Another case to discuss

[vector2]

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Stopping DAPT incurs a risk by itself, but there is certainly increased risk from surgery in addition to that risk due to the known inflammatory response that is stimulated by surgical insult.

This. The rate of neoepithelialization and arterial healing is so variable with DES that if I had my way I wouldn't do an elective procedure off DAPT until the pt was two years out from stent placement.

 

[coffeebythelake]

The problem with these preop clinics run by NPs is that all they are really doing is checking a box that a medical or cardiology clearance is present in the chart. They are not digging through the information nor do they have the proper knowledge to make decisions based on that information. To make these preop clinics even remotely efficient and prevent “day-of” surgery cancellations, anesthesiology has to be somewhat involved. It could be something as simple as making a reasonably broad statement like all patients with an MI, stroke, or cardiac intervention within the past year must be brought to the attention of the anesthesiology department before the day of surgery.

Oh I have plenty of stories about NPs and horroble preop clinic notes. Recent memorable case: pt with c4 spinal cord injury from 10 years ago, no mention that pt had previous trach, no mention of her frequent autonomic dysreflexia symptoms, or previous neurologist visit, or pulmonary status because they didn't know the implications to phrenic n function, no attempts to get previous anesthetic notes or airway histories, not to mention the pt was able to lift her arms or move her thumb suggesting level below c4.

Just rubber stamp.

Oh, NP spoke with pt about general anesthesia when clearly neuraxial would be the better option.

Essentially useless.

 

[Arch Guillotti]

This is exactly where I was going to take this thread if someone had not brought it up after the “fit for surgery” part of the discussion.

We have a periop clinic which is run by the hospitalists because they needed more RVU’s to justify adding staff and we didn’t. This was fine by my group because we didn’t want to sit in a clinic. That’s not why I went into anesthesia. I know some of you will take issue with this. But we made it clear that we needed complete involvement and that we were the final word on if a case went to the OR or not. Things were going pretty well with the hospitalists staffing the clinic and they enjoyed getting off the floor from time to time. Then at some point last year they decided to hire a NP to staff the clinic with physician backup. This has been an eye opening experience for all of us. The NP is good at collecting data and putting together a note. But she has zero understanding. This case should have been seen by an anesthesiologist before surgery, period. To put this on my plate at 7am on a Monday is an impossible task. It is a setup for failure and confrontation. And the fact that we get these pts through their surgery without any issues just makes it worse.

Was your group made aware of the NP before they were hired and when they started? If not, why not?

If they are sending patients to you that are not ready for surgery or who are not "optimized" then it sounds like you need to be more involved in the process that gets them to the OR.

 

[Noyac]

Was your group made aware of the NP before they were hired and when they started? If not, why not?

If they are sending patients to you that are not ready for surgery or who are not "optimized" then it sounds like you need to be more involved in the process that gets them to the OR.

Nope. We found out after the hire.
We now have a direct line of communication (Me) to the director. My group feels like we can get such sick pts through surgery because our surgeons are not the best I’ve worked with but they are mostly very good. And because we are an all MD group. We also understand that this may not be doing the pts any favors since all of us tend to push the envelope. But we try not to go too far outside the lines either.

 

[DocVapor]

Oh I have plenty of stories about NPs and horroble preop clinic notes. Recent memorable case: pt with c4 spinal cord injury from 10 years ago, no mention that pt had previous trach, no mention of her frequent autonomic dysreflexia symptoms, or previous neurologist visit, or pulmonary status because they didn't know the implications to phrenic n function, no attempts to get previous anesthetic notes or airway histories, not to mention the pt was able to lift her arms or move her thumb suggesting level below c4.

Just rubber stamp.

Oh, NP spoke with pt about general anesthesia when clearly neuraxial would be the better option.

Essentially useless.

I love all the NP "clearances" I read where essentially every word in the A+P section is wrong, and that's even at my basic (recently) CA-2 level understanding.

