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Case: Carotid Endarterectomy
Started by DreamMachine
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1. In this case yes it would be nice to have a cardiologist see the patient: good beta blockade with poorly controlled HTN, diabetic so could have silent MI as evidenced by the inferior Q-waves.
2. I think not, normally you should have >70% stenosis to be considered for surgery. Maybe the TIA changes this...? What is the evidence for the TIA could it have been an MI?
3. Carotid patients will always be hypertensive so those numbers are not to scary.
1. Consult Cards. According the ACC/AHA guidelines. Pt has unknown functional capacity at best and is undergoing vascular surgery with Stage 3 hypertension.
2. The stenosis doesn't seem to be that great. Another form of treatment could be anticoagulation.
3. All other clinical indicators negative then it may be ok to proceed but probably not in this case since there are other indicators.
The problem is determining the necessity of the CEA. If it is felt that she will have a full blown CVA, then CEA may be indicated and one could get records of the pts office visits. If the BP is more reasonable in these records, one could try giving some versed to see if the BP is stress related. I would rather a little hypertension than some hypotension in this case. But the risk of MI is significant in this pt.
2. The stenosis doesn't seem to be that great. Another form of treatment could be anticoagulation.
3. All other clinical indicators negative then it may be ok to proceed but probably not in this case since there are other indicators.
The problem is determining the necessity of the CEA. If it is felt that she will have a full blown CVA, then CEA may be indicated and one could get records of the pts office visits. If the BP is more reasonable in these records, one could try giving some versed to see if the BP is stress related. I would rather a little hypertension than some hypotension in this case. But the risk of MI is significant in this pt.
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According to acc/aha: non emergent, intermediate clinical predictors, mod risk surgery + poor et: cards work up.
A symptomatic carotid will be done with 60% stenosis as far as I know.
This is where it gets iffy. You are not going to do much about the heart(other than start some bp, statins) no matter how bad the work up comes. Some places will do carotid/cabg but most will do the cabg after the carotid. Why bother getting the workup if you are doing the carotid regardless?
Anyway, I would still get it. It might help you tailor the anesthetic, and help with the differential in case of hypotension post op.
A symptomatic carotid will be done with 60% stenosis as far as I know.
This is where it gets iffy. You are not going to do much about the heart(other than start some bp, statins) no matter how bad the work up comes. Some places will do carotid/cabg but most will do the cabg after the carotid. Why bother getting the workup if you are doing the carotid regardless?
Anyway, I would still get it. It might help you tailor the anesthetic, and help with the differential in case of hypotension post op.
According to the updated 2007 guidelines from the ACC/AHA, the new risk factors are CAD, CHF, h/o CVA, DM and CRI. This lady has 2 risk factors (CVA, DM) with unknown METs (assume less than 4) and undergoing vascular surgery. If you follow this pathway, the decision essentially becomes proceed to the OR with HR control (she is already well beta blocked) vs. further work-up if it will change your management.
I think you can make the arguement to proceed without a cards consult based on those guidelines. However, this is an elective surgery that may not be warranted (the European Carotid Surgery Trial back in the day demonstrated that CEA isn't indicated for those w/30-69% stenosis, even if symptomatic. >70% stenosis is the magic ticket).
I would certainly want to know if her stage III HTN is long-standing. If so, this is not something that we want to treat expediently and she will need a gradual reduction in her BP over time. If the decision to proceed is made and her HTN is long-standing, we'll have to make sure that her BP stays near where she lives in order to maintain cerebral blood flow (assuming that she has a rightward shift of her CPP curve and her cerebral vasculature is maximally dilated/pressure dependent distal to her obstruction).
Also, what were her TIA symptoms? Are they even referrable to the side of her operative lesion?
It's a lot to consider, but I think I would say there isn't a great indication for this CEA and she should have her HTN and TIA further evaluated and managed. It's entirely possible that her carotid stenosis is true/true and unrelated to her symptoms. Maybe she had a small hemorrhage 2/2 HTN, an embolic event from A-fib or she's a IV drug user with a PFO and R-L shunt...you get my drift.
I think you can make the arguement to proceed without a cards consult based on those guidelines. However, this is an elective surgery that may not be warranted (the European Carotid Surgery Trial back in the day demonstrated that CEA isn't indicated for those w/30-69% stenosis, even if symptomatic. >70% stenosis is the magic ticket).
I would certainly want to know if her stage III HTN is long-standing. If so, this is not something that we want to treat expediently and she will need a gradual reduction in her BP over time. If the decision to proceed is made and her HTN is long-standing, we'll have to make sure that her BP stays near where she lives in order to maintain cerebral blood flow (assuming that she has a rightward shift of her CPP curve and her cerebral vasculature is maximally dilated/pressure dependent distal to her obstruction).
