Carotid endarterectomy after DES

[Colba55o]

Hate to bring up this topic again..

Reviewing a chart today I came across a 67 year old lady, that is about 90 days out from a DES after an NSTEMI, scheduled for upcoming CEA due to critical ICA stenosis >90% occlusion that was found out routine screening. Been asymptomatic neurologically. Cardiologist has "cleared" patient provided ASA/plavix is not interrupted and vascular is fine with that.
Copied from a previous post, from ACC/AHA

5.2. Timing of Elective Noncardiac Surgery in Patients With Previous PCI
- Elective noncardiac surgery should be delayed 14 days after balloon angioplasty.
- Elective noncardiac surgery should optimally be delayed 365 days after DES.
- Consensus decision among treating physicians about risks of surgery and antiplatelet therapy.
- Elective noncardiac surgery after DES can be considered after 180 days, if the risk of further delay is greater than the risk of ischemia and stent thrombosis.
- Elective noncardiac surgery should not be performed within 30 days after BMS, or 12 months after DES if dual antiplatelet therapy will need to be discontinued periop.
- Elective noncardiac surgery should not be performed within 14 days of balloon angioplasty if aspirin will need to be discontinued periop.

The ambiguity for me is if the ASA/Plavix is to be continued is it ok to proceed with surgery less than 180 days post DES. How do we know the risk of CVA in the next 90 days is greater than risk of MI in the next 90 days if we go ahead with surgery? Is it even my call to make? I would think as long as we document that patient explained that she has an increased risk of perioperative MI than if we waited another 90 days we'd be covered but I'm not sure.

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[linkin06]

discuss with surgeons and cardiologists.

 

[vector2]

Her risk of stroke is probably 0.5-1% per year. Her risk of a perioperative MACE given her likely risk factors and not even being 6 months out from a DES is probably well over 5% (even if DAPT is continued). Make of that what you will.

 

[Ronin786]

The way I always understood these guidelines was non-cardiac surgery is a no-go within the first 180 days, after 180 days it's OK if further delay is worse with the caveat that DAPT be continued and all things go after one year.

 

[bigdan]

That's a tough one.

If she were mine, I'd like cardiology to say she's optimized post-PCI (ideally stopped smoking, taking her statins & beta-blocker along with the DAPT) and cardiac symptom free, as well as have the surgeon's input (and documentation) that waiting on this CEA puts the patient at risk. Then tell the patient the truth: she's in a pickle, and I'd be sure to mention that there is increased risk of in-stent thrombosis simply because of the surgery, and that in-stent thrombosis has a very high mortality. Stroke also carries the risk of mortality. Neither can be predicted in terms of time or severity. Does she still want to go to the OR? Assuming you get all that, I'd proceed on DAPT.

 

[pgg]

I would delay.

Something else to keep in mind, it's not just the DES timing. She had a MI. She didn't go in to see her cardiologist for a routine checkup, or even with some stable angina, wind up in the cath lab getting a stent 'cause why not, we're in there anyway ... she had a NSTEMI. Three months ago.

Asymptomatic carotid stenosis (even 90%) that was found on a routine screen has nowhere near the morbidity/mortality risk in the next 90 days that a vascular surgery procedure has 90 days out from a MI and DES.

Wait.

 

[Colba55o]

Thanks for input..

She's still smoking like a chimney and has a strong family hx of fatal MIs at an early age (nephew died at 34 from a STEMI)
Yet cardiology gave the go ahead and vascular surgeon wants to proceed.
Is it my call to refuse to do the case? Will I be on the hook if a cardiac event occurs post op? I work in a small community hospital if that matters.

 

[bigdan]

Can I backpedal now?

 

[GravelRider]

Thanks for input..

She's still smoking like a chimney and has a strong family hx of fatal MIs at an early age (nephew died at 34 from a STEMI)
Yet cardiology gave the go ahead and vascular surgeon wants to proceed.
Is it my call to refuse to do the case? Will I be on the hook if a cardiac event occurs post op? I work in a small community hospital if that matters.

Technically, it's the patient's call. As long as the patient demonstrates that she fully understands that the risks likely outweigh the benefits in this situation, all you can do is document your discussion.

A cardiology "clearance" doesn't really mean much. All they are usually saying is that there is nothing else for them to do...diagnostic or intervention. I would have this discussion with the surgeon first and then both the surgeon and patient. To be honest, the surgeon doesn't want to deal with the ramifications of a periop MI either. Express your concern and if he's reasonable, you can likely steer him in your direction.

 

[mimelim]

In my opinion...