 

[facted]

1. Pt already off plavix and every hour we wait the higher the risk to this patient. They need to be back on DAPT asap.

2. This is endoscopic case which I expect minimal stress and inflammatory response

3. This was not elective and patient cannot wait until 6 months. Her life expectancy was likely less than that, and this was done under the name of palliative care

Thoughts

Do the case because ERCP is not elective in this case, but this patient is at very high risk due in-stent thrombosis. They are already in a highly inflammatory state because of their cancer. They should ideally be on Plavix AND if it's ok with GI, I'd give the patient a dose.

 

[Gas you down]

Related to DES subject...
Had a case this am, asymptomatic pt who was sent for CTA after a bruit was heard. >70% bilaterally. During work up, had a positive stress, then a Xiance DES placed into RCA.
Now presents for CEA just shy of 4 weeks out. Still on ASA/plavix.
Cards told surgeon to go ahead but continue DAPT, but no note in the chart stating this.
Called the cardiologist, who was under the impression that this was an urgent/emergent case, and said it was ok to go this soon if meds continued.
I don’t consider this asymptomatic pt to be an emergency warranting such early intervention. If she was having symptoms at all, I’d drive on.
How would you personally approach this?

 

[Psai]

Related to DES subject...
Had a case this am, asymptomatic pt who was sent for CTA after a bruit was heard. >70% bilaterally. During work up, had a positive stress, then a Xiance DES placed into RCA.
Now presents for CEA just shy of 4 weeks out. Still on ASA/plavix.
Cards told surgeon to go ahead but continue DAPT, but no note in the chart stating this.
Called the cardiologist, who was under the impression that this was an urgent/emergent case, and said it was ok to go this soon if meds continued.
I don’t consider this asymptomatic pt to be an emergency warranting such early intervention. If she was having symptoms at all, I’d drive on.
How would you personally approach this?

That is a lot of intervention for an asymptomatic patient.

 

[dannyboy1]

Related to DES subject...
Had a case this am, asymptomatic pt who was sent for CTA after a bruit was heard. >70% bilaterally. During work up, had a positive stress, then a Xiance DES placed into RCA.
Now presents for CEA just shy of 4 weeks out. Still on ASA/plavix.
Cards told surgeon to go ahead but continue DAPT, but no note in the chart stating this.
Called the cardiologist, who was under the impression that this was an urgent/emergent case, and said it was ok to go this soon if meds continued.
I don’t consider this asymptomatic pt to be an emergency warranting such early intervention. If she was having symptoms at all, I’d drive on.
How would you personally approach this?

I had the exact same case except that the procedure was for a large squamous cell carcinoma exicion. Surgeon claimed that there was risk of “disfigurement” and the patient had a cardiac clearance to proceed on ASA/plavix. It is hard to argue skin with a plastic surgeon. It is even harder to argue vascular disease with a vascular surgeon.

 

[Gas you down]

I had the exact same case except that the procedure was for a large squamous cell carcinoma exicion. Surgeon claimed that there was risk of “disfigurement” and the patient had a cardiac clearance to proceed on ASA/plavix. It is hard to argue skin with a plastic surgeon. It is even harder to argue vascular disease with a vascular surgeon.

I straight up asked him is this an emergency and he said no. Nothing in the chart to say that either, had the documentation been different of course I would have gone forward. It was more of a hey the cardiologist said I could do it so I want to...

 

[Psai]

A note in the chart takes 5 minutes

 

[nimbus]

That case brings up the question. What is the optimal management of patient undergoing high risk procedures who are diagnosed with CAD during the preop workup?

Is medical management preferred for non elective surgeries that cannot wait a year? Did the cardiologist increase this patient’s risk of perioperative MI by placing the DES? Obviously it partly depends on the severity of coronary lesion. We know stents do not improve long term outcome in asymptomatix patients or those with stable coronary disease.

 

[dannyboy1]

That case brings up the question. What is the optimal management of patient undergoing high risk procedures who are diagnosed with CAD during the preop workup?

Is medical management preferred for non elective surgeries that cannot wait a year? Did the cardiologist increase this patient’s risk of perioperative MI by placing the DES? Obviously it partly depends on the severity of coronary lesion. We know stents do not improve long term outcome in asymptomatix patients or those with stable coronary disease.

