Another Day in Private Practice...

[sethco]

So, it has been a while since we last had a clinical case for discussion. As usual, residents and fellows treat this as practice for oral boards (i.e. Say your rational for what you would like to do).

84 y/o male with Past Med Hx significant for hypertension sees his PCM for progressive dyspnea over the past 1-2 years and new development of exertional angina. PCM does a cardiac exam and hears a loud systolic murmur and sends the patient for TTE. Echo reveals EF 35-40% with severe calcific AS (Valve Area 0.48 cm2), mod AI, and inferior wall hypokinesis. Pt was then sent for Cath that showed two vessel disease. Admitted for further workup and found to have Creatnine 1.6. Also found to have asymptomatic 90%+ right sided Carotid stenosis on U/S, confirmed by CT Angiography. CTA head shows patent Circle of Willis. Pt denies any pulmonary, endocrine, GI, or neurologic issues. Surgeon schedules patient for CEA/AVR/CABG in same procedure. Surgeon notes that he would prefer that the Carotid be done prior to the cardiac procedure.

Lets start with Preoperative Concerns and then move to how you want manage this patient Perioperatively

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[sevoflurane]

So, it has been a while since we last had a clinical case for discussion. As usual, residents and fellows treat this as practice for oral boards (i.e. Say your rational for what you would like to do).

84 y/o male with Past Med Hx significant for hypertension sees his PCM for progressive dyspnea over the past 1-2 years and new development of exertional angina. PCM does a cardiac exam and hears a loud systolic murmur and sends the patient for TTE. Echo reveals EF 35-40% with severe calcific AS (Valve Area 0.48 cm2), mod AI, and inferior wall hypokinesis. Pt was then sent for Cath that showed two vessel disease. Admitted for further workup and found to have Creatnine 1.6. Also found to have asymptomatic 90%+ right sided Carotid stenosis on U/S, confirmed by CT Angiography. CTA head shows patent Circle of Willis. Pt denies any pulmonary, endocrine, GI, or neurologic issues. Surgeon schedules patient for CEA/AVR/CABG in same procedure. Surgeon notes that he would prefer that the Carotid be done prior to the cardiac procedure.

Lets start with Preoperative Concerns and then move to how you want manage this patient Perioperatively

Dude... I had a very similar case this past week except for the fact that I had 100% occlusion of the right carotid and 99% occlusion of the left + the patient had unstable angina that was getting worse. Vmax of 5m/s and Mean of 50 something---> CEA/AVR/CABG.
I'm going to let some of the others tackle your stem, but there are a couple of differences btw/ your case and mine.

Good case Sethco.

 

[urge]

1 CTA head shows patent Circle of Willis.
2 Surgeon notes that he would prefer that the Carotid be done prior to the cardiac procedure.

1 Fancy stuff. Never heard of it being done.

2 Doing backwards doesn't make sense.

 

[TIVAndy]

So, it has been a while since we last had a clinical case for discussion. As usual, residents and fellows treat this as practice for oral boards (i.e. Say your rational for what you would like to do).

84 y/o male with Past Med Hx significant for hypertension sees his PCM for progressive dyspnea over the past 1-2 years and new development of exertional angina. PCM does a cardiac exam and hears a loud systolic murmur and sends the patient for TTE. Echo reveals EF 35-40% with severe calcific AS (Valve Area 0.48 cm2), mod AI, and inferior wall hypokinesis. Pt was then sent for Cath that showed two vessel disease. Admitted for further workup and found to have Creatnine 1.6. Also found to have asymptomatic 90%+ right sided Carotid stenosis on U/S, confirmed by CT Angiography. CTA head shows patent Circle of Willis. Pt denies any pulmonary, endocrine, GI, or neurologic issues. Surgeon schedules patient for CEA/AVR/CABG in same procedure. Surgeon notes that he would prefer that the Carotid be done prior to the cardiac procedure.

Lets start with Preoperative Concerns and then move to how you want manage this patient Perioperatively

severe AS + mod AI (prob LVH), two vessel disease is a recipe for CPR intraop if bp let down and CPP is compromised. also risk of stroke is high given ICA stenosis. Cr 1.6 should also be looked into, whether this is 2/2 cardiorenal vs other factors. I would probably assess/optimize CRF/ARF before doing anything. I think it maybe reasonable to do CEA first, assuming we can do it under regional (superficial/deep cervical block) then to proceed with AVR/CABG.

 

[sevoflurane]

What does the left carotid look like....