Doing this case is incredibly poor judgement. We currently have debates within vascular surgery if ANYONE that has asymptomatic carotid disease should get a CEA. Never mind people with a recent PCI. All of the trials that speak on this issue compared ASA vs. ASA + surgery. That means no plavix, no statins, etc. And, even in those trials, the risk reduction had to be measured at 5 years to get something of significance (11% vs. 5% risk of stroke). I was at a conference last year where several prominent stroke neurologists were pushing very hard to get rid of asymptomatic CEAs entirely. I would say that most of us still favor doing them in some patients and certainly if I have 80-99% stenosis, I'm getting a CEA. I think that offering a patient a CEA or even CAS this close to PCI is a poor decision.

Now, symptomatic? Entirely different story. The plaque pathology is different. The risk profile is different. Despite the guidelines from ACA/AHA, I would be a strong advocate of CEA for a patient with 50-99% stenosis who was symptomatic. I would do it 3-14 days after the neurological event and I would do it under local with awake neurological monitoring. Certainly not my preferred way of doing a CEA (general anesthesia with EEG or TCD monitoring), but I think offers an acceptable cardiac risk balanced against the neurological risk.

However, this is not your call. You certainly can voice your concerns and if the patient is not aware of what is going on, then I think that you need to make sure that the appropriate conversations have been had. But, at the end of the day, this surgeon is making a judgement call. Patient factors and surgeon factors make it 'possible' that the risk of stroke is greater than major adverse event. Hard to fathom, but again, an argument can be made. If the surgeon feels comfortable with the risk, I guarantee that they don't want the complication anymore than you do. I certainly know some that would probably do it if someone asked them to.

 

[Wiscoblue]

The fact that she had the DES for an MI is the most significant fact here. If it was for angina, I would proceed.


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[pgg]

Welcome, thanks for posting. Always great to have surgeons contribute.

Now, symptomatic? Entirely different story. The plaque pathology is different. The risk profile is different. Despite the guidelines from ACA/AHA, I would be a strong advocate of CEA for a patient with 50-99% stenosis who was symptomatic. I would do it 3-14 days after the neurological event and I would do it under local with awake neurological monitoring.

There is a lot of good data that shows that anesthetic method for CEA (awake vs general) has no effect on outcome. It's an error to think that we can tweak this patient's risk by doing this under local.

We see this line of thinking not infrequently from other specialties who "clear" patients for surgery (cardiology mostly). A patient who's in that marginal gray area might come with a note stating OK for MAC ... or spinal, or something else that is perceived to be lower risk. But the truth is that the bulk of the perioperative risk is related to the patient and the stress/inflammation of surgery, not which pharmacologic agent or anesthetic technique we use (within the margins of good judgement and skill).

Also, surgeons who can do these awake are rare these days. There is additional risk in doing a case in a manner unusual to an institution, even if the surgeon is comfortable with it.

However, this is not your call. You certainly can voice your concerns and if the patient is not aware of what is going on, then I think that you need to make sure that the appropriate conversations have been had. But, at the end of the day, this surgeon is making a judgement call. Patient factors and surgeon factors make it 'possible' that the risk of stroke is greater than major adverse event. Hard to fathom, but again, an argument can be made. If the surgeon feels comfortable with the risk, I guarantee that they don't want the complication anymore than you do. I certainly know some that would probably do it if someone asked them to.

Ah, but it is our call. We are doctors, not an ancillary service.

Refusing to do a case isn't something we should just randomly do. Of course we should discuss it with the surgeon first. It's absolutely possible that they know things we don't that influence the larger risk picture. Of course we should discuss it with the patient, with respect for their autonomy, factoring in their own wishes, risk tolerance, and quality of life goals.

But in the end, even though this is the surgeon's patient ... it's our patient too for the perioperative hours, and we have an obligation to do the right thing.

I wouldn't let a patient give "informed consent" to violate NPO guidelines, and I wouldn't let a surgeon dictate that NPO guidelines can be waived if we do an awake spinal instead of general anesthesia. And I wouldn't let either one overrule me about doing a CEA in an asymptomatic patient 3 months out from a DES and MI.

 

[Mman]

Personally I don't feel like it's my call to decide, but more my role to make sure appropriate discussions have been had with cardiologist and make sure the patient understands those risks. If the cardiologist and the patient and the surgeon have gone through all of that and everybody understands the risks/benefits, then I'll do my best to keep them safe.

On a related note, I almost never "cancel" a case for a medical concern. I get the patient to cancel it themselves after explaining the risks and why it might be better to come back another day.

 

[pgg]

On a related note, I almost never "cancel" a case for a medical concern. I get the patient to cancel it themselves after explaining the risks and why it might be better to come back another day.

I get your point on this, there's a diplomatic style to doing it in a way that keeps people happy.

I've always tried to do the same, on the very rare occasions where I think delay is the best option.

