Abstract:

Two clinical cases of treatment of spontaneous hematomas in elderly patients with COVID-19 using endovascular diagnostic and treatment methods are presented.

Aim: was to show the effectiveness of endovascular hemostasis and, in some cases, there is no alternative to the use of other techniques.

Material and methods: we presented two clinical cases and analyzed the work of domestic and foreign authors on the prevention of venous thrombosis in patients with COVID-19 and endovascular treatment of spontaneous hematomas in patients with COVID-19.

Results: article describes two case reports of catheter embolization in patients with spontaneous hematoma during treatment of severe COVID-19. Elderly patients underwent prevention of thromboembolic complications with low-molecular-weight anticoagulants in prophylactic dosages; during therapy, soft tissue hematomas were revealed in one case in abdominal wall, in the other in chest. In both cases, conservative treatment was ineffective; bleeding required transfusion of blood components. In both cases, embolization was effective, and patients' condition stabilized. In one case, the progression of respiratory failure led to death, the second patient was discharged for out-patient treatment.

Conclusion: catheter embolization for arterial bleeding can be used as monotherapy or as a stage of stabilizing the patient before open surgical treatment.

Abstract:

Introduction: intramural hematoma of the aortic wall is a component of acute aortic syndrome, and is also considered a precursor of aortic dissection. Due to peculiarities of the natural course, there are significant disagreements in choosing the optimal strategy for the treatment of intramural hematoma.

Aim: was to evaluate the possibility of a differential tactical approach to the treatment of acute intramural aortic hematoma in various situations.

Material and methods: two clinical cases demonstrate different approaches to the treatment of intramural aortic hematoma.

Results: in given clinical examples, a conservative tactics of managing patients with intramural hematoma of the aorta "watch and wait" was applied. However, in the first case, an emergency surgical intervention was required, due to the complicated course of the disease, according to dynamic studies. The second case demonstrated the acceptability of a conservative approach with long-term monitoring of the condition of the aortic wall.

Conclusions: the balance between risks of surgery and the safety of conservative therapy is the cornerstone in deciding on the optimal tactics for treating this pathology.

Abstract:

Introduction: coronavirus (COVID) pandemic has caused temporary changes in work algorithms of different hospitals, that have not previously provided care for infectious patients. However, the consequences of COVID go beyond infectious pathology. Widespread use of therapeutic doses of anticoagulants as a necessary treatment option and resistant to treatment, cough as a typical symptom, led to an increase in spontaneous ruptures of epigastric arteries with hematomas of abdominal wall, which was an undesirable complication of the main disease.

Aim: was to demonstrate possibilities of endovascular methods in treatment of patients with spontaneous rupture of epigastric arteries on the background of COVID-19 and anticoagulant therapy.

Material and methods: at joinant infectious hospital, inpatient care was provided to 421 patients with coronavirus infection. At the same time, during treatment 9 patients had hematomas of abdominal wall and two of them had spontaneous rupture of rectus abdominis muscle and branches of inferior epigastric artery were damaged. In this article, we present both observations demonstrating the potential of endovascular surgery in treatment of such lesions in patients with COVID-19. Both patients, on the 6 and 10th day of inpatient treatment (severity of lung involvement was Grade 1 and Grade 2) during intense coughing, noted pain and swelling of anterior abdominal wall, accompanied by clinical and laboratory signs of blood loss. Computed tomography angiography (CT-A) revealed extravasation from small branches of inferior epigastric artery with an extensive hematoma that spread into the retroperitoneal space. In a hybrid operating room, a selective embolization of inferior (in one case, due to the high localization of the hematoma, inferior and superior) epigastric artery with an adhesive composition (N-butyl cyanoacrylate with iodolipol) was performed with successful angiographic and clinical results. Patients were discharged without complications on the 7th and 9th days of the postoperative period.

Conclusion: timely CT-diagnostic of severe bleeding, even in cases with atypical localization, and its management by selective embolization of damaged artery is the basis in treatment of spontaneous (cough-associated) ruptures of rectus abdominis muscle in patients with new coronavirus infection.

Abstract:

Aim: was to evaluate the feasibility and effectiveness of using transperineal access for sanitation of «deep» exudative pelvic lesions in patients after gynecological operations.

Materials and methods: results of percutaneous drainage with perineal access of «deep» – perirectal postoperative exudative pelvic lesions in 18 patients after extirpation of the uterus in oncological pathology were subjected to retrospective analysis. Exudative formations in the pelvis were detected during continuous postoperative ultrasound screening of operated patients starting from 3rd day of the postoperative period, taking into account clinical data.

Perineal access was used in patients with verification of the nature of the pathological contents and subsequent drainage of the pathological exudation zone by 8fr drains with form memory using Seldinger method.

Results: manipulation was successful in all 18 patients. In 5 cases, a lyzed pelvic hematoma was drained, and in 13 cases, an abscess was drained. In three cases, the connection of the abscess cavity with the lumen of the rectum was revealed. There were no complications due to manipulation. The drainage period was 6-7 days for hematoma and 10-16 days for abscess without internal fistula. If there is a connection with the lumen of the rectum, the drainage period was 21 days, the drainage was removed with x-ray confirmed closure of the internal fistula.

Conclusion: our first positive experience of using transperineal access for the rehabilitation of intrapelvic exudative complications of the postoperative period in oncogynecological patients inspires cautious optimism, expands the arsenal of mini-invasive methods of treatment of intra-pelvic postoperative exudative complications, but undoubtedly requires further research for optimal integration of the technique into the practice of oncogynecology and x-ray surgery departments.

