Acute Medicine & Surgery最新文献

An 81-year-old woman presented with hemorrhagic shock. Contrast-enhanced computed tomography (CT) revealed a ruptured abdominal aortic aneurysm with aortic tortuosity and a large retroperitoneal hematoma (Figure 1A,B). As endovascular aneurysm repair (EVAR) was not available, transfer was arranged. During preparation, a 7-Fr resuscitative endovascular balloon occlusion of the aorta (REBOA; Rescue Balloon; Tokai Medical Products, Aichi, Japan) catheter was inserted via the right femoral artery. Inflation in Zone I, proximal to the aneurysm, stabilized hemodynamics despite shaft angulation (Figure 1C). Twenty minutes later, deflation to restore distal perfusion lowered systolic blood pressure to 50 mmHg; reinflation within seconds did not improve it. The catheter remained secured to the skin with a suture and stylet in place, without intentional manipulation. Fluoroscopy was not used immediately before or during these maneuvers. Subsequent fluoroscopy revealed catheter shaft kinking and looping, with distal migration of the balloon by approximately two vertebral body heights to the L2–L3 vertebral level, corresponding approximately to the upper extent of the aneurysm on preprocedural contrast-enhanced CT (Figure 1D). Failed guidewire advancement beyond the aneurysm from the femoral approach prompted replacement via the left brachial artery to avoid the tortuous aneurysmal segment. After transfer, the patient underwent successful EVAR.

Low-profile REBOA devices may reduce access-related vascular complications [1], but migration and looping remain possible [2]. Loss of balloon anchoring, restored aortic flow, and shaft tension release may contribute to migration and deformation within the tortuous aorta, although the mechanism remains unconfirmed. Therefore, assessing shaft configuration and reconfirming balloon position fluoroscopically after deflation/reinflation may facilitate early migration detection.

The authors have nothing to report.

The authors have nothing to report.

Informed consent was obtained from the patient's family.

Kenji Dohi is an Editorial Board member of Acute Medicine & Surgery and a co-author of this article. The other authors declare no conflicts of interest.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Apixaban-associated sublingual hematoma can mimic Ludwig's angina and cause delayed airway obstruction despite a stable initial presentation. Clinicians should prioritize airway monitoring and anticoagulation reversal and avoid routine surgical drainage unless infection is suspected.

A 61-year-old man with Madelung's disease presented for excision of a cervical lipoma (Figure 1A,B). Fiberoptic examination revealed posterior pharyngeal wall bulging with airway narrowing (Figure 1C), and computed tomography showed diffuse fat surrounding the anterior neck and spine (Figure 1D). Severe obstructive sleep apnea, a perioperative risk factor [1, 2], prompted preoperative continuous positive airway pressure initiation.

Cervical lipomatosis predicted failure of emergency front-of-neck access [3], and a maximum mouth opening of two fingerbreadths indicated difficult direct laryngoscopy [4]. Awake oral fiberoptic intubation was performed under nebulized lidocaine with intravenous fentanyl-droperidol sedation, and a 7-mm endotracheal tube was advanced without resistance. Had intubation failed, the plan was to abort while maintaining spontaneous ventilation and postpone surgery [5].

An initial absent cuff leak prompted continued intubation with daily retesting, while diuretics corrected positive fluid balance, gradually restoring the leak. Methylprednisolone was administered on postoperative Day 6; a spontaneous breathing trial confirmed readiness. On Day 7, extubation proceeded with extracorporeal membrane oxygenation on standby and pre-secured vascular access.

In Madelung's disease, where both intubation and emergency surgical airway may fail, awake intubation, which allows abortion if needed, should be chosen at induction, and extubation should not proceed without considering extracorporeal rescue.

This work was supported by the Japan Society for the Promotion of Science, JP26K11829.

The authors have nothing to report.

Written informed consent for publication was obtained from the patient.

The authors declare no conflicts of interest.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.