Outcomes of Bridging Intravenous Thrombolysis Versus Endovascular Therapy Alone in Late-Window Acute Ischemic Stroke.

BACKGROUND: Studies comparing bridging intravenous thrombolysis (IVT) with direct endovascular therapy (EVT) in patients with acute ischemic stroke who present late are limited. We aimed to compare the clinical outcomes and safety of bridging IVT in patients with acute ischemic stroke due to anterior circulation large vessel occlusion who underwent EVT 6 to 24 hours after time last known well. METHODS: We enrolled patients with anterior circulation large vessel occlusion stroke and a National Institutes of Health Stroke Scale score of ≥6 from 20 centers across 10 countries in the multicenter retrospective CLEAR study (CT for Late Endovascular Reperfusion) between January 2014 and May 2022. We used inverse probability of treatment weighting modeling adjusted for clinical and imaging confounders to compare functional outcomes, reperfusion success, symptomatic intracranial hemorrhage, and mortality between EVT patients with and without prior IVT. RESULTS: Of 5098 patients screened for eligibility, we included 2749 patients, of whom 549 received bridging IVT before EVT. The timing of IVT was not recorded. Witnessed stroke onset and transfer rates were higher in the bridging IVT group (25% versus 12% and 77% versus 55%, respectively, P value for both <0.0001), and time intervals between stroke onset and treatment were shorter (time last known well-start of EVT median 560 minutes [interquartile range, 432-791] versus 724 minutes [interquartile range, 544-912]; P<0.0001). After adjustment for confounders, there was no difference in functional outcome at 3 months (adjusted common odds ratio for modified Rankin Scale shift, 1.03 [95% CI, 0.89-1.19]; P=0.72) or successful reperfusion (adjusted odds ratio, 1.19 [95% CI, 0.81-1.75]; P=0.39). There were no safety concerns associated with bridging IVT versus direct EVT (symptomatic intracranial hemorrhage: adjusted odds ratio, 0.75 [95% CI, 0.38-1.48]; P=0.40; mortality: adjusted odds ratio, 1.14 [95% CI, 0.89-1.46]; P=0.31). Results were unchanged when the analysis was limited to patients who received IVT >6 hours after last known well. CONCLUSIONS: In patients with an anterior circulation large vessel occlusion stroke who underwent EVT 6 to 24 hours from last known well, bridging IVT was not associated with a difference in outcomes compared with direct EVT. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096248.

Sex Differences in Outcomes of Late-Window Endovascular Stroke Therapy.

BACKGROUND: The association between sex and outcome after endovascular thrombectomy of acute ischemic stroke is unclear. The aim of this study was to compare the clinical and safety outcomes between men and women treated with endovascular thrombectomy in the late 6-to-24-hour window period. METHODS: This multicenter, retrospective observational cohort study included consecutive patients who underwent endovascular thrombectomy of anterior circulation stroke in the late window from 66 clinical sites in 10 countries from January 2014 to May 2022. The primary outcome was the 90-day ordinal modified Rankin Scale score. Secondary outcomes included 90-day functional independence (FI), return of Rankin (RoR) to prestroke baseline, FI or RoR, symptomatic intracranial hemorrhage, and mortality. Multivariable and inverse probability of treatment weighting methods were used. We explored the interaction of sex with baseline characteristics on the outcomes ordinal modified Rankin Scale and FI or RoR. RESULTS: Of 1932 patients, 1055 were women and 877 were men. Women were older (77 versus 69 years), had higher rates of atrial fibrillation, hypertension, and greater prestroke disability, but there was no difference in baseline National Institutes of Health Stroke Scale score. Inverse probability of treatment weighting analysis showed no difference between women and men in ordinal modified Rankin Scale (odds ratio, 0.98 [95% CI, 0.79-1.21]), FI or RoR (odds ratio, 0.98 [95% CI, 0.78-1.22]), severe disability or mortality (odds ratio, 0.99 [95% CI, 0.80-1.23]). The multivariable analysis of the above end points was concordant. There were no interactions between baseline characteristics and sex on the outcomes of ordinal modified Rankin Scale and FI or RoR. CONCLUSIONS: In late presenting patients with anterior circulation stroke treated with endovascular thrombectomy in the 6 to 24-hour window, there was no difference in clinical or safety outcomes between men and women.