 

[sethco]

1 Fancy stuff. Never heard of it being done.

2 Doing backwards doesn't make sense.

OK, this is where I want the residents to chime in. What are the pros/cons of doing the carotid before the CABG/AVR? What special precautions should be taken?

 

[sethco]

What does the left carotid look like....

70% on the left. As above, asymptomatic.

Seen by Nephrology, felt to be Chronic Kidney Disease. Will follow postoperative.

 

[Shimmy8]

tight BP control with cleviprex during CEA

 

[vector2]

What's his baseline BP? Has his HTN been adequately controlled by his PCP to the extent his AS/CAD will tolerate? How's the RV look? Guy have normal mitral, normal PA pressures?

 

[deleted171991]

Per UpToDate, the patient does not need CEA before (or at the same time as the) CABG:

There is no consensus regarding the effectiveness or staging of prophylactic carotid revascularization in patients scheduled for CABG. The available data suggest that most perioperative strokes are not preventable by carotid revascularization. (See 'Prophylactic carotid intervention' above.)

For patients undergoing CABG who have carotid stenosis, we suggest carotid revascularization rather than no carotid intervention for the following subgroups (Grade 2C) (see 'Prophylactic carotid intervention' above):

•A recently symptomatic carotid stenosis (50 to 99 percent stenosis in men or 70 to 99 percent stenosis in women)

•Bilateral asymptomatic 80 to 99 percent carotid stenoses

•A unilateral asymptomatic stenosis of 70 to 99 percent combined with a contralateral total (100 percent) carotid occlusion

Especially since the Circle of Willis is patent.

One could also argue that the patient falls into the last category. Even then:

We suggest a staged carotid revascularization with carotid endarterectomy or carotid artery stenting before CABG, rather than a combined procedure, for patients with chronic stable angina in the absence of a recent myocardial infarction (Grade 2C).

Thank you for this interesting consult. Now go do a regular CABG and AVR for critical AS.

 

[Robotic Wis-Hipple]

First off, what is this supposed surgical planning input you speak of?


Otherwise, I agree with what's been said so far; asymptomatic carotid stenosis with intact cerebral collateral circ can be done last if not later altogether. But, as is, my plan would be to discuss with surgeon his/her concerns and rationale regarding current surgical plan and voice my concerns about a combined procedure (either cea-->AVR/cabg or AVR/cabg-->cea) vs a staged cea post cardiac surgery.

Periop concerns: baseline cardiovascular dx including significant cerebrovascular dx, periop stroke, htn and the req for maintaining adequate perfusion with both carotid stenosis and AS, as well as CKD that while not at the level that has been shown to increase periop mortality (Cr 1.9) remains significant.

Specific concerns with current surgical plan: cea preceding cardiac surgery/CPB and therefore systemic heparinization after iatrogenic vascular insult may lead to bleeding, expected perturbations in baroreceptor response post repair, as well as performing cea with AVR/cabg as combined procedure likely makes it a "complex procedure" and despite "only" Cr of 1.6 one could make the argument that periop mortality is likely to be increased without any proven benefit, certainly CVA risk is not reduced with cea performed concurrently.

Plan: pre-induction a-line, maintain BP at near baseline, cardiac induction (heavy opioid, minimal sedative hypnotic), cerebral co-ox if not neuromonitoring, tee eval with particular attention to aortic cannula though not as concerning as if LCA was the 90% occluded one, pressor of choice on pump (book says phenylephrine, I like NE though EF isn't that depressed so neo probably perfectly suitable).

Already longer than they'd let me go on an oral so I'll stop and get grilled here

 

[sethco]

What's his baseline BP? Has his HTN been adequately controlled by his PCP to the extent his AS/CAD will tolerate? How's the RV look? Guy have normal mitral, normal PA pressures?

SBP range during hospital admission 130-170s. Only on Metoprolol as outpatient.
Only Left Heart Cath was done and TTE states inadequate TR jet for estimating RVSP. However, TTE states normal RV function and no mention of any MR

 

[urge]

Per UpToDate, the patient does not need CEA before (or at the same time as the) CABG:

Especially since the Circle of Willis is patent.

One could also argue that the patient falls into the last category. Even then:


Thank you for this interesting consult. Now go do a regular CABG and AVR for critical AS.

The level of evidence is expert opinion, which opens the door to do whatever you want. Especially since this is not a national society consensus paper.

Anyway, you are probably right. It might not be needed at all.

 

[Random Anesthesiologist]

I might be convinced to do 2 alines on this. Also cerebral sats (edit: whoops, missed that part of wis-hipple's response).

