Carotid stent

[Patron]

Do you use an aline for carotid stent?

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[Arch Guillotti]

yes

 

[rsgillmd]

Do you use an aline for carotid stent?

No.

The caveat is that we don't have vascular at my current institution, so I haven't done a carotid since residency. During residency vascular surgery ran two rooms every weekday, and usually had cases on the weekends also. So carotid stents were relatively quick cases done under MAC sedation. There were not any significant hemodynamic changes. The most intense time was when the stent was deployed. I pushed atropine twice while having the patient cough for transient (but scary) asystole.

I'm not sure how an A-line would have benefited me.

 

[Mman]

Do you use an aline for carotid stent?

yes

although it doesn't provide a lot of benefit unless there is the rare disaster (carotid dissection for example)

 

[gtb]

I do. We have both neurosurgery and vascular surgery doing carotids at our hospital.

Neurosurgey does them under general anesthesia with both SSEP and intraoperative transcranial doppler monitoring for the cross clamp phase and emboli monitoring. These are typically patients with reasonably severe bilateral disease, and also some component of cerebrovascular stenosis. There's a trial clamp of the carotid, and if ipsilateral TCD velocity of the MCA drops more than 50%, we at least ensure the blood pressure is maintained at the patient's baseline. Then If there's any change in SSEP signals during cross clamp, I incrementally raise the BP, hoping to improve collateral flow. If unable to normalize the SSEPs, then the surgeons usually shunt.

The vascular surgeon I work with prefers awake patients. Not everyone gets an aline, usually however, those with fairly high baseline BP will get one. If the patient begins to get a little altered or has focal signs during the cross clamp, assuming BP is somewhere near baseline, I incrementally increase the BP and try to normalize the neural exam. If we can't restore function, they shunt or sometimes just work quickly when it's a short segment of stenosis.

 

[Idiopathic]

I do. We have both neurosurgery and vascular surgery doing carotids at our hospital.

Neurosurgey does them under general anesthesia with both SSEP and intraoperative transcranial doppler monitoring for the cross clamp phase and emboli monitoring. These are typically patients with reasonably severe bilateral disease, and also some component of cerebrovascular stenosis. There's a trial clamp of the carotid, and if ipsilateral TCD velocity of the MCA drops more than 50%, we at least ensure the blood pressure is maintained at the patient's baseline. Then If there's any change in SSEP signals during cross clamp, I incrementally raise the BP, hoping to improve collateral flow. If unable to normalize the SSEPs, then the surgeons usually shunt.

The vascular surgeon I work with prefers awake patients. Not everyone gets an aline, usually however, those with fairly high baseline BP will get one. If the patient begins to get a little altered or has focal signs during the cross clamp, assuming BP is somewhere near baseline, I incrementally increase the BP and try to normalize the neural exam. If we can't restore function, they shunt or sometimes just work quickly when it's a short segment of stenosis.

we are talking about carotid stents, which is an angiographic procedure, usually on an awake patient. i typically do not place one, as I am willing to rely on being able to slave off the sheath should the pressure go in the tank. I also give these patients no sedation (i.e. a 'true' MAC)

 

[sevoflurane]

Watch out for bradycardia as the stent is deployed. I give glyco preemptively. Plenty of cases that have arrested 2/2 Brady>asystole. I put in an a-line cuz I know I'll never regret it.

 

[sevoflurane]

http://www.ncbi.nlm.nih.gov/m/pubmed/21861740/

 

[Idiopathic]

Watch out for bradycardia as the stent is deployed. I give glyco preemptively. Plenty of cases that have arrested 2/2 Brady>asystole. I put in an a-line cuz I know I'll never regret it.

 

[sevoflurane]

Play nice.

 

[Idiopathic]

arterial lines have complications, to say you will never regret it is probably not true. but the real question is when do you abandon the difficult one, or do you carry on for 30-40 minutes, sticking an awake patient?

edit: i know what you mean is "ill never regret being able to monitor arterial blood pressure", and thats true, but its a discussion worth having

 

[sevoflurane]

Really? Dude... a-lines do not take 30-40 min. Use an USD and get it on your first stick if you feel it will take you that long. Bradycardia and asystole is for real in these cases. I can't remember the last time an Aline has taken me more than 5 min. No offense idio.

Risk vs benefit.

 

[Idiopathic]

Really? Dude... a-lines do not take 30-40 min. Use an USD and get it on your first stick if you feel it will take you that long. Bradycardia and asystole is for real in these cases. I can't remember the last time an Aline has taken me more than 5 min. No offense idio.