Frequently we do fem pop bypasses a day or two after patients get stents for CAD discovered in preop workup. The reason is non- healing ulcers. In all likelihood the leg is going to come off eventually anyways. I am not about to tell a patient who has carotid stenosis to hold off on the surgery. He is at high risk for stroke and the first thing the patient and family will say is “ the anesthesiologist cancelled the case”....

 

[Gas you down]

A note in the chart takes 5 minutes

Lol I wish. Cards wasn’t in the house and even if he was it’d easily be an hour

 

[nimbus]

Frequently we do fem pop bypasses a day or two after patients get stents for CAD discovered in preop workup. The reason is non- healing ulcers. In all likelihood the leg is going to come off eventually anyways. I am not about to tell a patient who has carotid stenosis to hold off on the surgery. He is at high risk for stroke and the first thing the patient and family will say is “ the anesthesiologist cancelled the case”....

I was referring to the coronary stent, not the carotid. Would this patient have been better off getting the coronary stent after her carotid surgery or not at all?

 

[IMGASMD]

A quick read got me here.

“The optimal treatment for ACAS remains a matter of debate. We showed low rates of stroke, making the benefit of carotid endarterectomy questionable in this cohort. The Asymptomatic Carotid Surgery Trial indicated that for patients <75 years, carotid endarterectomy significantly reduced the 10-year stroke risk (10.8% versus 16.9%),with a number needed to treat of 22.”

But obviously nothing about s/p cardiac stent. Have cardiac write a note, talk to patient, then......... I don’t know..

 

[Gas you down]

Frequently we do fem pop bypasses a day or two after patients get stents for CAD discovered in preop workup. The reason is non- healing ulcers. In all likelihood the leg is going to come off eventually anyways. I am not about to tell a patient who has carotid stenosis to hold off on the surgery. He is at high risk for stroke and the first thing the patient and family will say is “ the anesthesiologist cancelled the case”....

I’m right there with you on the bypasses! But an abscess on a leg that’s only going to get worse is diff from being neurologically asymptomatic. I def hear what you’re saying though, which is why I care here to begin with, just want to get others opinion. I was on the fence with this one but erred on what I thought was the side of caution...cont DAPT, she has flow through both carotids, has good flow through vertebrals. Who knows my attitude may evolve on this

 

[mimelim]

Related to DES subject...
Had a case this am, asymptomatic pt who was sent for CTA after a bruit was heard. >70% bilaterally. During work up, had a positive stress, then a Xiance DES placed into RCA.
Now presents for CEA just shy of 4 weeks out. Still on ASA/plavix.
Cards told surgeon to go ahead but continue DAPT, but no note in the chart stating this.
Called the cardiologist, who was under the impression that this was an urgent/emergent case, and said it was ok to go this soon if meds continued.
I don’t consider this asymptomatic pt to be an emergency warranting such early intervention. If she was having symptoms at all, I’d drive on.
How would you personally approach this?

That case brings up the question. What is the optimal management of patient undergoing high risk procedures who are diagnosed with CAD during the preop workup?

Is medical management preferred for non elective surgeries that cannot wait a year? Did the cardiologist increase this patient’s risk of perioperative MI by placing the DES? Obviously it partly depends on the severity of coronary lesion. We know stents do not improve long term outcome in asymptomatix patients or those with stable coronary disease.

Frequently we do fem pop bypasses a day or two after patients get stents for CAD discovered in preop workup. The reason is non- healing ulcers. In all likelihood the leg is going to come off eventually anyways. I am not about to tell a patient who has carotid stenosis to hold off on the surgery. He is at high risk for stroke and the first thing the patient and family will say is “ the anesthesiologist cancelled the case”....

A quick read got me here.

“The optimal treatment for ACAS remains a matter of debate. We showed low rates of stroke, making the benefit of carotid endarterectomy questionable in this cohort. The Asymptomatic Carotid Surgery Trial indicated that for patients <75 years, carotid endarterectomy significantly reduced the 10-year stroke risk (10.8% versus 16.9%),with a number needed to treat of 22.”

But obviously nothing about s/p cardiac stent. Have cardiac write a note, talk to patient, then......... I don’t know..