Endovascular Therapy for Acute Stroke: New Evidence and Indications.

Endovascular therapy (EVT) has revolutionized the treatment of acute ischemic stroke. In the past few years, endovascular treatment indications have expanded to include patients being treated in the extended window, with large ischemic core infarction, basilar artery occlusion (BAO) thrombectomy, as demonstrated by several randomized clinical trials. Intravenous thrombolysis (IVT) bridging to mechanical thrombectomy has also been studied via several randomized clinical trials, with the overall results indicating that IVT should not be skipped in patients who are candidates for both IVT and EVT. Simplification of neuroimaging protocols in the extended window to permit non-contrast CT, CTA collaterals have also expanded access to mechanical thrombectomy, particularly in regions across the world where access to advanced imaging may not be available. Ongoing study of areas to develop include rescue stenting in patients with failed thrombectomy, medium vessel occlusion thrombectomy, and carotid tandem occlusions. In this narrative review, we summarize recent trials and key data in the treatment of patients with large ischemic core infarct, simplification of neuroimaging protocols for the treatment of patients presenting in the late window, bridging thrombolysis, and BAO EVT evidence. We also summarize areas of ongoing study including medium and distal vessel occlusion.

Surgeons' Perspectives on Valve Surgery in People With Drug Use-Associated Infective Endocarditis.

BACKGROUND: Hospitalizations for drug-use associated infective endocarditis (DUA-IE) have led to increasing surgical consultation for valve replacement. Cardiothoracic surgeons' perspectives about the process of decision making around operation for people with DUA-IE are largely unknown. METHODS: This multisite semiqualitative study sought to gather the perspectives of cardiothoracic surgeons on initial and repeat valve surgery for people with DUA-IE through purposeful sampling of surgeons at 7 hospitals: University of Alabama, Tufts Medical Center, Boston Medical Center, Massachusetts General Hospital, University of North Carolina-Chapel Hill, Vanderbilt University Medical Center, and Rhode Island Hospital-Brown University. RESULTS: Nineteen cardiothoracic surgeons (53% acceptance) were interviewed. Perceptions of the drivers of addiction varied as well as approaches to repeat valve operations. There were mixed views on multidisciplinary meetings, although many surgeons expressed an interest in more efficient meetings and more intensive postoperative and posthospitalization multidisciplinary care. CONCLUSIONS: Cardiothoracic surgeons are emotionally and professionally impacted by making decisions about whether to perform valve operation for people with DUA-IE. The use of efficient, agenda-based multidisciplinary care teams is an actionable solution to improve cross-disciplinary partnerships and outcomes for people with DUA-IE.

Trends in the management and outcomes of esophageal perforations among racial-ethnic groups.

Background: Esophageal perforation (EP) is a life-threatening emergency requiring emergent surgical intervention. Little is known about potential racial-ethnic disparities among patients with EP. Methods: Hospitalizations of adult (≥18 years old) patients admitted with a diagnosis of EP were identified in the 2000-2017 National Inpatient Sample (NIS). Multivariable Cox proportional hazards regression was used to estimate the association between race-ethnicity and inpatient mortality. Inpatient complications were assessed using multivariable logistic regression. Results: There were an estimated 36,531 EP hospitalizations from 2000-2017. One quarter of hospitalizations were racial or ethnic minorities. Non-Hispanic (NH) White patients were, on average, older (median age 58 vs. 41 and 47 years, respectively, P<0.0001). The rate of EP admissions, per 1,000,000 the United States (US) adults, significantly increased among all groups over time. In-hospital mortality decreased for both NH White and NH Black patients (10.2% to 4.6% and 8.3% to 4.9%, respectively, P<0.0001) but increased for Hispanic patients and patients of other races (2.9% to 4.7% and 3.4% to 6.9%, P<0.0001). NH Black patients were more likely to have sepsis during their hospital course [odds ratio (OR) =1.34; 95% confidence interval (CI): 1.08 to 1.66], and patients of other races (OR =1.44; 95% CI: 1.01 to 2.07) were more likely to have pneumonia. Similar rates of surgical intervention were seen among all racial-ethic groups. After adjustment, inpatient mortality did not differ among racial-ethnic groups. Conclusions: Rates of EP admissions have increased for all racial-ethnic groups since 2000. Despite similar incidences of inpatient mortality across groups, NH Black and other race patients were more likely to experience postoperative complications, suggesting potential racial-ethnic disparities in quality or access to care.