I'm assuming this cath was not amenable to stent right? If it was, I'm thinking stent + tavr and cea at later date since not symptomatic.

 

[Noyac]

severe AS + mod AI (prob LVH), two vessel disease is a recipe for CPR intraop if bp let down and CPP is compromised. also risk of stroke is high given ICA stenosis. Cr 1.6 should also be looked into, whether this is 2/2 cardiorenal vs other factors. I would probably assess/optimize CRF/ARF before doing anything. I think it maybe reasonable to do CEA first, assuming we can do it under regional (superficial/deep cervical block) then to proceed with AVR/CABG.

CPR in a pt with this degree of AS? Good luck.

Also, if you only agree to regional then what happens when they cross lamp and the pt freaks? Bad idea in my book. But I know some have gotten away with it. GA all the way. Hope he wakes up.

 

[urge]

I might be convinced to do 2 alines on this. Also cerebral sats (edit: whoops, missed that part of wis-hipple's response).

I'm assuming this cath was not amenable to stent right? If it was, I'm thinking stent + tavr and cea at later date since not symptomatic.

Why 2 a lines?

 

[urge]

as CKD that while not at the level that has been shown to increase periop mortality (Cr 1.9) remains significant.

Care to add a reference on the 1.9 creatinine threshold for increased mortality?

 

[sethco]

I'm assuming this cath was not amenable to stent right? If it was, I'm thinking stent + tavr and cea at later date since not symptomatic.

Don't mean to single you out, but you can't do this on your oral boards. You don't get to decide what procedure the patient gets. You are dealt a stem and you roll with it. While in real life, you would most certainly be correct in your thinking, you cant answer this way on your boards.

 

[sethco]

Anybody care to chime in about the pros/cons of doing the carotid prior to AVR/CABG?

 

[sethco]

tee eval with particular attention to aortic cannula though not as concerning as if LCA was the 90% occluded one

Can you expand on your line of thinking regarding if the patient had critical left main disease? Also, what are you looking for in particular with your TEE evaluation of placement of the aortic cannula?

 

[psychbender]

Can you expand on your line of thinking regarding if the patient had critical left main disease? Also, what are you looking for in particular with your TEE evaluation of placement of the aortic cannula?

I believe he is talking about the left carotid artery, not the left coronary artery. I'm assuming his concern would be a malpositioned aortic cannula directing too much flow up the recently opened carotid artery, leading to cerebral hyperperfusion syndrome.

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[Robotic Wis-Hipple]

Care to add a reference on the 1.9 creatinine threshold for increased mortality?

So, I can't seem to find the primary source of that 1.9 threshold. I was pretty sure it came from STS but the closest I found was this (which breaks it down by GFR):

http://m.circ.ahajournals.org/content/113/8/1063.full.pdf

Or this showing renal failure starting at >1.5 increasing vent days, LOS, and mortality:

http://www.ncbi.nlm.nih.gov/m/pubmed/10845827/

In noncardiac surgery the line in the sand is 2.0, but I'm pretty sure I've been taught 1.9 for cardiac surgery, and there are multiple studies showing worse outcomes with ARF as well as studies showing chronic renal insufficiency increasing risk of ARF (and therefore likely increased mortality). But again, I can't find the exact paper that reports 1.9 as the point where increased mortality is seen.

 

[Noyac]

Why 2 a lines?

Ditto. Never heard of needing 2 A lines. But Random is pretty smart so I'm sure I will get some education here.

 

[sethco]

I believe he is talking about the left carotid artery, not the left coronary artery. I'm assuming his concern would be a malpositioned aortic cannula directing too much flow up the recently opened carotid artery, leading to cerebral hyperperfusion syndrome.

Sent from my SM-G920V using SDN mobile

OK, I see now. Makes sense. However, note that it is extremely difficult to diagnose aortic cannula malposition with TEE. What findings would you expect to see?

 

[deleted171991]

Why 2 a lines?

One in each carotid.

 

[sevoflurane]

OK, I see now. Makes sense. However, note that it is extremely difficult to diagnose aortic cannula malposition with TEE. What findings would you expect to see?

Picked this one up a while back after perfusion was commenting on high line pressure.

 

[Doctor4Life1769]

Ditto. Never heard of needing 2 A lines. But Random is pretty smart so I'm sure I will get some education here.

I only know of placing 2 art lines for Type A dissections to attain a proximal and distal BP due to risk of malperfusion. I'm interested as well.