First, asymptomatic carotids. Asymptomatic carotids are never an emergency. Someone that tells you otherwise has some other agenda. Also, ACAS is outdated, yet it is the quoted literature for justification of operating on asymptomatic carotid patients. The reality is, we don't actually have good quality data with modern medical management to say one way or the other. It is pretty well accepted in part of the stroke neuro community to have a hard and fast 'no intervention' stance for any asymptomatic patients. It is a strong enough held belief that depending on where you train now, you may grow up in a culture of never operating on asymptomatics. We have one faculty (out of 15) who is this way. So, the range of perspectives is, this is never an emergency to this should never be done.

Second, DAPT, I certainly can't speak for all vascular surgeons, but I never stop DAPT and will operate on just about anyone if necessary. I would like to stop it if it is unnecessary to continue (which happens from time to time that someone will show up in our office and they just haven't seen their cardiologist in a while, but if someone is supposed to be on DAPT for whatever reason, I will bite the bullet and operate on them. It is simply a part of life as a vascular surgeon. Yes, it bleeds more and yes, it is sometimes painful, but it kind of is what it is.

Third, coronoary optimization prior to urgent surgery. I've looked fairly exhaustively at the literature over the last several years as this comes up quite frequently. And as with everything, I think that this is a big, "It depends." I'm convinced that if we are expecting the potential for serious hemodynamic shifts, the heart needs to be revascularized prior to surgery. Certainly not backed up by level 1 data and hard to quantify, but I have a hard time taking someone back with known hemodynamically significant, albeit asymptomatic cardiac lesions.

Fourth, I'm sorry, but you should not be revascularizing legs that you don't have good expectations of limb salvage. The comment of, "In all likelihood the leg is going to come off eventually anyways." Is either naïveté or a product of fairly shoddy local medical practices.

 

[IMGASMD]

First, asymptomatic carotids. Asymptomatic carotids are never an emergency. Someone that tells you otherwise has some other agenda. Also, ACAS is outdated, yet it is the quoted literature for justification of operating on asymptomatic carotid patients. The reality is, we don't actually have good quality data with modern medical management to say one way or the other. It is pretty well accepted in part of the stroke neuro community to have a hard and fast 'no intervention' stance for any asymptomatic patients. It is a strong enough held belief that depending on where you train now, you may grow up in a culture of never operating on asymptomatics. We have one faculty (out of 15) who is this way. So, the range of perspectives is, this is never an emergency to this should never be done.

Second, DAPT, I certainly can't speak for all vascular surgeons, but I never stop DAPT and will operate on just about anyone if necessary. I would like to stop it if it is unnecessary to continue (which happens from time to time that someone will show up in our office and they just haven't seen their cardiologist in a while, but if someone is supposed to be on DAPT for whatever reason, I will bite the bullet and operate on them. It is simply a part of life as a vascular surgeon. Yes, it bleeds more and yes, it is sometimes painful, but it kind of is what it is.

Third, coronoary optimization prior to urgent surgery. I've looked fairly exhaustively at the literature over the last several years as this comes up quite frequently. And as with everything, I think that this is a big, "It depends." I'm convinced that if we are expecting the potential for serious hemodynamic shifts, the heart needs to be revascularized prior to surgery. Certainly not backed up by level 1 data and hard to quantify, but I have a hard time taking someone back with known hemodynamically significant, albeit asymptomatic cardiac lesions.

Fourth, I'm sorry, but you should not be revascularizing legs that you don't have good expectations of limb salvage. The comment of, "In all likelihood the leg is going to come off eventually anyways." Is either naïveté or a product of fairly shoddy local medical practices.

Vascular has spoken. Cancel the case.

So for you @mimelim would have never booked the case to begin with? Is that my correct read in this?

What if the patient was symptomatic? Would you wait to do the case? How long does your guideline say?

 

[mimelim]

Vascular has spoken. Cancel the case.

So for you @mimelim would have never booked the case to begin with? Is that my correct read in this?

What if the patient was symptomatic? Would you wait to do the case? How long does your guideline say?

