Safety of Intra-Arterial Thrombolysis in the Postoperative Period

Abstract

Background and Purpose-Limited systemic fibrinolysis and reduced dosage are features of intra-arterial thrombolyis (IAT) that may be advantageous in the treatment of postoperative strokes. However, IAT may increase the risk of surgical bleeding. We sought to determine the safety of postoperative IAT. Methods-This was a retrospective case series from 6 university hospitals. All cases of IAT within 2 weeks of surgery were identified. Demographics, stroke mechanism, stroke severity, imaging and angiographic findings, time between surgery and lysis, thrombolytic agent used, surgical site bleeding, intracranial bleeding, and mortality rates were determined. Death or complications directly related to IAT were determined. Results-Thirty-six patients (median age, 71.5 years; range, 45 to 85) were identified. Median time from surgery to stroke was 21.5 hours (range, 1 to 120). Open heart surgery was done in 18 (50%), carotid endarterectomy in 6 (17%), craniotomy in 3 (8%), ophthalmologic-ear, nose and throat surgery in 2 (6%), urologic-gynecologic surgery in 4 (11%), orthopedic surgery in 2 (6%), and plastic surgery in 1 (3%). The stroke causes were cardioembolism in 24 (67%), large-vessel atherosclerosis in 4 (11%), dissection in 3 (8%), postendarterectomy occlusion in 4 (11%), and radiation arteriopathy in 1 (3%). Median time to angiogram was 2.5 hours (0.1 to 5.5). Occlusion sites were M1 in 19 (53%), M2 in 9 (25%), internal carotid artery in 5 (14%), basilar artery in 2 (6%), and posterior communicating artery in 1 (3%).Thrombolysis was completed at a median of 4.5 hours (range, 1 to 8.0). Tissue plasminogen activator was used in 19 (53%) and urokinase in 17 (47%). Nine (26%) patients died. Surgical site bleeding occurred in 9 (25%) cases (minor in 6, major in 3). The major surgical bleeds were 2 post-craniotomy intracranial hemorrhages and 1 hemopericardium after coronary artery bypass grafting; all were fatal. Six deaths were non-IAT related: 3 caused by cerebral edema and 3 by systemic causes. Major bleeding complications were significantly more common among patients with craniotomy (PϽ0.02). Conclusions-Postoperative IAT carries a risk of bleeding in up to 25% of patients but is usually minor surgical site bleeding. Avoiding IAT in intracranial surgery patients may reduce complications. Mortality rate in this series was similar to that reported in prior IAT trials. IAT remains a viable therapeutic option for postoperative strokes.

Abdominal Adhesion Prevention: Still a Sticky Subject

“…Furthermore, this approach is associated with an increased risk of post-operative bleeding. The alternative approach of promoting fibrinolysis has also been met with concern due to the potential for postoperative bleeding [106]. …”

Successful Recovery from Carotid Terminus Occlusion after Mechanical Embolectomy in a Fully Anticoagulated Patient

“…Another study was undertaken to review a possible utilization of the intraarterial thrombolysis in early postoperative period. Unfortunately, 25% (9 patients) of the patients had surgical site bleeding complications [9]. Of them, three cases were fatal.…”

Perioperative Stroke

“…There are three main therapeutic options available in the management of ischemic stroke: systemic thrombolysis [111], intraarterial thrombolysis [118][119][120], or catheterbased mechanical interventions [121]. If ischemic stroke is confirmed radiologically and clinically, then a meticulous, multidisciplinary, risk-benefit analysis should be performed regarding patient suitability for thrombolysis.…”