Objective: Spontaneous pneumomediastinum is characterized by the presence of interstitial air in the mediastinum without any apparent precipitating factor. The purpose of this study is to review and discuss our experience with this condition. Methods: A descriptive, retrospective study of 41 cases -34 men (83%) and 7 women (17%) -treated at our hospital for spontaneous pneumomediastinum from January 1990 through June 2006. Results: The mean age of the patients was 21 years (range, 14—35 years). Notably, 22% of patients had a prior history of asthma. No precipitating factor was identified in 51% of cases while onset was associated with physical effort in 12%. Chest pain (85%) and dyspnea (49%) were the most common symptoms. Subcutaneous emphysema, which presented in 71% of patients, was the most common sign. Pneumomediastinum was diagnosed by plain chest radiography in all cases. In certain cases, a computed tomography scan of the chest, contrast-enhanced swallow, or bronchoscopy wasperformed. All patientswereadmittedtothe hospitalwithgoodprogressand noinstancesof morbidity ormortality. Treatment included analgesia, rest, and/or initial oxygen therapy. The mean length of hospital stay was 5 days (range, 1—9 days) with only one case of early recurrence, which was resolved satisfactorily. Conclusions:Spontaneous pneumomediastinum is a benign process primarily affecting young men. Despite its low incidence, spontaneous pneumomediastinum should be considered in the differential diagnosis of acute chest pain because it requires a high index of suspicion. Patients with spontaneous pneumomediastinum respond well to medical treatment, with no recurrence in the great majority of cases. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

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Spontaneous pneumomediastinum: 41 cases.

BACKGROUNDTorso hemorrhage remains a leading cause of potentially preventable death within trauma, acute care, vascular, and obstetric practice. A proportion of patients exsanguinate before hemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct designed t

A systematic review of the use of resuscitative endovascular balloon occlusion of the aorta in the management of hemorrhagic shock.

Spontaneous pneumomediastinum (SPM) is described as free air or gas located within the mediastinum that is not associated with any noticeable cause such as chest trauma. SPM has been associated with many conditions and triggers, including bronchial asthma, diabetic ketoacidosis, forceful straining during exercise, inhalation of drugs, as well as other activities associated with the Valsalva maneuver. The Macklin effect appears on thoracic computed tomography (CT) as linear collections of air contiguous to the bronchovascular sheaths. With the recent availability of multidetector-row CT, the Macklin effect has been seen in the clinical setting more frequently than expected. The aim of this review article is to describe the CT imaging spectrum of the Macklin effect in patients with SPM, focusing on the common appearance of the Macklin effect, pneumorrhachis, and persistent SPM with pneumatocele.

Spontaneous pneumomediastinum and Macklin effect: Overview and appearance on computed tomography.

Background Portal vein embolization (PVE) has been gaining increasing acceptance before major hepatectomy. This review presents the application, outcome, and recent developments of PVE. Methods After a systematic search of “portal vein embolization” in PubMed, we reviewed and retrieved articles written in English related to PVE. There were no other criteria for exclusion of published information pertaining to this topic. Results Hypertrophy of future liver remnants with PVE in patients with hepatobiliary malignancy results in fewer complications and shorter hospital stays after major hepatectomy, and add to the pool of candidates for surgical treatment. Some new techniques, such as sequential hepatic artery-portal vein embolization and PVE with stem cell administration, have showed a promising clinical future. Conclusions PVE has achieved significant improvement in the outcome of major hepatectomy, and has enlarged the candidate pool of liver resection as well. Future study is needed to identify the precise mechanism of liver regeneration after PVE.