I would want to be a minimum of 6 weeks out from coronary intervention prior to CEA. Ideally, I'd hold off for 3+ months if the referring docs will let me get away with it. Personally, I think that it should be fixed and it shouldn't be ignored for too long, but I don't think the benefits are big enough to justify the increased acute coronary risk. I would also consider doing a stent via TCAR as I can do that under MAC/local. But, it comes down to communication with the patient, family and the referring docs. Nobody has fired back at me for taking a more conservative route when it comes to asymptomatics. If anything my non-surgical colleagues respect me more for being willing to hold off (with a plan in place for when we will do it.)

Symptomatic, 3-14 days after completion stroke. TIA or ongoing emboli on TCD I'm doing it as soon as the next day. Both of those are pretty well backed up by the data.

In general, when treating combined carotid, coronary and valve disease, symptomatic vascular bed takes priority in terms of timing.

 

[sigrhoillusion]

I would want to be a minimum of 6 weeks out from coronary intervention prior to CEA. Ideally, I'd hold off for 3+ months if the referring docs will let me get away with it. Personally, I think that it should be fixed and it shouldn't be ignored for too long, but I don't think the benefits are big enough to justify the increased acute coronary risk. I would also consider doing a stent via TCAR as I can do that under MAC/local. But, it comes down to communication with the patient, family and the referring docs. Nobody has fired back at me for taking a more conservative route when it comes to asymptomatics. If anything my non-surgical colleagues respect me more for being willing to hold off (with a plan in place for when we will do it.)

Symptomatic, 3-14 days after completion stroke. TIA or ongoing emboli on TCD I'm doing it as soon as the next day. Both of those are pretty well backed up by the data.

In general, when treating combined carotid, coronary and valve disease, symptomatic vascular bed takes priority in terms of timing.

 

[chocomorsel]

And another one!
He/She and the plastic surgeon. Do these surgeons really exist? They tend to be the outliers!

 

[sigrhoillusion]

And another one!
He/She and the plastic surgeon. Do these surgeons really exist? They tend to be the outliers!

Most vascular surgeons I know think:
Angio
Angio
Angio + Stent
Angio + another stent
Fem-pop
Toe amp
Toe amp revision
2nd and 3rd digit amps
Foot amp
Foot amp revision
BKA
AKA
Move on to next extremity

 

[nimbus]

Most vascular surgeons I know think:
Angio
Angio
Angio + Stent
Angio + another stent
Fem-pop
Toe amp
Toe amp revision
2nd and 3rd digit amps
Foot amp
Foot amp revision
BKA
AKA
Move on to next extremity

That is a hard life.

 

[anbuitachi]

That is a hard life.

For the patient

 

[pgg]

Most vascular surgeons I know think:
Angio
Angio
Angio + Stent
Angio + another stent
Fem-pop
Toe amp
Toe amp revision
2nd and 3rd digit amps
Foot amp
Foot amp revision
BKA
AKA
Move on to next extremity

It's the fem pop chop chop hop

 

[DrZzZz]

Most vascular surgeons I know think:
Angio
Angio
Angio + Stent
Angio + another stent
Fem-pop
Toe amp
Toe amp revision
2nd and 3rd digit amps
Foot amp
Foot amp revision
BKA
AKA
Move on to next extremity

You forgot the stump revision!

 

[IMGASMD]

And perm cath/AV graft. Since now after all the angio and DM. Kidney no working no mo’

@mimelim just pulling your leg, dude. We really appreciated your thoughtful answer.

 

[Robotic Wis-Hipple]

I would want to be a minimum of 6 weeks out from coronary intervention prior to CEA. Ideally, I'd hold off for 3+ months if the referring docs will let me get away with it. Personally, I think that it should be fixed and it shouldn't be ignored for too long, but I don't think the benefits are big enough to justify the increased acute coronary risk. I would also consider doing a stent via TCAR as I can do that under MAC/local. But, it comes down to communication with the patient, family and the referring docs. Nobody has fired back at me for taking a more conservative route when it comes to asymptomatics. If anything my non-surgical colleagues respect me more for being willing to hold off (with a plan in place for when we will do it.)