But let's be completely honest, if we steer the conversation and manipulate patients or surgeons into cancelling or delaying cases, we are effectively cancelling. Sure it's a collaborative multidisciplinary consensus-building synergistic groupy way to do it, something any passive aggressive nurse would be proud of, but until we got involved, the surgeon and patient were going full speed ahead. Let's own our role and admit, even if just to ourselves, that we're the ones stopping the show.

In this specific case, even if the patient and surgeon can't be brought around, and I can't talk them into delaying the case themselves, I'm still not doing it.

 

[Mman]

In this specific case, even if the patient and surgeon can't be brought around, and I can't talk them into delaying the case themselves, I'm still not doing it.

So if the patient, cardiologist, and surgeon think it's in the patient's best interest to have this surgery right now, you aren't going to do it? Really? WTF are you going to do? Send them back to a different cardiologist for a different opinion that you like better? Let them find one of your other colleagues to do the case?

It is what it is. The patient's cardiologist feels they are in optimal condition to undergo the procedure given the risks/benefits laid out by the surgeon.

 

[GravelRider]

So if the patient, cardiologist, and surgeon think it's in the patient's best interest to have this surgery right now, you aren't going to do it? Really? WTF are you going to do? Send them back to a different cardiologist for a different opinion that you like better? Let them find one of your other colleagues to do the case?

It is what it is. The patient's cardiologist feels they are in optimal condition to undergo the procedure given the risks/benefits laid out by the surgeon.

It is ultimately the patient's decision in this case, but I guess you can bring up a slippery slope argument. You may understand that a CEA in this patient is a risk outweighing the benefit type of case, but the patient and surgeon are willing to take on that risk. However, where do you draw the line? If a patient comes in for an elective knee arthroscopy, but just ate a big mac, are you going to cancel? What if both the patient and surgeon say they understand the risk of aspiration, but they are willing to take that risk? Are you still going to go through with the case?

That's an extreme example, but the point is, we are more than just techs. If a surgery is truly unwarranted or unnecessarily risky then you ought to cancel...for the patient's sake. The vast majority of the time the risks/benefits have not been explained thoroughly to the patient.

 

[Southpaw]

In my opinion...

However, this is not your call. You certainly can voice your concerns and if the patient is not aware of what is going on, then I think that you need to make sure that the appropriate conversations have been had. But, at the end of the day, this surgeon is making a judgement call. Patient factors and surgeon factors make it 'possible' that the risk of stroke is greater than major adverse event. Hard to fathom, but again, an argument can be made. If the surgeon feels comfortable with the risk, I guarantee that they don't want the complication anymore than you do. I certainly know some that would probably do it if someone asked them to.

I appreciate your opinion. It's your call whether or not you proceed with surgery. It's my call whether or not I provide you with anesthesia services. And fortunately with these cases, at my place, if I say 'No', my whole group says 'No'.

In the case of a bad outcome, you think I won't be named in the lawsuit simply because you decided it was ok to proceed? Yeah right. In the eye of the law, and when I look in the mirror each day, I face the fact that I'm a responsible physician and must act as such. In this case, we have a noncompliant patient hoping to have elective surgery that goes against published literature. Cards wants to proceed? Surgery wants to proceed? Sure, go ahead. I elect to find other work.

 

[Southpaw]

So if the patient, cardiologist, and surgeon think it's in the patient's best interest to have this surgery right now, you aren't going to do it? Really? WTF are you going to do? Send them back to a different cardiologist for a different opinion that you like better? Let them find one of your other colleagues to do the case?

It is what it is. The patient's cardiologist feels they are in optimal condition to undergo the procedure given the risks/benefits laid out by the surgeon.

I assure you, if this case ends in a bad outcome, and is brought before any good, responsible peer review, it won't end without a severe dent in my reputation at best. And it may/should end with a lawsuit.

I don't care what cardiology or vascular says. The patient is asymptomatic neurologically! They can wait another 3 months to minimize the risk. The patient is also noncompliant! I'm in private practice and cancel minimally, but I'm not sticking my neck out for a patient who doesn't even want a decent enough outcome to stop smoking. We can move on the next surgery, and see this patient later on down the road.

 

[seinfeld]

I am with Mman for the most part on this one. Take the flip side, say the case gets cancelled by you and then the person has a massive CVA, will the guidelines protect you when the surgeon, the cardiologist and the patient decided to it was the best thing to do? I always ask the patients what they were told of the risks, if they were never told of the risk of thrombosis then I call the cardiologist and the surgeon and tell them the failed to properly consent the patient, and that THEY need to discuss with the patient before we go any further. Then I would document the conversations with all parties that I presented the question of waiting

 

[pgg]

So if the patient, cardiologist, and surgeon think it's in the patient's best interest to have this surgery right now, you aren't going to do it? Really? WTF are you going to do?

