Safety of urgent carotid endarterectomy following thrombolysis

INTRODUCTION: Acute ischemic stroke is a leading cause of morbidity and mortality worldwide, and the incidence of ischemic stroke is predicted to increase in coming years. Carotid atherosclerotic occlusive disease accounts for up to 20% of all ischemic strokes, and mounting evidence suggests that, in the setting of an acute ischemic stroke due to carotid disease, earlier treatment with carotid intervention results in better outcomes. In patients with acute ischemic stroke, systemic or intravenous thrombolysis (IVT) has revolutionized ischemic stroke therapy, and intravenous tissue plasminogen activator (tPA) has become the principal treatment for acute ischemic stroke when administered within 3 to 4.5 hours of neurologic symptom onset. Given these trends in acute ischemic stroke therapy, vascular specialists are increasingly asked to perform carotid intervention following IVT, but reports in the literature examining outcomes in this circumstance are scarce, and the data regarding the appropriate interval from IVT to carotid endarterectomy (CEA) remains controversial.EVIDENCE ACQUISITION: Literature searches were performed in PubMed (MEDLINE) and Ovid examining journal articles published between January let, 1998 and September 30th, 2019. The search terms used were: "urgent carotid endarterectomy," "carotid endarterectomy" AND "thrombolysis," "acute stroke and thrombolysis," "timing of carotid endarterectomy," and various combinations of these terms.EVIDENCE SYTNHESIS: A total of 21 published reports detailing outcomes in 1165 patients have been published to date, with an average interval from IVT to CEA of 7.1 days, a cumulative 30-day stroke and death rate of 4.1% (0-18%) and a mean frequency of intracranial hemorrhage of 2.6% (0-18%). The aggregate data from the 21 reported series suggest that CEA can be performed safely within the first 14 days after the onset of neurologic symptoms in patients receiving antecedent IVT. however, data regarding the safety of urgent CEA within 48 to 72 hours of thrombolysis is conflicting, with some series reporting excellent results and others showing an increased risk of ICH, stroke, and/or death in these select patients.CONCLUSIONS: Given the trend toward expedited treatment of acute ischemic stroke with subsequent transfer to regional referral centers. vascular specialists will be confronted with an increasing number of patients who may require urgent CEA after antecedent IVT Further study is warranted to clearly delineate the appropriate interval from IVT to CEA and, specifically, to establish the safety of CEA with 72 hours of tPA administration

Laparoscopic inferior mesenteric artery ligation: An alternative for the treatment of type II endoleaks

One of the complications of endovascular repair of abdominal aortic aneurysm is endoleak from a patent inferior mesenteric artery (IMA). Between 1995 and 2002, of 213 patients who had endografts placed for abdominal aortic aneurysm, 4 (1.8%) had enlarging aneurysms from type II endoleaks involving a patent IMA and underwent a secondary procedure. Two patients had endovascular embolizations through the superior mesenteric artery, and two patients underwent laparoscopic inferior mesenteric artery ligation. In the laparoscopic group, operative time was 85 minutes (range, 35-136 minutes). One laparoscopic procedure had to be redone due to a missed IMA branch. Length of stay was 0 and 3 days. At mean followup at 16 months (range, 2-42 months), all patients had had successful resolution of endoleaks. Laparoscopic ligation is a minimally invasive treatment for IMA-mediated type II endoleaks

Treatment of Digital Ischemia with Liposomal Bupivacaine

Objective. This report describes a case in which the off-label use of liposomal bupivacaine (Exparel) in a peripheral nerve block resulted in marked improvement of a patient’s vasoocclusive symptoms. The vasodilating and analgesic properties of liposomal bupivacaine in patients with ischemic symptoms are unknown, but our clinical experience suggests a role in the management of patients suffering from vasoocclusive disease. Case Report. A 45-year-old African American female was admitted to the hospital with severe digital ischemic pain. She was not a candidate for any vascular surgical or procedural interventions. Two continuous supraclavicular nerve blocks were placed with modest clinical improvement. These effects were also short-lived, with the benefits resolving after the discontinuation of the peripheral nerve blocks. She continued to report severe pain and was on multiple anticoagulant medications, so a decision was made to perform an axillary nerve block using liposomal bupivacaine (Exparel) given the compressibility of the site as well as the superficial nature of the target structures. Conclusions. This case report describes the successful off-label usage of liposomal bupivacaine (Exparel) in a patient with digital ischemia. Liposomal bupivacaine (Exparel) is currently FDA approved only for wound infiltration use at this time