Nasal Intubation is not Associated with "Smoother" Emergence from General Anesthesia for Carotid Endarterectomy: A Case-Cohort Study.

BACKGROUND: Postoperative hematoma after carotid endarterectomy (CEA) is a devastating complication and may be more likely in patients with uncontrolled hypertension and coughing on emergence from anesthesia. We sought to determine if intubation with a nasal endotracheal tube (ETT)-instead of an oral ETT-is associated with "smoother" (i.e., less hemodynamic instability) emergence from general anesthesia for CEA. METHODS: Patients receiving CEA between December 2015 and September 2021 at a single tertiary academic medical center were included. We examined the electronic anesthesia records for 323 patients who underwent CEA during the 6-year study period and recorded consecutive systolic blood pressure (SBP) values during the 10 minutes before extubation as a surrogate for "smoothness" of the emergence. RESULTS: Intubation with a nasal ETT, when compared with intubation with an oral ETT, was not associated with any difference in maximum, minimum, average, median, or standard deviation of serial SBP values in the 10 minutes before extubation. The average SBP on emergence for patients with an oral ETT was 141 mm Hg and with a nasal ETT was 144 mm Hg (P = 0.562). The maximum SBP for patients with oral and nasal ETTs were 170 mm Hg and 174 mm Hg, respectively (P = 0.491). There were also no differences in the qualitative "smoothness" of emergence or in the percentage of patients who required an intravenous dose of 1 or more antihypertensive medications. The incidence of postoperative complications was similar between the 2 groups. CONCLUSIONS: When SBP is used as a surrogate for smoothness of emergence from general anesthesia for CEA, intubation with a nasal ETT was not associated with better hemodynamic stability compared to intubation with an oral ETT.

Ultrasound-assisted catheter directed thrombolysis for pulmonary embolus during extracorporeal membrane oxygenation.

BACKGROUND: Acute pulmonary embolism (PE) is the third most common cause of cardiovascular death. For patients who are hemodynamically unstable, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support has been shown to provide hemodynamic stability, and allow time for definitive treatment and recovery. Ultrasound-assisted catheter directed thrombolysis (USAT) has the potential to be a safe adjunct and expedite right ventricular (RV) recovery for patients requiring VA-ECMO for PE. METHODS: A review of all VA-ECMO patients from January 2017 to September 2019 was performed. A total of 49 of these patients were cannulated due to a PE. USAT therapy was used as an adjunct in 6 (12%) of these patients. These 6 patients were given standardized USAT therapy with EKOs catheters at 1 mg/h of tissue plasminogen activator with an unfractionated heparin infusion for additional systemic anticoagulation. Outcomes, including in-hospital death, 90-day survival, RV recovery, and complications, were examined in the cohort of patients that received USAT as an adjunct to ECMO. RESULTS: Median age was 54 years old. Five of the six patients presented with a massive PE and had a PE severity score of Class V. One patient presented with a submassive PE with a Bova score of 2, but was cannulated to VA-ECMO in the setting of worsening RV function. All patients demonstrated recovery of RV function, were free from in-hospital death, and were alive at 90-day follow-up. CONCLUSION: Ekosonic endovascular system therapy may be a safe and feasible adjunct for patients on VA-ECMO for PE, and allow for survival with RV recovery with minimal complications.

Endovascular Vertebral Artery Transposition Using Flow Reversal Technique for Left Subclavian Artery Stump Syndrome.

BACKGROUND: Cerebellar strokes are a rare complication related to thoracic endovascular aortic repair (TEVAR). This can manifest in an indolent manner or as a neurological catastrophe. Often it is unclear when a surgical intervention would be needed. Patients at risk for this relatively rare complication are not easily identified. CASE: We describe an endovascular option with flow reversal for left vertebral artery transposition using stent grafts for relocating arterial inflow and excluding a floating thrombus at the proximal subclavian artery (SCA) related to a previous TEVAR. CONCLUSIONS: Ligation of the subclavian artery proximal to the vertebral artery should be considered when performing a carotid subclavian bypass for elective TEVAR. This case details a unique, less invasive approach for vertebral artery transposition and thrombus exclusion in a high-risk patient with previous neck dissection.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Not Yet Applicable for Widespread Out-of-Hospital Use: A Case of Nonsurvivable Complication from Prolonged REBOA Inflation.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is being considered for temporizing catastrophic hemorrhage before arriving at a specialty center for definitive surgical management. CASE: We describe the clinical case of a 72-year-old male with a ruptured infrarenal aortic abdominal aneurysm initially stabilized with REBOA at an outside facility and transferred to our care. Transport time was >100 minutes. Despite successful surgical repair of the ruptured aneurysm, the patient expired from multiple-organ failure likely related to ischemia-reperfusion injuries from prolonged balloon occlusion of the aorta. CONCLUSIONS: Ischemia-mitigating techniques and therapies need to improve drastically before the clinical application of REBOA can be effectively extended to outside the vicinity of specialty centers.