Also, what were her TIA symptoms? Are they even referrable to the side of her operative lesion?
It's a lot to consider, but I think I would say there isn't a great indication for this CEA and she should have her HTN and TIA further evaluated and managed. It's entirely possible that her carotid stenosis is true/true and unrelated to her symptoms. Maybe she had a small hemorrhage 2/2 HTN, an embolic event from A-fib or she's a IV drug user with a PFO and R-L shunt...you get my drift.
That's really old. Maybe even older than you. I'm not at work, so I cannot look up any recent stuff. In my search I have found several surgical programs (baylor, nyu..) claiming symptomatic 50% occlusion as an indication. It might be worth to look up recent recommendations.
Best I found was a Cochrane review of CEA for symptomatic stenosis:
Carotid endarterectomy reduced the risk of disabling stroke or death for patients with stenosis exceeding ECST-measured 70% or NASCET-measured 50%. This result is generalizable only to surgically-fit patients operated on by surgeons with low complication rates (less than 6%).
North American Symptomatic Carotid Endarterectomy Trial (NASCET), and the European Carotid Surgery Trial (ECST) have different methods of measuring stenosis. Severe stenosis is ECST > 80% = NASCET > 70%. Our vascular lab reports which method is used (usually NASCET).
From BestBets.org for asymptomatic carotid stenosis needing CABG:
CEA followed by CABG has a stroke rate of 1.5%, unprotected CABG then CEA had a stroke rate of 3.8%, CABG and CEA at the same operation had a stroke rate of 3.9%.
Carotid endarterectomy reduced the risk of disabling stroke or death for patients with stenosis exceeding ECST-measured 70% or NASCET-measured 50%. This result is generalizable only to surgically-fit patients operated on by surgeons with low complication rates (less than 6%).
North American Symptomatic Carotid Endarterectomy Trial (NASCET), and the European Carotid Surgery Trial (ECST) have different methods of measuring stenosis. Severe stenosis is ECST > 80% = NASCET > 70%. Our vascular lab reports which method is used (usually NASCET).
From BestBets.org for asymptomatic carotid stenosis needing CABG:
CEA followed by CABG has a stroke rate of 1.5%, unprotected CABG then CEA had a stroke rate of 3.8%, CABG and CEA at the same operation had a stroke rate of 3.9%.
Agreed, that's just the one I could remember as it was the one I got pimped on once.
I would get the consult although I don't really think it's necessary. I would also ask the surgeon to do it completely awake under superficial and deep cervical plexus blocks. Have her squeze the rubber ducky throughout the case + 2-4 mg of versed.
Why?
I think you should do this case the way you do all your other Carotids.
So if you do all of them awake then do it awake but I don't see a reason to do this particular case awake.
I think awake carotids are much, much smoother than asleep carotids IMHO. This is definately what I want when I'm 75 y/o in need of a CEA.
If you had the option of doing it awake vs asleep, I'd do it awake because you...
Avoid induction, GA, narcs, laryngoscopy, extubation on a potentially bad heart (with potentially a recent MI) + uncontrolled HTN. Surgical time is much shorter with awake CEA's.
This patient is obese right? Maybe she has a difficult airway, maybe not. If she does you may or may not run into even further hypertension or hypotension if trying to secure an unexpected difficult airway.
Hypertensive patients like this one may be unpredictable once you render them under the effects of GA. Large fluctuations in B.P are not uncommon, especially if your starting B.P. is 190/100. Of course, we could treat it and make it better, but you don't see this BP variability in chronic hypertensive patients with awake carotids- no reason for the body to react that way.
Overall, I think awake carotids are more elegant. I see great benefits in doing it awake vs. asleep. We ha'd a neurosurgeon during residency that would take no more than 45 minutes to do an awake CEA. Patients never complained of pain, never had n/v or sore throats and were D/C'd home the same day (23hr. stay)
If your surgeon does them all asleep, then that is another story.
If you had the option of doing it awake vs asleep, I'd do it awake because you...
Avoid induction, GA, narcs, laryngoscopy, extubation on a potentially bad heart (with potentially a recent MI) + uncontrolled HTN. Surgical time is much shorter with awake CEA's.
This patient is obese right? Maybe she has a difficult airway, maybe not. If she does you may or may not run into even further hypertension or hypotension if trying to secure an unexpected difficult airway.
Hypertensive patients like this one may be unpredictable once you render them under the effects of GA. Large fluctuations in B.P are not uncommon, especially if your starting B.P. is 190/100. Of course, we could treat it and make it better, but you don't see this BP variability in chronic hypertensive patients with awake carotids- no reason for the body to react that way.
