Tension pneumomediastinum from opioid inhalation.

Pneumomediastinum is a rare complication of substance use, likely due to a Valsalva maneuver after drug inhalation. There are no previously documented associations between pneumomediastinum and opioid use. A 30-year-old man with a history of recent heroin and fentanyl inhalation presented to the emergency department in respiratory distress requiring intubation. His course was complicated by pneumomediastinum which subsequently developed tension physiology. He required emergent surgical decompression with a "blowhole incision" to his anterior chest. Although a rare complication of polysubstance use, pneumomediastinum can progress to tension physiology, requiring prompt diagnosis and management.

Resurrection of Chronically Occluded Prosthetic Bypass Grafts in a Single Stage with Suction Thrombectomy and Intervention.

BACKGROUND: Peripheral arterial occlusive disease (PAOD) continues to be a vexing problem despite the advent of endovascular techniques augmenting traditional open repair. At our institution, we have found there is a growing number of patients with PAOD who are vein-challenged and have undergone prosthetic bypass previously for infrainguinal arterial reconstruction. When occluded, these grafts have been abandoned for a new bypass strategy or amputation. We present a novel technique of reestablishing flow through chronically occluded prosthetic bypass grafts. METHODS: A retrospective review of a prospectively maintained database compiled at 2 institutions between 2016 and 2019 was performed. Six patients had previous prosthetic bypass grafts with 4 patients having femoral to popliteal grafts, 1 patient with a femoral to femoral graft, and 1 with a femoral to posterior tibial bypass graft. All patients had an attempted single-stage intervention to clear chronically occluded grafts. RESULTS: A total of 6 patients were included in the study. Indications for intervention were chronic, critical limb ischemia with tissue loss (3), severe claudication (2), and acute on chronic limb ischemia (1). Average time from bypass to suction thrombectomy was 29 months (6-60 months). Mean patency duration is 13 months (1-28 months). Adjunctive procedures include overnight lysis to improve outflow in 1 patient (16.6%), drug-coated balloon angioplasty (83.3%), or stents (83.3%). There were no embolic complications during these procedures. All (2) wounds healed and all are maintained on full-dose anticoagulation and/or antiplatelet therapy. CONCLUSIONS: Often, the timing of bypass graft occlusion is unknown, and the risk of embolism with lysis for chronically occluded bypass grafts is concerning with traditional peripheral intervention techniques. We report a new and unique minimally invasive approach to resurrect chronically occluded prosthetic bypass grafts often successful in just one stage. This tool offers an alternative technique for limb salvage in complex patients and as use increases, requires further interrogation.

Initial Results of Selected Use of Covered Stents in Transcarotid Artery Revascularization.

BACKGROUND: Transcarotid artery revascularization (TCAR) is a novel, hybrid approach to treating carotid disease in the treatment of stroke and stroke prevention. Early results of this hybrid approach to carotid stenting using flow reversal have been promising, with reported stroke rates around 1-2.8%.1,2 Currently, carotid stenting, regardless of approach, is performed with uncovered stents, which incurs the risk of plaque protrusion through the stent and in-stent restenosis. Overall, plaque protrusion is a rare event, with a reported incidence of 2.8% on angiography, but it is associated a high rate of ischemic complications (up to 66.7%).3 The use of covered stents could eliminate the risk of plaque protrusion and therefore short to midterm embolic phenomenon during the remodeling process. It also may improve rates of in-stent restenosis as it is a fully covered stent. Adoption of this technique has the potential to further improve the safety, efficacy, and durability of TCAR. METHODS: We performed a retrospective review of a prospectively maintained database of patients undergoing TCAR with covered stents between September 2018 and December 2019. Procedures were performed by the same operator at 2 separate institutions. Indications included severe asymptomatic or symptomatic carotid stenosis with high-risk lesions defined as lesions 2 cm lesions or longer and/or >50% of the lesion containing soft plaque or bleeding carotid pseudoaneurysm. Our primary outcomes included periprocedural and 30-day stroke rates. Secondary outcomes included stent patency and other procedure-related complications. All patients were maintained on clopidogrel postprocedure for 3 months and then transitioned to aspirin, unless otherwise indicated. RESULTS: A total of 6 patients underwent TCAR with covered stent angioplasty during this time period. Patient demographics included 5 males and 1 female, with an average age of 70.8 ± 4.6 years. Indications for stenting included 4 patients with asymptomatic >70% carotid stenosis and 1 patient with transient ischemic attack-like symptoms and >70% stenosis, and 1 patient with bleeding carotid pseudoaneurysm. Gore Viabahn covered stents were used in all patients. There were no periprocedural or postprocedural ischemic events at 30 days. All 6 stents remained patent at follow-up on duplex ultrasound, and all patients remained asymptomatic on clinical follow-up (average 3.4 [1.4-6.9] months). CONCLUSIONS: The use of covered stents for TCAR appears to be a safe and effective in select patients requiring carotid intervention. It holds the potential to decrease ischemic events from plaque protrusion and in-stent restenosis in the long-term. Further investigation in device design or clinical evaluation is warranted.

The Implementation of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Program at a Level 1 New England Trauma Center: Feasibility and Early Outcomes.

OBJECTIVES: We evaluated the feasibility of implementing a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) program at our urban level 1 trauma center and evaluated early outcomes. DESIGN: A multidisciplinary committee including physicians (trauma surgery, emergency medicine, vascular surgery, and interventional radiology) and nurses created clinical practice guidelines for the placement of REBOA at our institution. All trauma surgeons and critical care board certified emergency medicine physicians were trained in placement and nurses received management training. A formal review process was implemented to identify areas for improvement. Finally, we instituted refresher training to maintain REBOA competency. Trauma patients with noncompressible torso hemorrhage from blunt or penetrating injuries who were partial or nonresponders to blood product resuscitation were included. Pregnant patients, children, or patients with significant hemothorax or suspected aortic or cardiac injury were excluded. RESULTS: Over seven months, eight catheters were successfully placed, all on the first attempt, including six in Zone 3 and two in Zone 1. All Zone 3 catheters were placed for pelvic fracture-related bleeding which were subsequently embolized. The Zone 1 catheters were placed immediately preoperatively for intraabdominal bleeding. Upon committee review, one critique was made regarding zone selection. One patient developed an arteriovenous fistula after placement which resolved without intervention. There were no other complications and all patients survived to discharge. CONCLUSIONS: An REBOA program is feasible and safe following a comprehensive multidisciplinary effort. The efforts described here can be utilized by similar trauma programs for adaptation of this endovascular approach to bleeding control.