Cerebral O2 sats just like anytime one is going on bypass and/or hypothermic arrest.

 

[Random Anesthesiologist]

Why 2 a lines?

We've done some combo cases recently and had issues with radial lines. I would have two with one for backup. Could be a fem line from surgery. They're also doing a lot of surgery to large vessels on one side.

 

[Random Anesthesiologist]

Don't mean to single you out, but you can't do this on your oral boards. You don't get to decide what procedure the patient gets. You are dealt a stem and you roll with it. While in real life, you would most certainly be correct in your thinking, you cant answer this way on your boards.

Well, to be fair, I wouldn't really say this on the boards. It was just running through my head here. I wouldn't also tell a CTS what to do but I might ask about it. The CTS I work with are great about telling me why or why not an idea is good or not so good.

 

[Robotic Wis-Hipple]

Ok so I'm genuinely interested in what the pro's would do or are doing in this scenario. Looking at the Gravlee cardiac book it mentions mod-severe carotid stenosis increases CVA risk however I'm pretty sure recent studies have concluded no statistically significant decrease in CVA risk with combined procedure. Theoretically to me I'd guess you're trading lower hypoperfusion/ischemic stroke risk for higher hyperemia/embolic stroke risk, especially if CEA done first.

I've done quite a few hearts and have never done one with combined CEA, patients where the surgeon is concerned or H&P elicits risk get doppler'd and CEA first. If severity of carotids isn't enough to result in operative management we have done cases with neuromonitoring (all our hearts get cerebral co-ox) though I admit I'm not sure how common, if at all this occurs out in PP world.

 

[Noyac]

Ok so I'm genuinely interested in what the pro's would do or are doing in this scenario. Looking at the Gravlee cardiac book it mentions mod-severe carotid stenosis increases CVA risk however I'm pretty sure recent studies have concluded no statistically significant decrease in CVA risk with combined procedure. Theoretically to me I'd guess you're trading lower hypoperfusion/ischemic stroke risk for higher hyperemia/embolic stroke risk, especially if CEA done first.

I've done quite a few hearts and have never done one with combined CEA, patients where the surgeon is concerned or H&P elicits risk get doppler'd and CEA first. If severity of carotids isn't enough to result in operative management we have done cases with neuromonitoring (all our hearts get cerebral co-ox) though I admit I'm not sure how common, if at all this occurs out in PP world.

My personal experience wasn't all that good with the combo CEA/AVR/CABG. We did the CEA first and left the neck open for closure at the end of the case. This way we wouldn't get a huge hematoma while anticoagulated on pump. This was good in theory but the neck bled tremendously during the pump run and I had to start transfusing early. Surgeon looked at me after the case and said, " Don't ever let me try that again!" The pt did fine tho.

But Sevo recently did one with much better results intraop. They probably had the advantage of a better surgeon and anesthesiologist that day. Would be interested to hear more from him. Sevo, you listening?

 

[deleted171991]

But Sevo recently did one with much better results intraop. They probably had the advantage of a better surgeon and anesthesiologist that day. Would be interested to hear more from him. Sevo, you listening?

@Noyac calling @sevoflurane...

Now it should alert him, when he logs in.

 

[sevoflurane]

My personal experience wasn't all that good with the combo CEA/AVR/CABG. We did the CEA first and left the neck open for closure at the end of the case. This way we wouldn't get a huge hematoma while anticoagulated on pump. This was good in theory but the neck bled tremendously during the pump run and I had to start transfusing early. Surgeon looked at me after the case and said, " Don't ever let me try that again!" The pt did fine tho.

But Sevo recently did one with much better results intraop. They probably had the advantage of a better surgeon and anesthesiologist that day. Would be interested to hear more from him. Sevo, you listening?

10-4 brotha.

As you know, I’ve done 2 of these cases in the last 6 months. The one last week was a combined CEA/AVR/CABG. One of the carotids was 100% occluded so there was nothing to be done on that side. The other side was 99% occluded. Basically, this guy would have stroked out with a pump run. This individual also had unstable angina with bouts of substernal chest pain secondary to his 99% occlusion of his LAD and severe aortic stenosis. A tough case for all those involved. CT surgery called me up and consulted me on the case. Vascular, CT surgery and I subsequently all sat down and decided that a combined technique was the most reasonable approach. Posterior communicating artery was open bilaterally and I think that it’s good information to know.

CEA first. Lined him up/ TEE and draped for both surgeries. I am lucky in that my CT and Vascular surgeons are the best I have seen in my career- Just awesome at what they do. Team players, fast, extremely talented as well as good people/friends (Noy you met one of them on our bike trip- the big dude).