Symptomatic, 3-14 days after completion stroke. TIA or ongoing emboli on TCD I'm doing it as soon as the next day. Both of those are pretty well backed up by the data.

In general, when treating combined carotid, coronary and valve disease, symptomatic vascular bed takes priority in terms of timing.

Where are you getting this 6 weeks?

BMS: 30 days
DES: 3-6mo is gray area if it can be argued surgical intervention is needed though still not emergent, >6mo for purely elective/asymptomatic surgical issue.

Otherwise I wish I dealt with any surgeons that thought like you.

 

[mimelim]

Where are you getting this 6 weeks?

BMS: 30 days
DES: 3-6mo is gray area if it can be argued surgical intervention is needed though still not emergent, >6mo for purely elective/asymptomatic surgical issue.

Otherwise I wish I dealt with any surgeons that thought like you.

6 weeks? My ass.

The correct answer is 3+ months. I find that that is unacceptable for many patients and other providers and so begrudgingly we will sometimes accommodate. Some of it is anxiety, and some of it is simply vascular surgery. It is so rare that I plan operations more than a month in advance. We just don't deal with things that can wait that long. Maybe it is a product of the practice environments that I have been exposed to, but we don't see a lot of claudicants or small aneurysms that we can follow and schedule months in advance. When I have to talk to our anesthesia about operating after recent PCI, I'm asking knowing the elevated risks, but know that either life or limb is currently at stake well within 3 months (usually <2 days).

Cardiac risk stratification is a mandatory part of every operation that I do. In my surgical training, you did a full month of cardiology as in internal medicine cardiology, completely non-surgical and you were expected to come away from that rotation being able to appropriately risk stratify and know what the 'optimal' workup should be for every patient undergoing surgery. The overlap between the vascular population and cardiac is way too high to not do this. Just as important as it is to know for planning to operate (or not operate), if you don't know, then you can't have a real, honest and effective conversation with the patient and their family about their operative risks.

 

[dannyboy1]

Great to see that there are some thoutful caring surgeons out there. However what happens in most cases is this: vascular surgeon gets a referral for possible endarterectomy. He evaluates the patient and decides that one is needed (whatever criteria he uses). He then tells the patient that you are at risk for stroke so we need to operate. He then sends the patient to cardiology for workup. Cardiology decides that a cath is needed and then a stent. Then he tells the patient “you are good to go, good luck”. Now after all this you meet the patient in holding area. Are you really going to tell the patient “hey, you don’t need this procedure now and maybe not ever”. (In other words your vascular surgeon is a *****) this conversation will not go well....

 

[MoMoGesiologist]

Great to see that there are some thoutful caring surgeons out there. However what happens in most cases is this: vascular surgeon gets a referral for possible endarterectomy. He evaluates the patient and decides that ones is needed (whatever criteria he uses). He then tells the patient that you are at risk for stroke so we need to operate. He then sends the patient to cardiology for workup. Cardiology decides that a cath is needed and then a stent. Then he tells the patient “you are good to go, good luck”. Now after all this you meet the patient in holding area. Are you really going to tell the patient “hey, you don’t need this procedure now and maybe not ever”. (In other words your vascular surgeon is a *****) this conversation will not go well....

As long as the patient continues his DAPT, how much is the increased risk of surgery? Yes surgery is prothrombotic and pro inflammatory, but if DAPT is on board, what are the chances of ISR or new MI? Often we are heparinizing vascular patients as well in the OR.

From my understanding, cardiac interventions don't result in less periop major adverse cardiac events (same risk of MI as if they never got a stent), but also they don't have increased risk of MACE. Patients getting revascularized just reduces their lifetime risk (regardless of surgery). Does anyone else have different information?

 

[Ronin786]

As long as the patient continues his DAPT, how much is the increased risk of surgery? Yes surgery is prothrombotic and pro inflammatory, but if DAPT is on board, what are the chances of ISR or new MI? Often we are heparinizing vascular patients as well in the OR.

From my understanding, cardiac interventions don't result in less periop major adverse cardiac events (same risk of MI as if they never got a stent), but also they don't have increased risk of MACE. Patients getting revascularized just reduces their lifetime risk (regardless of surgery). Does anyone else have different information?