Pulmonary complications observed in patients with infective endocarditis with and without injection drug use: An analysis of the National Inpatient Sample.

BACKGROUND: The impact of cardiovascular and neurologic complications on infective endocarditis (IE) are well studied, yet the prevalence and significance of pulmonary complications in IE is not defined. To better characterize the multifaceted nature of IE management, we aimed to describe the occurrence and significance of pulmonary complications in IE, including among persons with IE related to drug use. METHODS: Hospitalizations of adult (≥18 years old) patients diagnosed with IE were identified in the 2016 National Inpatient Sample using ICD-10 codes. Multivariable logistic and linear regression were used to compare IE patient outcomes between those with and without pulmonary complications and to identify predictors of pulmonary complications. Interaction terms were used to assess the impact of drug-use IE (DU-IE) and pulmonary complications on inpatient outcomes. RESULTS: In 2016, there were an estimated 88,995 hospitalizations of patients diagnosed with IE. Of these hospitalizations,15,490 (17%) were drug-use related. Drug-use IE (DU-IE) had the highest odds of pulmonary complications (OR 2.97, 95% CI 2.50, 3.45). At least one pulmonary complication was identified in 6,580 (7%) of IE patients. DU-IE hospitalizations were more likely to have a diagnosis of pyothorax (3% vs. 1%, p<0.001), lung abscess (3% vs. <1%, p<0.001), and septic pulmonary embolism (27% vs. 2%, p<0.001). Pulmonary complications were associated with longer average lengths of stay (CIE 7.22 days 95% CI 6.11, 8.32), higher hospital charges (CIE 78.51 thousand dollars 95% CI 57.44, 99.57), more frequent post-discharge transfers (acute care: OR 1.37, 95% CI 1.09, 1.71; long-term care: OR 2.19, 95% CI 1.83, 2.61), and increased odds of inpatient mortality (OR 1.81 95% CI 1.39, 2.35). CONCLUSION AND RELEVANCE: IE with pulmonary complications is associated with worse outcomes. Patients with DU-IE have a particularly high prevalence of pulmonary complications that may require timely thoracic surgical intervention, likely owing to right-sided valve involvement. More research is needed to determine optimal management strategies for complications to improve patient outcomes.

Away Rotations at Integrated Thoracic Surgery Programs: Applicant and Program Director Perspectives.