Is this a trick question? I told you what I would do.

If the surgeon/cardiologist gave me a reason why this patient's carotid stenosis was different than all the other 90% asymptomatic lesions out there, I might be swayed. I'm a reasonable guy.

I'll do a lot of dubious cases if the benefit is articulated and documented (even something as nebulous as "quality of life" or "pain") but this one is about as clear cut as they come. The risk of a vascular surgical procedure just 90 days out from an MI and DES is much higher than the risk of CVA from an asymptomatic carotid in the next 90 days. As presented, there is no good reason to do this case now rather than 3 months from now, and compelling reasons to wait.

 

[Mman]

I appreciate your opinion. It's your call whether or not you proceed with surgery. It's my call whether or not I provide you with anesthesia services. And fortunately with these cases, at my place, if I say 'No', my whole group says 'No'.

In the case of a bad outcome, you think I won't be named in the lawsuit simply because you decided it was ok to proceed? Yeah right. In the eye of the law, and when I look in the mirror each day, I face the fact that I'm a responsible physician and must act as such. In this case, we have a noncompliant patient hoping to have elective surgery that goes against published literature. Cards wants to proceed? Surgery wants to proceed? Sure, go ahead. I elect to find other work.

So what do you tell the patient? Do you suggest they go find new doctors to take care of them because you don't trust the ones they have? How well does that go over, especially since they've possibly known those docs for years and just met you this morning?

 

[Mman]

Is this a trick question? I told you what I would do.

If the surgeon/cardiologist gave me a reason why this patient's carotid stenosis was different than all the other 90% asymptomatic lesions out there, I might be swayed. I'm a reasonable guy.

So do you tell the patient to go back to their cardiologist? Do you tell them to get a new one? I'm curious on the mechanics of how this works out. Every box checked with preop assessment but you are cancelling on day of surgery. Does the patient shake your hand and thank you or does everybody now hate you and write nasty notes to hospital CEO?

 

[pgg]

What's missing from this text-based SDN forum debate is the actual conversation that would be had with the surgeon and/or cardiologist about this case.

I can point to data and guidelines that demonstrate what a bad idea this is. In the real world, I'd use my powers to convince the surgeon to cancel.

I'm more interested in how the surgeon and cardiologist can possibly defend this plan, than I am what the hospital CEO says. If these kind of shenanigans are rare, then no one's going to get too upset over a single cancellation. If they're common, then I'd quit working at a place with such clowns.

As I have before.

 

[GravelRider]

I am with Mman for the most part on this one. Take the flip side, say the case gets cancelled by you and then the person has a massive CVA, will the guidelines protect you when the surgeon, the cardiologist and the patient decided to it was the best thing to do? I always ask the patients what they were told of the risks, if they were never told of the risk of thrombosis then I call the cardiologist and the surgeon and tell them the failed to properly consent the patient, and that THEY need to discuss with the patient before we go any further. Then I would document the conversations with all parties that I presented the question of waiting

To be honest, I think many lawyers would stay away from this case. Lawyers look for slam dunks and layups when it comes to malpractice. They look for actual negligence, going against "standard practice," and frankly bad documentation. Malpractice lawyers are not like the Supreme Court looking to set legal (or medical) precedent. The guidelines actually do protect you here because it would be very easy to get expert witness testimony backing you up. This is all assuming you document your conversation with the patient and your concerns. I think if a family decides to sue, a lawyer would look at the chart, find your thorough documentation and inform the family that there is unfortunately not much of a case.

Not every patient who ends up with a morbidity or mortality sues their doctors. I think malpractice risk should be the last thing on your mind in this case. You need to make the decision in the here and now based on the available evidence that is best for your patient. I do think the fear of malpractice is overblown sometimes.

 

[GravelRider]

So do you tell the patient to go back to their cardiologist? Do you tell them to get a new one? I'm curious on the mechanics of how this works out. Every box checked with preop assessment but you are cancelling on day of surgery. Does the patient shake your hand and thank you or does everybody now hate you and write nasty notes to hospital CEO?

I know it's a bad word around here, but this is part of what the perioperative surgical home could accomplish. It could prevent these day of surgery cancellations. That way you avoid the angry patient who fasted all night and lost sleep due to anxiety and is now being told they are not having surgery. It's confusing to patients when doctors are not all on the same page. This is a high risk patient who should probably be discussed in some sort of meeting or conference where anesthesiology had a presence. These conferences occur in other specialties in the form of "Tumor Boards" and liver transplant meetings. Why not for high risk surgeries?