I'd have to pull up the data, but there's a reason the guidelines recommend at least 3 months if you're going to continue your DAPT. The anti-platelets are good, but they're not going to prevent a clot if the stent hasn't properly endothelialized and you add a prothrombotic/inflammatory insult.

FWIW, there continues to be a discussion in cardiology circles about the optimum time of DAPT. The risk of bleeding outweighs the risk of thrombosis at some point, but even long term you can still get in-stent thrombosis. And that's in normal patients not subjected to surgical stress.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4369425/pdf/nihms651281.pdf

 

[Robotic Wis-Hipple]

6 weeks? My ass.

The correct answer is 3+ months. I find that that is unacceptable for many patients and other providers and so begrudgingly we will sometimes accommodate. Some of it is anxiety, and some of it is simply vascular surgery. It is so rare that I plan operations more than a month in advance. We just don't deal with things that can wait that long. Maybe it is a product of the practice environments that I have been exposed to, but we don't see a lot of claudicants or small aneurysms that we can follow and schedule months in advance. When I have to talk to our anesthesia about operating after recent PCI, I'm asking knowing the elevated risks, but know that either life or limb is currently at stake well within 3 months (usually <2 days).

Cardiac risk stratification is a mandatory part of every operation that I do. In my surgical training, you did a full month of cardiology as in internal medicine cardiology, completely non-surgical and you were expected to come away from that rotation being able to appropriately risk stratify and know what the 'optimal' workup should be for every patient undergoing surgery. The overlap between the vascular population and cardiac is way too high to not do this. Just as important as it is to know for planning to operate (or not operate), if you don't know, then you can't have a real, honest and effective conversation with the patient and their family about their operative risks.

Holy crap. Well, I applaud you and 100% agree that most surgical training should include this. The AHA/ACC guidelines should not be some document that may as well be in Latin to a surgeon. Bravo

 

[Robotic Wis-Hipple]

As long as the patient continues his DAPT, how much is the increased risk of surgery? Yes surgery is prothrombotic and pro inflammatory, but if DAPT is on board, what are the chances of ISR or new MI? Often we are heparinizing vascular patients as well in the OR.

From my understanding, cardiac interventions don't result in less periop major adverse cardiac events (same risk of MI as if they never got a stent), but also they don't have increased risk of MACE. Patients getting revascularized just reduces their lifetime risk (regardless of surgery). Does anyone else have different information?

Agree with Ronin, there’s a reason guidelines exist, in fact, surgical intervention inside of 1 month after stenting is declared Class III for clear harm/risk independent of DAPT, in fact nobody would think of doing it off DAPT. Inflammatory response from surgery actually peaks around day 3, which just so happens to line up fairly well with the most common timing of postop MI......

 

[Gas you down]

Great to see that there are some thoutful caring surgeons out there. However what happens in most cases is this: vascular surgeon gets a referral for possible endarterectomy. He evaluates the patient and decides that one is needed (whatever criteria he uses). He then tells the patient that you are at risk for stroke so we need to operate. He then sends the patient to cardiology for workup. Cardiology decides that a cath is needed and then a stent. Then he tells the patient “you are good to go, good luck”. Now after all this you meet the patient in holding area. Are you really going to tell the patient “hey, you don’t need this procedure now and maybe not ever”. (In other words your vascular surgeon is a *****) this conversation will not go well....

The above is basically what happened.

Upda

 

[Gas you down]

Damn fingers

Update: spoke to the vascular surgeon who had discussed it with the chief of cardiology. Said as long as ASA/Plavix is continued, they could do the case anytime, even the next day. Wtf

 

[Arch Guillotti]

Related to DES subject...
Had a case this am, asymptomatic pt who was sent for CTA after a bruit was heard. >70% bilaterally. During work up, had a positive stress, then a Xiance DES placed into RCA.
Now presents for CEA just shy of 4 weeks out. Still on ASA/plavix.
Cards told surgeon to go ahead but continue DAPT, but no note in the chart stating this.
Called the cardiologist, who was under the impression that this was an urgent/emergent case, and said it was ok to go this soon if meds continued.
I don’t consider this asymptomatic pt to be an emergency warranting such early intervention. If she was having symptoms at all, I’d drive on.
How would you personally approach this?

