Background No recommendation exists about the timing and setting for tracheal intubation and mechanical ventilation in septic shock. Patients and methods This prospective multicenter observational study was conducted in 30 ICUs in France and Spain. All consecutive patients presenting with septic shock were eligible. The use of tracheal intubation was described across the participating ICUs. A multivariate analysis was performed to identify parameters associated with early intubation (before H8 following vasopressor onset). Results Eight hundred and fifty-nine patients were enrolled. Two hundred and nine patients were intubated early (24%, range 4.5–47%), across the 18 centers with at least 20 patients included. The cumulative intubation rate during the ICU stay was 324/859 (38%, range 14–65%). In the multivariate analysis, seven parameters were significantly associated with early intubation and ranked as follows by decreasing weight: Glasgow score, center effect, use of accessory respiratory muscles, lactate level, vasopressor dose, pH and inability to clear tracheal secretions. Global R-square of the model was only 60% indicating that 40% of the variability of the intubation process was related to other parameters than those entered in this analysis. Conclusion Neurological, respiratory and hemodynamic parameters only partially explained the use of tracheal intubation in septic shock patients. Center effect was important. Finally, a vast part of the variability of intubation remained unexplained by patient characteristics. Trial registration Clinical trials NCT02780466, registered on May 23, 2016. https://clinicaltrials.gov/ct2/show/NCT02780466?term=intubatic&draw=2&rank=1.

No abstract

Background: Arterialization of the foot veins in patients with ischemic foot usually result in excessive foot edema, wound infection, venous gangrene, long hospitalization duration, and a high rate of amputation. We herein present an improved method of foot revascularization via the superficial venous system by in situ reverse arterialization (ISRA) of the foot venous bed, leaving the distal saphenous side branches open. Methods: A 69-year-old patient with toe wet gangrene and end-stage peripheral vascular disease with absence of foot target arteries underwent ISRA procedure, using the great saphenous vein, which was anastomosed end-to-side to the proximal superficial femoral artery. Only proximal saphenous tributaries were ligated until arterial flow reached the pedal superficial veins. Results: Postoperatively, the foot regained normal pulsation over the superficial venous system. The patient did not experience foot edema. On-table subtraction angiography demonstrated arterial flow through the long saphenous and dorsal foot veins, with returned venous flow through the anterior and posterior tibial veins. Methoxyisobutylisonitrile scan conducted 4 weeks postoperatively demonstrated positive oxygen uptake of the pedal muscles, which was absent before surgery. Electron microscopy of the muscles at the level of the transmetatarsal amputation demonstrated regeneration of muscle tissue with mitosis 6 weeks postoperatively. During 1,000 days of follow-up postsurgery, the flow was reduced and the transcutaneous pO 2 level of the foot increased up to 76 mm Hg. Conclusions: This new modified surgical technique of ISRA, in which only proximal saphenous tributaries were ligated in order to prevent high systemic pressure in the foot venous low pressure system, resulted in increased levels of transcutaneous pO 2 and reduced flow, leading to full recovery of the ischemic foot.

No abstract

Blue toe syndrome (BTS), is a well-known entity of toe gangrene and rest pain secondary to micro emboli lodged within the digital arteries. BTS among young patients should alert physicians to look for causes such as trauma, connective tissue disease, hypercoagulability state, and others. We hereby describe a 32-year-old female with right BTS. A mass obstructing 80% of the right popliteal artery lumen was the source of emboli. The histologic results of the replaced arterial segment revealed a thrombus on top of epithelioid hemangioendothelioma. This is the first description of the association between primary vascular tumor and BTS.

No abstract

No abstract

Objective: Thoracic aortic pseudoaneurysms are rare. The main causes of aortic pseudoaneurysms are iatrogenic injury, trauma, atherosclerosis, and infection. Whereas aortic pseudoaneurysm might be asymptomatic, it is potentially fatal and may cause death of 32% to 40% if ruptured. Therefore, treatment should be considered as soon as the diagnosis is made. Treatment options available are surgical, endovascular, and hybrid (surgical and endovascular) methods. However, taking into consideration the etiology of thoracic aorta pseudoaneurysm, the surgical option in patients with multiple combined traumatic injuries, repeated open thoracic surgery, and comorbidities might be associated with higher morbidity and mortality rates. Endovascular treatment of thoracic aortic pseudoaneurysm is a safe, durable, and less invasive alternative. Methods: In this paper, we share our experience in treating thoracic aortic pseudoaneurysm endovascularly. We reviewed cases of thoracic aorta pseudoaneurysm treated endovascularly in our institutions between the years 2017 and 2019. Results: Six patients are included in this study (five male, one female). The mean age was 51 years. The etiology of thoracic aortic pseudoaneurysm was atherosclerosis in two patients, trauma in two patients, and iatrogenic (postsurgical) in two patients. As for the location of the pseudoaneurysms, two were in the ascending aorta (after cardiac surgery). Four were in the aortic arch, of which two were next to the left subclavian artery (post-traumatic). Five patients were treated with thoracic aortic stent grafts. One patient was treated with a multilayer flow modulator stent. In four of these cases, parallel stenting (chimney) was performed to the subclavian and carotid arteries. In these cases, a catheter was placed in the false aneurysm. After deployment of the stent graft, the catheter was used to deliver coils into the false aneurysm. This procedure was devised to expedite thrombosis of the false aneurysm. Some of these aneurysms were gigantic, ranging between 7 and 9 cm in diameter. All procedures were technically successful with excluded pseudoaneurysms. Conclusions: Early outcomes that have been achieved with endovascular repair in this series were satisfactory. Endovascular treatment is safe and effective for thoracic aortic pseudoaneurysm. The choice of treatment should be tailored for patients, taking into consideration the etiology and location of the pseudoaneurysm.