 

[pgg]

Also Mman, I'll add one more thing. I know you work at a successful practice, that probably is associated with a successful hospital, and that package probably attracts good surgeons. Maybe you don't ever get to work with malpractice magnets.

There are some surgeons with really, really bad judgement out there, and sometimes the right thing to do is refuse to go along with their plans. You have to do it tactfully, you have to do it with good evidence, you have to do it with good documentation, but you have to do it.

What you don't have to do is any case any surgeon puts in front of you.

 

[Southpaw]

Mman, I basically agree with w everything pgg has said. In 3 years of private practice, cases like this aren't the norm and are discussed days/weeks/ months out from surgery. After discussing my thoughts, especially with having clear evidence here, it's exceedingly rare to have a surgeon NOT say 'yeah waiting another 3 months sounds like the right thing here'. Really, what's the upside of pushing forward so hard here?

Anyway, I consider myself very reasonable, so if the surgeon has his reasons for pushing forward in spite of pretty compelling evidence that the risks outweigh the benefits here, I'm happy to listen.

 

[Mman]

What you don't have to do is any case any surgeon puts in front of you.

Obviously. My point is more about cancelling a case for a cardiology reason when the patient's own cardiologist said they are good to go. How exactly do you explain that line of reasoning to the patient? "Well, your cardiologist is pretty stupid so I'm going to do you a solid and we'll just ignore them." How exactly do you help the surgeon for the future? If he's got a patient with major cardiac issues, is he not supposed to send them to their cardiologist for appropriate work up?

 

[pgg]

To take this to a silly extreme, if this patient was just 1 week out from a MI and stent, and the cardiologist said it was OK to halt DAT for an elective hernia repair, would you do it?

Because the cardiologist said the cardiac risk was OK? Even though you know it's not?


What do you do when a consultant who should know better, says something totally wrong?

This scenario (asymptomatic carotid 90 days after MI and stent) isn't esoteric or complicated. The risks are well characterized, and they're not even close. We know the risk of in-stent thrombosis this soon is significant, and this isn't a cataract - it's vascular surgery! We know the stroke risk for an asymptomatic 90% carotid in the next 90 days is close to zero.

This is nuts.

The cardiologist doesn't clear the patient for surgery, I do.

You seem very hung up on the awkwardness of telling a patient something different than another doctor did. Yeah, it's awkward. The patient's cardiologist made a mistake. You have the power to stop the chain of errors that got this poor patient to within 50' of the OR. Do the right thing. Stop it.


And maybe take a look at why this patient is coming to your department's attention for the first time in the holding area on DOS. I make fun of the perisurgical operating home base superclinic nonsense as much as the next sane person, but there's a place for an anesthesiologist to at least do chart reviews for ASA 3+ patients before DOS to identify brewing ****storms like this one.

 

[GravelRider]

A cardiologist is likely not familiar with data on CEA and stroke. For a cardiologist knows, a CEA is an urgent procedure. When a cardiologist is seeing a patient preop they are not "clearing" a patient (I despise that terminology). They are assessing their cardiac risk factors and determining whether or not more diagnostic work up or interventions need to be done to further risk stratify them or optimize them. That's all they are doing. This makes it easy to explain to the patient. You are not throwing the cardiologist under the bus, and I bet after a thorough explanation to the patient, she will be grateful for having met an astute, knowledgeable, and caring anesthesiologist.

 

[Ronin786]

If you look at the AHA guidelines for asymptomatic carotid stenosis, their recommendation is to proceed if the overall surgical risk is <3% and life expectancy is >5 years. For patients with a risk between 3-5% there appears to be some room for negotiation, but there isn't an indication for patients with a risk between 5-10%.

Based on this person's recent MI I'd bet her risk is >5%.

http://circ.ahajournals.org/content/97/5/501

 

[Psai]

In my opinion...

Doing this case is incredibly poor judgement. We currently have debates within vascular surgery if ANYONE that has asymptomatic carotid disease should get a CEA. Never mind people with a recent PCI. All of the trials that speak on this issue compared ASA vs. ASA + surgery. That means no plavix, no statins, etc. And, even in those trials, the risk reduction had to be measured at 5 years to get something of significance (11% vs. 5% risk of stroke). I was at a conference last year where several prominent stroke neurologists were pushing very hard to get rid of asymptomatic CEAs entirely. I would say that most of us still favor doing them in some patients and certainly if I have 80-99% stenosis, I'm getting a CEA. I think that offering a patient a CEA or even CAS this close to PCI is a poor decision.

Now, symptomatic? Entirely different story. The plaque pathology is different. The risk profile is different. Despite the guidelines from ACA/AHA, I would be a strong advocate of CEA for a patient with 50-99% stenosis who was symptomatic. I would do it 3-14 days after the neurological event and I would do it under local with awake neurological monitoring. Certainly not my preferred way of doing a CEA (general anesthesia with EEG or TCD monitoring), but I think offers an acceptable cardiac risk balanced against the neurological risk.