We did run EEGs to try and pick up on any changes during the CEA. We closed the carotid before the CABG/AVR (didn’t leave the carotid open like Noy’s case). We left a window on the field so that we could see the incision during bypass. Stayed super dry the entire time. We also had a Jackson-Pratt drain that I had at the head of the bed so I could pick up on increase drainage from the CEA during full heparinization- there was none. The patient did require some tight BP control throughout the combined procedure… but that’s what we do every day in anesthesia.

The case went smoothly. He was moving everything and appropriate after 45 minutes in the ICU. He was extubated shortly afterwards and was discharged on Monday.

This does not belong on this thread, but for the record... anesthesia has it's issues, but day to day work is awesome. Overall, I wouldn't pick anything else.

 

[sethco]

So, main purpose and teaching part of this case was to get everybody thinking of Carotid Stenosis management in the setting of more pressing issues (in this case severe AS/Unstable Angina)

FFP alluded to recommendations from UpToDate about whether to perform CEA prior to CABG. Unfortunately, this is a class 2C recommendation, so not everybody agress with it. Another way to think about is if a guy shows up to your OR for elective surgery and had 90% Carotid Stenosis (assuming without AS or CAD), would you feel comfortable doing the elective surgery prior to fixing his Carotid?

Sevo had a good case and agree with his management. Our plan was to either leave open or place a drain in the neck prior to moving on to the AVR/CABG. Funny thing is, the last case I presennted here a couple months ago had his Carotid fixed 3 days prior to a double valve/CABG. On the day of surgery he developed a neck hematoma, but we had to proceed because he had a IABP in place was starting to shows signs of distal ischemia presumably secondary to IABP.

Pros of CEA prior to CABG/AVR:
-Despite the 2C recommendation, presumably lower intraop/postop CVA risk
-No need to maintain higher perfusion pressures on bypass
-Lowers risk of aortic injury in the post-bypass setting secondary to not needing higher pressures


Disadvantages:
-Higher risk of reperfusion injury going unrecognized
-Possibly delayed assessment of neurologic function post-CEA (Wake-up test prior to CABG/AVR?)
-Questionable risk reduction of CVA
-Not addressing the more urgent issue may lead to injury (i.e. Higher perfusion pressures needed for the CEA may result in myocardial ischemia)
-Heparination required for bypass may result in significant bleeding from surgical site

I am sure others have more to add, but all of these factors should be weighed carefully in your discussion with the surgeon.

 

[deleted171991]

I personally think that every single cardiac surgery patient should be advised that their IQ will drop by at least 10 points, after bypass (in this particular case, I would bet on 20+). Then we should go from there, deciding if they need the surgery and exactly what surgery.

 

[sevoflurane]

So, main purpose and teaching part of this case was to get everybody thinking of Carotid Stenosis management in the setting of more pressing issues (in this case severe AS/Unstable Angina)

FFP alluded to recommendations from UpToDate about whether to perform CEA prior to CABG. Unfortunately, this is a class 2C recommendation, so not everybody agress with it. Another way to think about is if a guy shows up to your OR for elective surgery and had 90% Carotid Stenosis (assuming without AS or CAD), would you feel comfortable doing the elective surgery prior to fixing his Carotid?

Sevo had a good case and agree with his management. Our plan was to either leave open or place a drain in the neck prior to moving on to the AVR/CABG. Funny thing is, the last case I presennted here a couple months ago had his Carotid fixed 3 days prior to a double valve/CABG. On the day of surgery he developed a neck hematoma, but we had to proceed because he had a IABP in place was starting to shows signs of distal ischemia presumably secondary to IABP.

Pros of CEA prior to CABG/AVR:
-Despite the 2C recommendation, presumably lower intraop/postop CVA risk
-No need to maintain higher perfusion pressures on bypass
-Lowers risk of aortic injury in the post-bypass setting secondary to not needing higher pressures


Disadvantages:
-Higher risk of reperfusion injury going unrecognized
-Possibly delayed assessment of neurologic function post-CEA (Wake-up test prior to CABG/AVR?)
-Questionable risk reduction of CVA
-Not addressing the more urgent issue may lead to injury (i.e. Higher perfusion pressures needed for the CEA may result in myocardial ischemia)
-Heparination required for bypass may result in significant bleeding from surgical site

I am sure others have more to add, but all of these factors should be weighed carefully in your discussion with the surgeon.

Great case to think about.
Thanks for sharing.