Risk vs benefit.

so how does an arterial line protect you against bradycardia/asystole? is there a rule against pretreatment with an anticholinergic prior to stent deployment? why not place a CVC so you can temporarily pace? im just playing devils advocate. I only did about 5 of these as a resident, and a few more as an attending (we mostly do open CEA), but I get the risk.benefit thing, just trying to figure out where the benefit is when you get exactly the same information (pulse) as you would from your EKG/pleth

 

[Idiopathic]

Really? Dude... a-lines do not take 30-40 min. Use an USD and get it on your first stick if you feel it will take you that long. Bradycardia and asystole is for real in these cases. I can't remember the last time an Aline has taken me more than 5 min. No offense idio.

Risk vs benefit.

our residents place the arterial lines. there are times when the challenging ones are time-consuming.

 

[sevoflurane]

Well for one, an arterial line will give me an immediate blood pressure in someone who has severe carotid stenosis who is at high risk for a stroke. I mean... think about it Idio... why do these people get carotid stents?

THEY ARE TOO SICK FOR AN OPEN CAROTID!

"Carotid stenting is the preferred therapy for patients who are at an increased risk with carotid surgery. High risk factors include medical comorbidities (severe heart disease, heart failure, severe lung disease, age > 75/80, etc) and anatomic features (contralateral carotid occlusion, radiation therapy to the neck, prior ipsilateral carotid artery surgery, intra-thoracic or intracranial carotid disease) that make surgery difficult or risky"

Do you put an a-line in for your open carotids? I do.

To further answer your question, when bradycardia presents itself an aline will give me an immediate BP. It will allow me to choose between ephedrine and atropine or both or even epi. More importantly, if bradycardia progresses to aystole, I have an a line for the mini code or full code that follows.

Regarding your comment on anticholinergics... there are many carotid stent guidelines that suggest to give atropine or glyco for this potential risk. There are few rules in medicine and anesthesia and honestly I’m not quite sure what you are saying with that comment. Glyco is better than atropine IMO. Next carotid stent you do, I’d recommend glyco when testing and before deployment.

Have a read:

http://pvs.sagepub.com/content/22/3/164.abstract

Lastly, I’ve been there without an a-line, so what I’m doing is giving you and the OP my experience. I don’t like it when people stop responding to verbal stimulation and are asystolic. A-lines are helpful when these things happen. But you can go off a pulse ox waveform and a BP cuff if you wish to practice that way. I’m sure some do. I don’t.

Moreover, in my practice, I am a solo pilot without the ability to get extra hands.... anesthesia help overhead does not exist. So, I do what is safest for my patient, which is placing an a-line in these carotid stents. Different that an academic center for sure. There is no 30-40 minute a lines or residents and free floating attendings all over the place.

I’ll say it again: I will put in an aline every single time in these cases cuz I’ll never regret it.

You can do what you want. But please don’t criticise my practice when you have no clue about it.

Discussions are better taken on these forums whe they are that: discussions. They can be very useful... which is why you and I have frequented them for so long.

http://www.ncbi.nlm.nih.gov/pubmed/15944593

Just my perspective Idio. Again, no offense intended:

 

[Idiopathic]

sorry, man, i didnt know you werent up for a discussion, and obviously took my joke the wrong way. ill keep any more comments to myself.

 

[sevoflurane]

sorry, man, i didnt know you werent up for a discussion, and obviously took my joke the wrong way. ill keep any more comments to myself.

The apologies lie with me then. I couldn't quite get the tone of your joke. It's hard on an internet forum where there is a lot of bravado flung around in all directions.

Always up for a good discussion bro... I hope to continue to hear your comments.

I find your posts intelligent and thoughtful.

 

[DrN2O]

Yes to a-line. A-line does not protect you against brady/asystole, but it's a lot nicer to place an a-line before the pulse disappears. On a side note, I have yet to regret to HAVING an a-line. But yes, I have regretted TRYING and not getting an a-line

 

[nap$ter]

no to aline. at my institution IR does these under MAC with non-CRNA nurse sedation, and they just call us for standby during stent deployment.

we stand in the corner with some drugs, then leave if all goes well.

arrythmia is the issue, with secondary hemodynamic change. ecg is sufficient. fix the rhythm, CO will follow.

alines are not always benign, especially in these arteriopaths.