OBJECTIVE: Integrated thoracic surgery residency program (IP) applicants often complete away rotations to stand out from the objective standard criteria. Little is known about the perceptions of these rotations. We aimed to examine the perceptions of value, cost, and expectations of away rotations among IP applicants and program directors. DESIGN: Between March and April 2020, anonymous electronic surveys were distributed through e-mails gathered from the Electronic Residency Application Service and the Accreditation Council for Graduate Medical Education IP email list. A follow-up email was sent to all applicants and program directors 1 week after the initial request to improve response rate. Questions assessed the cost, frequency, goals, and objectives for away rotations, as well as the perceived value of these experiences. SETTING: United States PARTICIPANTS: All IP program directors and United States senior medical students who applied to our institution's IP during the 2019-2020 cycle. RESULTS: Seventy-eight US medical students participated in the 2020 IP Match with 65 applicants applying to our institution's IP. Thirty-three responses were obtained from applicants who applied to our program (51% response rate). Survey responses were obtained from 8 program directors (31% response rate). Ninety-four percent of applicant respondents completed an IP away rotation (n = 31). Fifty-seven percent of these applicants spent on average $5000 in total for away rotations (n = 19). Overall, applicants felt that away rotations helped refine their perception of program location, educational and operative experience, treatment of medical students, and collegiality. Applicants and program directors acknowledged that creating a good impression and finding a compatible program were central values for participating in away rotations. However, program directors viewed the overall strength of the applicant as the most important factor when evaluating applicants. Fifty-five percent of applicant respondents matched at an IP (n = 17) with 35% matching at an IP where they had completed an away rotation (n = 6). CONCLUSION: Extended interactions that can help create good impressions and establish compatibility are benefits to away rotations. However, given the current application conditions imposed by the pandemic, future studies should examine the impact of no away rotations on the IP Match process so that moving forward applicants and program directors can continue to weigh benefits to the costs and logistics of completing an away rotation.

The use of grape juice in the detection of esophageal leaks.

BACKGROUND: Esophagectomies and repair of esophageal perforations are operations used for a variety of clinical indications. Anastomotic leaks are a major post-operative complication after these procedures. At our institution, we routinely use grape juice to detect esophageal leaks in the post-operative setting in addition to other standard imaging modalities. We hypothesize that grape juice can provide similar diagnostic sensitivity and specificity to other modalities for leak detection. METHODS: A retrospective review of all patients who underwent an esophagectomy or repair of esophageal perforations from 2013-2019 by the thoracic surgery service at our institution was performed. All patients underwent a barium swallow study, CT imaging or upper endoscopy, as well as ingesting purple grape juice on post-operative day 5 or greater. Purple grape juice observed in the tube thoracostomy drainage system was identified as a positive esophageal leak. RESULTS: Sixty-four patients were included in the study period (25% female, 88% white, median age 62 years old). Sixty-three patients had both a barium swallow study and grape juice test, while one patient underwent CT imaging and grape juice study. Grape juice test sensitivity and specificity were found to be 80% and 98.3%, respectively. CONCLUSIONS: This pilot study demonstrates the effectiveness of using grape juice in detecting esophageal leaks after esophageal operations in patients with tube thoracostomies. Grape juice may be cheaper and potentially less morbid than other studies performed to detect esophageal leaks. Further research is needed to justify the increased use of grape juice in patients who undergo esophageal operations.

Multidisciplinary Management of an Aorto-esophageal Injury Caused by Foreign Body Ingestion.

A 37-year-old incarcerated male ingested a complex "X-shaped" foreign body that resulted in a penetrating aorto-esophageal injury. A primary esophagotomy with retrieval of the foreign body and muscle flap closure was performed simultaneously with thoracic endovascular aortic repair. This multidisciplinary surgical approach controls for both immediate exsanguination and postoperative complications to improve patient outcome.

Recent Trends in Cardiothoracic Surgery Training: Data from the National Resident Matching Program.

OBJECTIVE: In 2008, integrated thoracic residency programs (IP) for cardiothoracic (CT) training were created in response to a decline in CT trainees. However, few studies have reported on trends in the CT training pathway since the inception of IPs. This manuscript examines the current trends related to the overall number of surgical trainees entering CT surgery training following the introduction of IPs into the National Resident Match Program (NRMP). DESIGN: Main and specialty match data were gathered from NRMP annual reports between 2008 and 2018. Descriptive statistics were used to analyze program size, applications, and filled and unfilled positions for IPs and traditional CT residency programs. Pearson's correlation coefficient was used to determine associations between program variables. SETTING: NRMP main and specialty match in 2008 to 2018. PARTICIPANTS: Participants of the NRMP main and specialty match in 2008 to 2018. RESULTS: IPs increased from 2 programs offering 3 positions in 2008 to 28 programs offering 36 positions in 2018. However, during the same time period, the number of available traditional CT residency positions have decreased by 29% (130 to 92). As the number of IPs increased, there was a significant decrease in the number of traditional CT residency positions (ρ = -0.95, p < 0.001). Although, the overall number of CT residency programs (traditional and IP) remained largely unchanged, the proportion of filled CT residency positions increased from 67.7% in 2008 up to 97.7% in 2018. CONCLUSION: The IP training format has shown success in increasing the number of trainees entering into CT training programs. Consideration should be given to increasing the number of IP positions or increase interest in CT among general surgery residents to increase the number of CT surgery trainees with the goal of increasing the size of the future CT workforce.