However, this is not your call. You certainly can voice your concerns and if the patient is not aware of what is going on, then I think that you need to make sure that the appropriate conversations have been had. But, at the end of the day, this surgeon is making a judgement call. Patient factors and surgeon factors make it 'possible' that the risk of stroke is greater than major adverse event. Hard to fathom, but again, an argument can be made. If the surgeon feels comfortable with the risk, I guarantee that they don't want the complication anymore than you do. I certainly know some that would probably do it if someone asked them to.

Remember the time you went to medical school and became a doctor? I did the same thing and I definitely have a call.

 

[Colba55o]

Great input and conversation!

As for how things turned out, I discussed with my chief and he felt that I should proceed with the case as long as everything was documented as I described. If I had refused to do the case it likely would have fallen on one of my partner's laps and I hate dodging messy situations.

Everyone has valid points...I think most salient is that the cardiologist may not 100% appreciate the increased risk SURGERY can have on a cardiac event, he is an expert in medical management. Vascular is an expert in surgery but not the pathophysiology of inflammation leading to coronary stent thrombosis etc. We are kind of the impartial party riding the fence looking at the whole picture, so I think I would have been justified in refusing to do it.
In any event, case went uneventfully, but I guess its a waiting game to see if she has an MI over the next few days

 

[BLADEMDA]

Great input and conversation!

As for how things turned out, I discussed with my chief and he felt that I should proceed with the case as long as everything was documented as I described. If I had refused to do the case it likely would have fallen on one of my partner's laps and I hate dodging messy situations.

Everyone has valid points...I think most salient is that the cardiologist may not 100% appreciate the increased risk SURGERY can have on a cardiac event, he is an expert in medical management. Vascular is an expert in surgery but not the pathophysiology of inflammation leading to coronary stent thrombosis etc. We are kind of the impartial party riding the fence looking at the whole picture, so I think I would have been justified in refusing to do it.
In any event, case went uneventfully, but I guess its a waiting game to see if she has an MI over the next few days

PGG is absolutely correct in his posts. In his world a cancellation is likely if not probable. But, in the private practice world this case doesn't get cancelled 99% of the time because the cardiologist and vascular surgeon/CT surgeon agreed to do the case with Plavix/asa on board.

So, should the case be cancelled? Absolutely yes. I suspect in the military, the VA and many academic hospitals that is exactly what would occur. But, in the other 90% of hospitals this case proceeds with documentation that risks discussed with patient (increased risk of MI, stent thromosis, etc) and surgeon.

As for us being real doctors and not ancillary staff I'm not so sure that is how we get treated in private practice by those around us. NPO status? The hernia went from "semi-urgent" to "emergent incarceration" when the case got posted for 5:00 PM regardless of NPO status.

 

[BLADEMDA]

I was following right along with you up until here.

Anesthesiologists absolutely get a call. They have skin in the game too.

I can always tell when Surgeons have never been sued by family members or patients. They really don't get the way our system works in court. I can assure you that the "Academic experts" which include Anesthesiologists and Vascular Surgeons would question your judgment in doing such a case as this one.

Were the patient and family members truly "informed" of these increased risks vs waiting another 90 days to perform the surgery?

I've seen many complications and deaths from poor judgment which could have been avoided.

 

[Icefrog]

Didn't see this mentioned so I'll put it out there.
The 2016 ACC/AHA guidelines state that dual antiplatelet therapy after DES can be discontinued after 180 days if the DES was for stable ischemic heart disease.
If the DES was placed for ACS including NSTEMI or STEMI, then it clearly states that DAPT should be continued for 1 year. This is a class I recommendation.

www.acc.org/latest-in-cardiology/ten-points-to-remember/2016/03/25/14/56/2016-acc-aha-guideline-focused-update-on-duration-of-dapt

I apologize if this was already brought up and I accidentally missed it.

 

[Mman]

You seem very hung up on the awkwardness of telling a patient something different than another doctor did. Yeah, it's awkward. The patient's cardiologist made a mistake. You have the power to stop the chain of errors that got this poor patient to within 50' of the OR. Do the right thing. Stop it.

No, I'm wondering what your plan is? Are you telling the patient to go find a new cardiologist? Are you sending them back to see a different cardiologist? Or do you just tell them to screw off and come back in 3 months?