References

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4.     Albuquerque A, Pereira E. Current applications of transperineal ultrasound in gastroenterology. World J Radiol. 2016; 8(4): 370-377.

5.     Sperling DC, Needleman L, Eschelman DJ, Hovsepian DM, Lev-Toaff AS. Deep pelvic abscesses: transperineal US-guided drainage. Radiology. 1998; 208(1):111-5.

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Abstract

Aim: was to determine the role of radiation and interventional methods of diagnosis and treatment of traumatic pelvic bleeding.

Material and methods: for the period 2016 -2019, we analyzed results of diagnosis and treatment of 37 patients with pelvic injuries, complicated by intra-pelvic bleeding. CT scanning of retroperitoneal pelvic hematoma (RPH) was performed in all cases, results of calculations were compared with the surgical classification of I.Z. Kozlova (1988) on the spread of retroperitoneal hemorrhage and volume of blood loss in pelvic fractures. MSCT-A was performed in 16 (45%) injured. Digital subtraction angiography (DSA) was performed in 10 (27%) cases, of which after MSCT-A – in 4 cases, and as the primary method for the diagnosis of arterial bleeding – in 6 cases.

Results: according to MSCT, the frequency of minor hemorrhages was 18 (50%), medium 16 (43%), large 3 (8%). CT calculation of the volume of small hemorrhages ranged from 92 to 541 cm3, medium – 477-1147 cm3, large –1534 cm3 and more. MSCT-A revealed signs of damage of arteries of the pelvic cavity: extravasation of contrast medium – in 4, cliff and «stop-contrast» – in 1, post-traumatic false aneurysm – in 1, displacement and compression of the vascular bundle – in 4 observations. DSA revealed signs of damage of vessels of the pelvis: extravasation of contrast medium – 3, angiospasm – 2 and occlusion – 2 observations. According to results of angiography, embolization of damaged arteries was performed in 5 observations.

Conclusion: MSCT is a highly sensitive method in assessing the distribution and calculation of RPH volume. The presence of a hematoma volume of more than 50-100 cm3, regardless of the type of pelvic damage, was an indication for MSCT. In patients with stable hemodynamics, DSA was used as a clarifying diagnostic method; in patients with unstable hemodynamics, it was used as the main method for diagnosis and treatment of injuries of pelvic vessels. Damage of pelvic vessels detected by angiography was observed predominantly in unstable pelvic fractures, accompanied by medium and large retroperitoneal pelvic hemorrhages.

References 

1.     Butovskij DI. The role of retroperitoneal hematomas in thanatogenesis in pelvic injuries. Sudmedekspert. 2003; 4: 14-16 [In Russ].

2.     Smolyar AN. Retroperitoneal hemorrhage in pelvic fractures. Hirurgiya. 2009; 8: 48-51 [In Russ].

3.     Fengbiao Wang, Fang Wang. The diagnosis and treatment of traumatic retroperitoneal hematoma. Pakistan Journal of Medical Sciences. 2013 Apr; 29(2): 573-576.

4.     Dorovskih GN. Radiation diagnosis of pelvic fractures, complicated by damage of pelvic organs. Radiologiya-praktika. 2013; 2: 4-15 [In Russ].

5.     Vasil'ev AV, Balickaya NV. Radiation diagnosis of pelvic injuries resulting traffic accidents. Medicinskaya vizualizaciya. 2012; 3: 135-138 [In Russ].

6.     Mahmoud Hussami, Silke Grabherr, Reto A Meuli, Sabine Schmidt. Severe pelvic injury: vascular lesions detected by ante- and post-mortem contrast mediumenhanced CT and associations with pelvic fractures. International Journal of Legal Medicine. 2017; 131: 731-738.

Abstract:

Aim: was to improve results of treatment of patients with myocardial infarction who underwent emergency coronary stenting, by prevention of bleeding complications from puncture place.

Materials and methods: we present retrospective analysis of clinical case of interventional treatment of myocardial infarction, with late post-puncture bleeding complication (41 day after PCI). Its consequences caused the thrombosis of the external iliac vein with further pulmonary embolism, and acute reocclusion of previously stented coronary artery

Results: developed complications were surgically treated (recurrent coronary stenting, elimination of defect of the femoral artery, implantation of cava filter with its subsequent removal), and thrombolytic therapy Patient was discharged to outpatient care without any indications of cardiopulmonary insufficiency and compensated arterial and venous circulation of operated lower limb. After 11 months, the patient’s condition was without negative dynamics with a satisfactory quality of life.

Conclusion: this clinical example demonstrates how difficult is to detect bleeding from a puncture wound. In cases of femoral access, the routine use of vascular closure devices can reduce the risk of bleeding complications. 

References 

1.    Rekomendacii po lecheniju ostrogo koronarnogo sindroma bez stojkogo pod#joma segmenta ST Evropejskogo obshhestva kardiologov [European cardiological society recommendation: treatment of acute coronary syndrome without stable ST-segment elevation]. Racional'naja farmakoterapija v kardiologii. 2012; 2: 2-64[In Russ].

2.    Sulimov V.A. Antitromboticheskaja terapija pri chreskozhnyh koronarnyh vmeshatel'stvah [Antithrombotic therapy during percutaneous coronary interventions]. Racional'naja farmakoterapija v kardiologii. 2008; 3: 91-100 [In Russ].

3.    Goloshhapov-Aksjonov R.S., Sitanov A.S. Luchevoj arterial'nyj dostup - prioritetnyj dostup dlja vypolnenii chreskozhnoj koronarnoj angioplasti