Was this pt. seen in a preop clinic prior to surgery?

 

[Gas you down]

We don’t have a preop clinic, but do review charts in advance. The doc requested cardiac clearance, which was verbally given to the vascular surgeon.

So I curbsided a couple of cardiologists who said the bigger question was did this person need a CEA to begin with. Usually should be symptomatic, or >80% to really justify intervening. Also both said they’d wait 6 mths for 2nd gen stents, 3 mths for 3rd, for elective cases.

As opposed to when I spoke to the chief, who said he’d clear any elective case as long as they were on DAPT, no matter the time since stent.

 

[Arch Guillotti]

We don’t have a preop clinic, but do review charts in advance. The doc requested cardiac clearance, which was verbally given to the vascular surgeon.

So I curbsided a couple of cardiologists who said the bigger question was did this person need a CEA to begin with. Usually should be symptomatic, or >80% to really justify intervening. Also both said they’d wait 6 mths for 2nd gen stents, 3 mths for 3rd, for elective cases.

As opposed to when I spoke to the chief, who said he’d clear any elective case as long as they were on DAPT, no matter the time since stent.

The guy who requested cardiac clearance should have done the case😉.

 

[mimelim]

Funny story, taking someone to the OR right now, 1 hour after PCI.

Yay iatragenic cold pulseless extremities. Made me think of this thread 😉

 

[IMGASMD]

Funny story, taking someone to the OR right now, 1 hour after PCI.

Yay iatragenic cold pulseless extremities. Made me think of this thread 😉

Is the coronary fixed?! 😉

 

[Psai]

Funny story, taking someone to the OR right now, 1 hour after PCI.

Yay iatragenic cold pulseless extremities. Made me think of this thread 😉

radial or femoral?

 

[narcotics999]

Our field is fxxxxd. We are constantly pushed to do things not in the best interest of patients and ours.

 

[Mman]

Funny story, taking someone to the OR right now, 1 hour after PCI.

Yay iatragenic cold pulseless extremities. Made me think of this thread 😉

I did one about a year ago that had a STEMI, got several stents placed and 300 mg load of Plavix, and then developed compartment syndrome related to the catheterization site hematoma requiring emergent fasciotomy to save the limb. I suggested to the surgeon that he make it short and sweet and we got out of OR as fast as f'in possible. The patient survived and did not have any further cardiac event that hospitalization.

 

[MoMoGesiologist]

Damn fingers

Update: spoke to the vascular surgeon who had discussed it with the chief of cardiology. Said as long as ASA/Plavix is continued, they could do the case anytime, even the next day. Wtf

Maybe we as anesthesia are not understanding the cardiology guidelines?

 

[deleted171991]

Update: spoke to the vascular surgeon who had discussed it with the chief of cardiology. Said as long as ASA/Plavix is continued, they could do the case anytime, even the next day. Wtf

Show me the study! Show meeeeeeeeeee the studyyyyyyyyyyyyyyyyyy!

Or was it "show me the money"? Can't remember. 😀

 

[deleted171991]

Our field is fxxxxd. We are constantly pushed to do things not in the best interest of patients and ours.

But our employers make nice profits, and, if we get sued and settle, they'll just hire another sucker.

That's what's wrong with the malpractice situation in the US. It should be as at the VA: the employer pays, and the patient cannot sue the employee. Suddenly, all these crappy surgeries wouldn't be safe anymore.

 

[mimelim]

Is the coronary fixed?! 😉

Yes, but let us be honest, someone getting their only open coronary stented with impella support is in bad shape, even post stenting...

radial or femoral?

Femoral, 14Fr hole with 4 proglides and an angioseal. Radial arteries occlude all the time, extremely rare for it to be an issue. We have our own access related issues, but it is alarming how many of these can be avoided with even the most basic of understandings. It is a training issue. While I have huge respect for the IR and IC people that developed many of the endovascular techniques, the concept that you can compare my 5 years of endo training with 12-18 months is absurd.