This isn't a totally cut and dry scenario. A carotid isn't a totally elective surgery. It's not liposuction or a boob job. There is some risk to waiting which implies there is some degree of urgency to the case. As the anesthesiologist we aren't the ones to determine the degree of electiveness/urgency to the surgery. I'm trying to figure out how you say, nah this is BS, I'm a doctor and your cardiologist is insane and your surgeon is crazy too, and oh by the way you've never even met me in your life so just trust me on this one.

To me this is a completely gray area and it is not black and white.

 

[BLADEMDA]

No, I'm wondering what your plan is? Are you telling the patient to go find a new cardiologist? Are you sending them back to see a different cardiologist? Or do you just tell them to screw off and come back in 3 months?

This isn't a totally cut and dry scenario. A carotid isn't a totally elective surgery. It's not liposuction or a boob job. There is some risk to waiting which implies there is some degree of urgency to the case. As the anesthesiologist we aren't the ones to determine the degree of electiveness/urgency to the surgery. I'm trying to figure out how you say, nah this is BS, I'm a doctor and your cardiologist is insane and your surgeon is crazy too, and oh by the way you've never even met me in your life so just trust me on this one.

To me this is a completely gray area and it is not black and white.

Relax. You come from a different perspective than PGG due to the practice environment. In his world the case gets cancelled while in your world when the Cardiologist and Surgeon agree to proceed with the case it gets done by you or another Anesthesiologist from your group.

There is no way I would have survived in practice practice cancelling cases which were "cleared by the cardiologist" and scheduled by the surgeon. In the past I have disagreed with their "calls" many times but I typically do not cancel the case. I have gotten fresh TTEs (which I read with the tech) prior to the surgery which results in a short delay in the case. In all my years I've cancelled about 3 cases which cardiology "cleared for surgery" so I understand the flack which comes from saying no.

The bottom line is unless the evidence is overwhelmingly compelling I do not over-rule the cardiologist and the surgeon. PGG believes this is such a situation while Mman disagrees.

 

[Mman]

Relax. You come from a different perspective than PGG due to the practice environment. In his world the case get cancelled while in your world when the Cardiologist and Surgeon agree to proceed with the case it gets done by you or another Anesthesiologist from your group.

I agree. I remember academia days. I just think medically this is not a cut and dry situation. This isn't hey I just had an MI last week but the surgeon wants to fix my hip and I have never seen a cardiologist and oh my chest hurts. Moses didn't carve rules out for this case into stone tablets.

 

[BLADEMDA]

If you look at the AHA guidelines for asymptomatic carotid stenosis, their recommendation is to proceed if the overall surgical risk is <3% and life expectancy is >5 years. For patients with a risk between 3-5% there appears to be some room for negotiation, but there isn't an indication for patients with a risk between 5-10%.

Based on this person's recent MI I'd bet her risk is >5%.

http://circ.ahajournals.org/content/97/5/501

I'm not sure this is as black and white as you post.

http://www.ncbi.nlm.nih.gov/pubmed/24177257

http://content.onlinejacc.org/article.aspx?articleid=1886826


http://www.aahs.org/medstaff/wp-content/uploads/NoncardiacSuJAMA2013.pdf

MACE of 6-7% at 3 months.
MACE of 4-5% at 6 months
MACE of 3-4% at 12 months

 

[Ronin786]

I'm not sure this is as black and white as you post.

http://www.ncbi.nlm.nih.gov/pubmed/24177257

http://content.onlinejacc.org/article.aspx?articleid=1886826


http://www.aahs.org/medstaff/wp-content/uploads/NoncardiacSuJAMA2013.pdf

MACE of 6-7% at 3 months.
MACE of 4-5% at 6 months
MACE of 3-4% at 12 months

The data you provided seems to back up what I posted, other than that study where they weren't even undergoing surgery . Based on my understanding of the AHA recommendations, they factor in all complications into their "surgical risk". That includes preoperative stroke and additional complications as well as the risk of MACE. I don't see how this patient doesn't have an overall risk of >5%, or how there's enough of a reason to justify fixing her asymptomatic stenosis given the potential side effects.

If I'm the anesthesiologist, I'm telling her that there's a real risk of her stent closing in the OR today and her dying and she needs to weigh that against getting this asymptomatic problem taken care of.

 

[Arch Guillotti]

If I'm the anesthesiologist, I'm telling her that there's a real risk of her stent closing in the OR today and her dying

I think the chance of this happening in the OR is incredibly low.

 

[Arch Guillotti]

The bottom line is unless the evidence is overwhelmingly compelling I do not over-rule the cardiologist and the surgeon.

Agree.

 

[DrN2O]

So, should the case be cancelled? Absolutely yes. I suspect in the military, the VA and many academic hospitals that is exactly what would occur. But, in the other 90% of hospitals this case proceeds with documentation that risks discussed with patient (increased risk of MI, stent thromosis, etc) and surgeon.
.