Does routine uniportal thoracoscopy during rib fixation identify more injuries and impact outcomes?

BACKGROUND: Flail chest and severely displaced rib fractures due to blunt trauma can be associated with intrathoracic injuries. At our institution, two thoracic surgeons perform all surgical stabilization of rib fractures (SSRF): one performs routine uniportal thoracoscopy (R-VATS) at the time of SSRF and the other for only select cases (S-VATS). In this pilot study, we hypothesized that R-VATS at the time of SSRF identifies and addresses intrathoracic injuries not seen on imaging and may impact patient outcomes. METHODS: A retrospective review of all patients who underwent SSRF from 2013-2019 at our institution was performed for severely displaced rib fractures or flail chest. Data collected included demographics, imaging results, treatment strategy, and operative findings. RESULTS: Ninety-nine patients underwent SSRF. Uniportal thoracoscopy was performed on 69% of these patients. When thoracoscopy was performed, 31 additional injuries were identified. R-VATS identified 23 additional intrathoracic findings at time of thoracoscopy not seen on CT scan compared to 8 findings in the S-VATS group (P=0.367). At 3 months follow-up, one empyema and one diaphragmatic hernia required reoperation-neither of which underwent thoracoscopy at time of SSRF. There were no differences in LOS, operative times, and overall mortality between the SSRF/thoracoscopy and SSRF only groups. CONCLUSIONS: R-VATS at the time of SSRF did not identify a statistically significant greater number of occult intrathoracic injuries compared to S-VATS. R-VATS was not associated with increased operative time, LOS, and mortality. Further study is needed to determine if there is benefit to R-VATS in patients meeting requirements for rib fracture repair.

Postoperative Urinary Retention in Patients Undergoing Lung Resection: Incidence and Risk Factors.

BACKGROUND: The purpose of this study was to (1) determine the incidence of postoperative urinary retention (POUR) in patients undergoing lung resection at our institution, (2) identify differences in potential risk factors between patients with and without POUR, and (3) describe patient outcomes across POUR status. METHODS: The medical records of 225 patients between 2016 and 2017 were reviewed, and 191 met criteria for inclusion. The institution's catheterization removal protocol was followed in all patients. Recatheterization was defined as requiring in-and-out catheterization or Foley catheter placement. Fisher exact and Wilcoxon tests were used for analysis. RESULTS: POUR developed in 35 patients (18%). Patients with POUR were older (P = .01), had increased baseline creatinine (P = .04), and a higher prevalence of benign prostatic hyperplasia (P = .007). POUR patients were also less likely to get a Foley catheter intraoperatively (P = .0002). Other intraoperative factors, such as surgical approach and extent of resection, were not significantly different between patients with and without POUR. Postoperative factors (epidural use or days with chest tube) were similar. Although patients with POUR were more likely to be discharged with a Foley catheter (13% vs 0%, P = .002), no difference in length of stay, incidences of urinary tract infections, or 30-day readmission were observed. CONCLUSIONS: POUR develops in approximately 1 in 5 patients undergoing lung resection. Patients with POUR were more likely to not have a Foley catheter placed intraoperatively. However, patients who had POUR did not have worsened patient outcomes (urinary tract infections, length of stay, or 30-day readmission).