Superior gluteal artery as a reliable back door to embolize mycotic pseudoaneurysm of an isolated Internal Iliac artery.

BACKGROUND: Antegrade access through the origin of the internal iliac and direct percutaneous access under cross-sectional imaging guidance are commonly used for embolization of internal iliac artery aneurysms, pseudoaneurysms, or endoleaks. Here, we report superior gluteal artery retrograde access to treat internal iliac artery mycotic pseudoaneurysm in a patient with failed direct percutaneous access. CASE PRESENTATION: We present a 65-year-old female with a history of diverticulitis and sigmoidectomy. Post-sigmoidectomy course was complicated by left common iliac artery (CIA) iatrogenic injury which required surgical ligation of the left CIA and graft placement. However, the graft was subsequently resection due to infection. Follow up CT imaging showed a 6 cm mycotic pseudoaneurysm (PSA) of the left internal iliac artery. Initially, the PSA sac was directly accessed and embolized under direct CT-guidance using Onyx. However, enlargement of the PSA sac was noted on one week follow-up CT images. Then, superior gluteal artery was accessed under ultrasound guidance, and the PSA sac and feeding vessels were re-embolized with coil and Onyx under fluoroscopy. CONCLUSION: Retrograde access through superior gluteal artery is a feasible and safe approach to embolize internal iliac aneurysms, pseudoaneurysms, or endoleaks, when the antegrade or direct percutaneous access is limited.

Vacuum-Assisted Incisional Closure Therapy After Groin Reconstruction With Muscle Flap.

Background Groin reconstruction with muscle flap coverage is associated with high wound complication rates. Incisional vacuum-assisted closure (iVAC) therapy may lower wound complications. We evaluated the impact of iVAC on postoperative outcomes in patients following groin reconstruction with muscle flap coverage. Methods We conducted a retrospective review of patients who underwent groin reconstruction with muscle flap coverage in 2012-2018. Patients were divided into those who received iVAC therapy and those who received standard sterile dressings (SSD). Results Of the 57 patients included, most received iVAC therapy (71%, n = 41) and the rest received SSD (28%, n = 16). The iVAC group had higher rates of diabetes, hypertension, coronary artery disease, and peripheral artery disease (p < 0.05). However, iVAC patients had comparable length of hospital stay (12 vs 8.5 days p = 0.0735), reoperations (34% vs 31%, p = 0.8415), and readmissions (32% vs 37%, p = 0.6801) with SSD patients. iVAC placement was less likely in prophylactic flaps (odds ratio 0.08, p = 0.0049). Conclusion Patients with a prophylactic flap were less likely to receive vacuum therapy, which may highlight a selection bias where surgeons pre-emptively use iVAC therapy in surgical candidates identified as high risk. The pre-emptive use of iVAC may minimize adverse postoperative outcomes in high-risk patients.

Successful Treatment of Acute Limb Ischemia Secondary to Iatrogenic Distal Embolization Using Catheter Directed Aspiration Thrombectomy.

Objective: Acute limb ischemia (ALI) due to thromboembolism is a limb- and life-threatening condition regularly encountered by vascular surgeons. Iatrogenic distal embolization is occasionally seen as a complication of various endovascular procedures. We present a series of four patients who developed ALI due to arterial embolization during cardiovascular procedures that were successfully treated via catheter directed aspiration embolectomy. Methods: Retrospective review of demographics, risk factors, and procedural outcomes was completed for 4 patients who presented with ALI due to distal embolization following cardiovascular procedures. All patients were successfully treated with catheter directed aspiration embolectomy using the Penumbra Indigo System (Penumbra Inc., Alameda, California). All patients had high-quality angiography demonstrating successful embolectomy and end-procedure patency. Results: Three patients presented with Rutherford 2A and one with Rutherford 2B ALI secondary to intraoperative distal embolization. Three patients presented with ALI secondary to distal embolization during peripheral vascular interventions, and one following emergent intra-aortic balloon pump (IABP) placement for myocardial infarction. All emboli were located in the infra-inguinal vasculature. Median post-operative ABIs were 0.94 (n = 4). Median length of stay was 2 days. There were no mortalities and no need for adjunctive fasciotomy, amputation, or bypass for limb salvage. All patients improved clinically after intervention, and returned to their reported pre-hospitalization functional status. Conclusion: All procedures achieved technical success with catheter-directed aspiration thrombectomy with or without adjunctive lysis. Catheter-directed aspiration embolectomy with the Penumbra Indigo System for ALI following an iatrogenic embolic event is a safe, less-invasive treatment option. The use of this technology may reduce the need for traditional open thrombectomy or thrombolytic therapy to address ALI.