 5 of these patients required surgery and 3 had reembolizations. Of the 3 patients who underwent reembolization, 2 developed ischemic bowel and 1 stopped bleeding; surgery was required in 1 patient. Mesenteric angiography for lower gastrointestinal bleeding effectively identifies the site of bleeding in 48% of patients and allows embolization in 45%. Embolization achieves clinical success in 76% of patients but repeat embolization is associated with a high rate of complications.

Antivascular effects of electrochemotherapy: implications in treatment of bleeding metastases

Solid tumors of various etiologies can be treated efficiently by electrochemotherapy (ECT), a combined use of electroporation (EP) and chemotherapeutic drugs, such as bleomycin and cisplatin. EP alone and ECT in particular, induce a profound reduction in tumor blood flow, which contributes to the antitumor effect. After EP and ECT, the time course of blood flow changes and follows the same two-phase pattern. The first rapid and short-lived vasoconstriction phase is followed by the second much longer-lived phase resulting from disrupted cytoskeletal structures and a compromised barrier function of the microvascular endothelium. In the case of ECT, however, tumor vascular endothelial cells are also affected by the chemotherapeutic drug, which leads to irrecoverable damage to tumor vessels and to a further decrease in tumor blood flow within hours after application of ECT. Tumor cells surviving the direct effects of ECT are consequently exposed to lack of oxygen and nutrients and are pushed into the secondary cascade of induced cell death. Clinically, the antitumor effectiveness of ECT has been proven extensively in the treatment of melanoma metastases, with 70–80% complete responses. The antivascular effects of ECT were also exploited for palliative treatment of bleeding melanoma metastases, with immediate cessation of bleeding and very good antitumor effectiveness. The antivascular effect of ECT is of utmost importance for translation of ECT into the treatment of deep-seated tumors, especially in well vascularized organs, such as the liver, where it prevents bleeding of the treated area.

Stent-grafts placement for treatment of massive hemorrhage from ruptured hepatic artery after pancreaticoduodenectomy

To present a series of cases with life-threatening hemorrhage from ruptured hepatic artery pseudoaneurysm after pancreaticoduodenectomy (PD) treated with placement of stent-grafts. Massive hemorrhage from ruptured hepatic artery pseudoaneurysm after PD in 9 patients (6 men, 3 women) at the age of 23-75 years (mean 48 years), were treated with placement of percutaneous endovascular balloon-expandable coronary stent-grafts. All patients were not suitable for embolization because of a non-patent portal vein. One or more stent-grafts, ranging 3-6 mm in diameter and 16-55 mm in length, were placed to exclude ruptured pseudoaneurysm. Follow-up data, including clinical condition, liver function tests, and Doppler ultrasound examination, were recorded at the outpatient clinic. Immediate technical success was achieved in all the 9 patients. All stent-grafts were deployed in the intended position for immediate cessation of bleeding and preservation of satisfactory hepatic arterial blood flow. No significant procedure-related complications occurred. Recurrent bleeding occurred in 2 patients at 16 and 24 h, respectively, after placement of stent-grafts and treated with surgical revision. One patient died of sepsis 12 d after the interventional procedure. The remaining 6 patients were survived when they were discharged. The mean follow-up time was 10.5 mo (range 4-16 mo). No patient had recurrent bleeding after discharge. Doppler ultrasound examination verified the patency of hepatic artery and stent-grafts during the follow-up. Placement of stent-grafts is an effective and safe procedure for acute life-threatening hemorrhage from ruptured hepatic artery pseudoaneurysm.

Ultrastructural and Morphological Analyses of the In Vitro and In Vivo Hemostatic Effects of Ankaferd Blood Stopper

Ultrastructural and morphological analyses of a novel hemostatic agent, Ankaferd Blood Stopper (ABS), in comparison to its in vitro and in vivo hemostatic effects were investigated. High-resolution scanning electron microscopy (SEM) images accompanied with morphological analysis after topical application of ABS revealed a very rapid (<1 second) protein network formation within concurrent vital erythroid aggregation covering the classical coagulation cascade. Histopathological examination revealed similar in vivo ABS-induced hemostatic network at the porcine hepatic tissue injury model. Instantaneous control of bleeding was achieved in human surgery-induced dental tissue injury associated with primary and secondary hemostatic abnormalities. Ankaferd Blood Stopper could hold a great premise for clinical management of surgery bleedings as well as immediate cessation of bleeding on external injuries based on upcoming clinical trials.