Present status and future perspectives of preoperative portal vein embolization

Circulatory collapse is a leading cause of mortality among traumatic major exsanguination and in ruptured aortic aneurysm patients. Approximately 40% of patients die before hemorrhage control is achieved. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct designed to sustain the circulation until definitive surgical or endovascular repair. A systematic review was conducted for the current clinical use of REBOA in patients with hemodynamic instability and to discuss its potential role in improving prehospital and in-hospital outcome. Systematic review and meta-analysis (1900–2017) using MEDLINE, Cochrane, EMBASE, Web of Science and Central and Emcare using the keywords “aortic balloon occlusion”, “aortic balloon tamponade”, “REBOA”, and “Resuscitative Endovascular Balloon Occlusion” in combination with hemorrhage control, hemorrhage, resuscitation, shock, ruptured abdominal or thoracic aorta, endovascular repair, and open repair. Original published studies on human subjects were considered. A total of 490 studies were identified; 89 met criteria for inclusion. Of the 1436 patients, overall reported mortality was 49.2% (613/1246) with significant differences (p < 0.001) between clinical indications. Hemodynamic shock was evident in 79.3%, values between clinical indications showed significant difference (p < 0.001). REBOA was favored as treatment in trauma patients in terms of mortality. Pooled analysis demonstrated an increase in mean systolic pressure by almost 50 mmHg following REBOA use. REBOA has been used in trauma patients and ruptured aortic aneurysm patients with improvement of hemodynamic parameters and outcomes for several decades. Formal, prospective study is warranted to clarify the role of this adjunct in all hemodynamic unstable patients.

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A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination.

Objective: The purpose of this study was to evaluate the Macklin effect in patients with spontaneous pneumomediastinum by multidetector-row computed tomography (MDCT). Methods: Chest computed tomography (CT) reports between July 2000 and January 2003 at our institution were retrospectively reviewed. Nine patients with spontaneous pneumomediastinum were identified, and their CT scans were evaluated to detect the Macklin effect. The patient diagnoses included interstitial lung diseases (n = 4), bronchiolitis obliterans organizing pneumonia or pneumonia (n = 3), asthma (n = 1), and spontaneous pneumomediastinum without definite pulmonary disease (n = 1). Results: The Macklin effect was observed in 8 (89%) of 9 patients. In 4 patients, the Macklin effect was observed in perihilar and peripheral areas, and in 4 patients, it was observed only in the perihilar area. Conclusions: The Macklin effect can frequently be demonstrated in patients with spontaneous pneumomediastinum of nontraumatic respiratory causes by MDCT. A CT-proven Macklin effect may be useful in differentiating respiratory from other causes of pneumomediastinum.

Frequent cause of the Macklin effect in spontaneous pneumomediastinum: demonstration by multidetector-row computed tomography.

Background: Only few reports are available on the use of aortic balloon catheter for cesarean hysterectomy in placenta previa percreta. Case: A 32-year-old woman

Elective Use of Aortic Balloon Occlusion in Cesarean Hysterectomy for Placenta Previa Percreta

Purpose
The aim of this study was to evaluate the effectiveness of computed tomography (CT) findings in the diagnosis of mediastinitis after cardiovascular surgery with median sternotomy.

Infectious mediastinitis after cardiovascular surgery: role of computed tomography

Rupture of a pseudoaneurysm after vaginal delivery is a rare cause of postpartum hemorrhage. A 29-year-old primigravida delivered a healthy boy by vacuum extraction at 38 weeks of gestation. The patient underwent repair of a right mediolateral episiotomy and left vaginal wall laceration. On the third postpartum day she experienced massive vaginal bleeding with vaginal wall laceration, and the vaginal bleeding progressively increased. A selective angiogram of the left internal iliac artery showed a pseudoaneurysm with extravasation originating from the left internal pudendal artery. Complete occlusion of the pseudoaneurysm was achieved by embolization of the left internal pudendal artery. The postprocedural course was uneventful. A pseudoaneurysm should be considered in unclear cases of postpartum hemorrhage.

Rupture of pseudoaneurysm after vaginal delivery successfully treated by selective arterial embolization

Purpose
The purpose of the present study was to show the feasibility and safety of ipsilateral portal vein embolization (PVE) using an improved four-lumen balloon catheter with fibrin glue.

Masaki Gibo

Papers

Frequent cause of the Macklin effect in spontaneous pneumomediastinum: demonstration by multidetector-row computed tomography.

Elective Use of Aortic Balloon Occlusion in Cesarean Hysterectomy for Placenta Previa Percreta

Infectious mediastinitis after cardiovascular surgery: role of computed tomography

Rupture of pseudoaneurysm after vaginal delivery successfully treated by selective arterial embolization

Percutaneous ipsilateral portal vein embolization using a modified four-lumen balloon catheter with fibrin glue: initial clinical experience.