Why would the academic guys block the case? Malpractice and lawyers are covered by the medical center. We do questionable cases with doubtful (f)utility all the time. Just put "require cardiac anesthesia" in the note, it's somebody else's problem.

 

[BLADEMDA]

Why would the academic guys block the case? Malpractice and lawyers are covered by the medical center. We do questionable cases with doubtful (f)utility all the time. Just put "require cardiac anesthesia" in the note, it's somebody else's problem.

This patient would likely not make it past the preop clinic for surgery just 3 months after an MI followed by a DES.

 

[BLADEMDA]

The data you provided seems to back up what I posted, other than that study where they weren't even undergoing surgery . Based on my understanding of the AHA recommendations, they factor in all complications into their "surgical risk". That includes preoperative stroke and additional complications as well as the risk of MACE. I don't see how this patient doesn't have an overall risk of >5%, or how there's enough of a reason to justify fixing her asymptomatic stenosis given the potential side effects.

If I'm the anesthesiologist, I'm telling her that there's a real risk of her stent closing in the OR today and her dying and she needs to weigh that against getting this asymptomatic problem taken care of.

I'm not sure even if you wait the additional 3 months or even 9 months the risk drops below 3%. So, the real conversation goes something like this:

Your Surgeon and Cardiologist want to proceed with the cleaning out your blocked Carotid Artery in your neck. Based on the best available evidence there is about a 3% increased risk if we proceed with the surgery today vs waiting another 9 months. The chance that something bad happens to your heart is around 5-6% right now but it decreases to 3-4% if we wait another 9 months. Do you wish to proceed or reschedule the surgery?

The next question you may be asked is the following: I'm not sure what to do doctor; do you think I should reschedule my surgery or follow the advice of my other doctors? I'm kind of uncertain what to do. What do you recommend I do?

 

[DrN2O]

This patient would likely not make it past the preop clinic for surgery just 3 months after an MI followed by a DES.

Not if the vascular surgeon admits the patient the night before for IV hydration and bypass the preop clinic.

 

[GravelRider]

Not if the vascular surgeon admits the patient the night before for IV hydration and bypass the preop clinic.

That's not happening in the world of bundled payments.

 

[nlax30]

Cardio here and I found this thread very interesting and a lot of great points made by all here. I agree in that this isn't a black and white issue and honestly I don't think there is one absolute/correct answer.

I DO agree in that there needs to be a frank discussion between all involved, and notable between the surgeon and patient regarding all the risks. Obviously just going by guidelines we should hold off and wait ideally after 1 year, though probably 6 months is sufficient as risk of MACE seems to level off then.

That said, a lot of these studies (certainly up until the mid-late 2000's) that looked at risks of stent thrombosis involved BMS and the 1st-gen DES. The newer 2nd Generation DES (which I'm assuming she had received) have even better/lower rates of late stent thrombosis (I've seen <1% at 12 months in some studies, outside of needing non-cardiac surgery of course).

There's still on-going debate in our literature on not only how long to keep patients on DAPT, but on the minimum DAPT time needed, with some even advocating that DAPT <6 months for those receiving the 2nd Gen DES as sufficient and allowing non-cardiac surgery 4-6 weeks after PCI. In the past if we knew someone needed surgery in the upcoming few months it was thought that we should implant a BMS, keep on DAPT for 4-6 weeks then let them have surgery. Though now with 2nd Gen DES there is some data that even tailored therapy as short as 30 days in patients with a higher bleeding risk/high thrombotic risk with a Zotarolimus-eluting stent is superior to BMS. (ZEUS Trial, JACC 2015)

I do agree that surgery at this point after her ACS event increases her overall risk and many other factors would need to be factored in here.... urgency of the CEA as deemed by the vascular surgeon, location of her stent (distal RCA vs a proximal LAD stent) and extent of her CAD/atherosclerotic burden overall, continued smoking, and frankly her wishes as well as which problem she is going to be worried about more (risk of a periop cardiac event vs risk of sitting there with a significant carotid stenosis) regardless of what the actually percentages may be.

While I'm not in practice quite yet, if I were seeing her in the office for a pre-op visit and she was 3 months out from an ACS event with PCI, I would certainly have a discussion on the above and officially say she is at an increased cardiac risk (though likely not prohibitive) and probably just give the surgeon a call as my preference would be to wait an additional 3 months, though if the surgeon and patient both perceive it as needing to be done sooner than so be it, while continuing DAPT of course.

 

[nlax30]

Short version....
1. Officially say at increased cardiac risk and contact surgeon and suggest waiting at least 3 more months
2. Continue DAPT
3. Stress to her that she MUST STOP SMOKING regardess of any of this as it's just a matter of time before her next MI or first CVA.