Atypical Manifestation of Patent Ductus Venosus in a Child: Intervening against a Paradoxical Presentation

A 6-year-old boy with massive gastrointestinal bleeding was found to have a large patent ductus venosus (PDV). Systemic symptoms of PDV (eg, hypergalactosemia and hepatic, pulmonary, and cardiac dysfunction) are frequent. However, gastrointestinal bleeding with the presence of a large portosystemic shunt is not a known complication of this anomaly. The shunt was successfully treated with embolization by using the Amplatzer vascular plug, with immediate cessation of bleeding. The authors propose that relative ischemia of the bowel, rather than portal hypertension, was the cause of the gastrointestinal bleeding in this child.

Calcium Phosphate Cements to Control Bleeding in Osteoporotic Sternums

A new method to control bleeding from fragile, severely osteoporotic sternums in patients undergoing open heart surgery. From January 2006 and January 2007, we used orthopedic calcium phosphate cement in 11 patients to control sternal table bleeding. Each patient had greater than 35% of their sternal table surface missing and had associated bleeding after open heart surgery. The cement was packed into the deficient sternal table surface at the conclusion of surgery, just prior to closure. All patients had immediate cessation of bleeding from their sternums, despite large superficial sternal deficits, after the cement was applied. All patients made uneventful recoveries and none required exploration for bleeding after surgery. There were no instances of superficial or deep sternal wound infections. At follow-up all sternums were well healed and firm. Seven patients had computed tomographic scans performed at 6 months revealing excellent complete sternal healing. Calcium phosphate cement can be used safely to control bleeding in patients with osteoporotic sternums and seems to be safe to use in the sternum.

Minnesota Tube for Bleeding Rectal Varices

A 51 year old man with Child's C hepatitis C cirrhosis, paroxysmal atrial fibrillation was admitted with decompensated cirrhosis, increasing ascites, and hepatic encephalopathy. As a part of pre-transplant work-up, he underwent colonoscopy which showed polyps in the descending colon as well as non bleeding rectal varices. Polypectomy was performed with no immediate complications. Within 24 hours of discharge, he presented with bright red rectal bleeding which led to hemorrhagic shock and admission to the intensive care unit, requiring massive blood and blood products transfusion. Emergency mesenteric angiogram was non-diagnostic. Despite the correction of his coagulopathy, he continued to bleed requiring emergent laparotomy, left hemicolectomy, and colostomy. Post operatively he had another episode of bleeding and he was taken back to OR for ligation of feeding vessels to rectal varices in addition to intra and extraluminal packing. In the interim, he underwent TIPS procedure for portal hypertension. One day later he returned to OR to have the packings removed, only to find the rectal varices still oozing. It was decided to place Minnesota tube to apply direct pressure using inflated gastric balloon to rectal varices. Due to the presence of rectal stump, which was around 15 cm, 10cm of the tube was cut. The tube was inserted into the rectal stump and gastric balloon was inflated with 200mls of air with immediate cessation of bleeding. The gastric aspiration port was aspirated every 2 hours. The balloon remained inflated for the next 24 hours with no evidence of further bleeding. Discussion: Minnesota tube can be used as rescue treatment for bleeding rectal varices when all other modes of therapy failed to stop bleeding. There has been similar case reports describing the use of Sengstaken-Blakemore tube in patients with rectal bleeding due to angiodysplasia, post partum hemorrhage. However, this is the first case that describes the use of Minnesota tube which has a larger gastric balloon in patient with rectal bleeding due to varices. [figure 1]Figure 1

Stent-Graft Treatment of Patients with Acute Bleeding from Hepatic Artery Branches

To present a new treatment option in patients with acute bleeding from the hepatic artery branches. Four male patients, 23-49 years old (mean 36.3 years), were treated for acute bleeding and subsequent transient hypotension. Bleeding episodes were secondary to hepatic artery pseudoaneurysms in two patients and surgical suture insufficiency in one patient. In the remaining patient, anastomotic leakage occurred following thrombolysis for hepatic artery thrombosis. Patients were treated by endovascular placement of one or two balloon-expandable stent-grafts, ranging from 17 to 28 mm in length. All procedures were carried out without serious complications. All stent-grafts were deployed in the intended position with immediate cessation of bleeding and initial preservation of satisfactory blood flow. Bleeding from the hepatic artery can be treated by insertion of balloon-expandable stent-grafts in the acute setting.