Overall, I think awake carotids are more elegant. I see great benefits in doing it awake vs. asleep. We ha'd a neurosurgeon during residency that would take no more than 45 minutes to do an awake CEA. Patients never complained of pain, never had n/v or sore throats and were D/C'd home the same day (23hr. stay)
If your surgeon does them all asleep, then that is another story.
1 of our 4 vacular surgeons at my current practice likes to have me not extubate until the patient moves all 4 extremities.
It drives me nuts... 
To have a patient wake up and be forced to move all 4's when the ETT is in place, frequently requires pharmacological management in order to keep B.P.'s where they need to be (despite LTA). I've fought with him on this and explained to him that if a deficit does appear in the pacu we would just proceed back to the OR and take care of things there. He has had a handful of bring back CEA's in 8 yrs and adds a good 5 minutes or more to a lot of cases + I can't extubate them deep as I usually do. I don't like to stir up the mud to much, but....😡
It's like doing a "wake up test" at the begining of a big spine case because you flipped the patient prone and the orthopod wants to document neurological intactness. This practice did not last very long at my old institution.
Anyone else testing for deficits in the OR before the ETT is out?
Addendum: another benefit of awake CEA's
It drives me nuts... To have a patient wake up and be forced to move all 4's when the ETT is in place, frequently requires pharmacological management in order to keep B.P.'s where they need to be (despite LTA). I've fought with him on this and explained to him that if a deficit does appear in the pacu we would just proceed back to the OR and take care of things there. He has had a handful of bring back CEA's in 8 yrs and adds a good 5 minutes or more to a lot of cases + I can't extubate them deep as I usually do. I don't like to stir up the mud to much, but....😡
It's like doing a "wake up test" at the begining of a big spine case because you flipped the patient prone and the orthopod wants to document neurological intactness. This practice did not last very long at my old institution.
Anyone else testing for deficits in the OR before the ETT is out?
Addendum: another benefit of awake CEA's
You will continue to like awake carotids until the first time you get a patient who gets ischemic and as a result becomes confused and combative (with versed making it worse), then decides to sit up and at the same time pulls out the IV and the A line, when this happens to you for the first time, and it will, you will stop thinking that awake carotids are elegant. 🙂
I don't think I'd like that at all. I have had to convert 2 or 3 becasue they became confused/dysarthric, but so far none of them stood up, yanked their IV and d/c'd their a-line. Nope Plank... I don't think I'd like that at all. Here is for hoping it won't happen 
I agree with the assessment. However i would leave the decision as to whether the CEA needs to be done to the surgeon. All i would ensure is that once the decision is made to proceed the pt is optimized to proceed. I dont pretend to know or take on the responsibility of deciding who needs what surgery and when. There will always be some exceptions to this but in general i try not to get involved from that standpoint. My most notable exception is when doing TEE and find a valve which is bad and push the surgeon to fix it.
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Arch Guillotti
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Why not just do a superficial block?
Arch Guillotti
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My 2 cents:
I am pretty ambivalent about a cards workup. I just don't think that it would change the management much. I also think that it is up to the surgeon to decide if the operation needs to be done or not. I would probably prefer to do it asleep, unless I feel that the patient would be an excellent candidate for an awke one. Awake is obviously better in terms of the hemodynamics but if you are careful with the asleep you can control the hemodynamics just like you want them. Superficial cervical plexus block seems to work well, although the surgeonn invariably supplements. I generally avoid benzos in carotids (awake and asleep).
Doing an awake carotid on the wrong patient is MISERABLE. This lady is fat and has back pain which may make her very uncomfortable during the procedure. Conversion is the last thing I want to do.
Finally, I wouldn't get too excited about the BP.
I am pretty ambivalent about a cards workup. I just don't think that it would change the management much. I also think that it is up to the surgeon to decide if the operation needs to be done or not. I would probably prefer to do it asleep, unless I feel that the patient would be an excellent candidate for an awke one. Awake is obviously better in terms of the hemodynamics but if you are careful with the asleep you can control the hemodynamics just like you want them. Superficial cervical plexus block seems to work well, although the surgeonn invariably supplements. I generally avoid benzos in carotids (awake and asleep).
Doing an awake carotid on the wrong patient is MISERABLE. This lady is fat and has back pain which may make her very uncomfortable during the procedure. Conversion is the last thing I want to do.
Finally, I wouldn't get too excited about the BP.
I do the superficial 15-20 minutes before incision. The surgeon does the deep/supplement once trorugh the skin. I believe the deep would cover ant. neck muscles and provide less discomfort with traction.
