Last Case of the Week

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periopdoc

periopdoc

Cardiac Anesthesiologist
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Friday morning with just one quick heart case before the big weekend off. Scheduled for LIMA to LAD and one or two vein grafts all of which you know your CT surg buddy can do with a 20 min pump run or so if you even have to go on pump. There is a good chance you are going to make it out by noon today.

Of course the A-line doesn't go, won't thread blah blah blah. Call for U/S and drop it in, but your usual 1-3 min procedure took 15 min. Blech.

Induce and fight with the pressure for a few minutes then get set up for your usual double stick right IJ CVP and PAC. Prep, drape, and start surveying the IJ with U/S which reveals the following as you scan from superiorly to inferiorly,

[YOUTUBE]IsOnmr-cwCY[/YOUTUBE]

[YOUTUBE]TLtNZXvGrJ4[/YOUTUBE]

Your next move?

- pod
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CA1 here (haven't done my CT rotation yet)...lemme take a stab at it.

So superiorly it looks like relatively normal anatomy with a pretty normal, compressible superficial IJ anteriolateral to the carotid. As you scan inferiorly it reveals a very large pulsatile vessel just deep to the IJ. Dissection of the R carotid artery possibly? The only thing that is throwing me is the still relatively normal appearing carotid posteriolateral to the weird pulsatile vessel. I am guessing one is true lumen and one is false?

Did he relay any history of stroke/TIA/syncope/etc? Any prior carotid ultrasounds that you have?

Decision tree at this point would be wake up the pt versus have a look on the left side and see if he has normal looking anatomy. I would probably base that decision on how urgently this CABG is being done and if he is symptomatic from this vascular anomaly.
 
Last edited:
Any long axis views?

I'm beginning to think that if this is indeed a dissection that his CABG needs to be put off unless it is absolutely emergent. Risk of CVA is already very high in cardiac cases. His would be much higher. Unless I am reading this whole thing wrong that is.
 
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i cant quite figure out from the picture what it is exactly, but i presume some sort of dissection of external carotid/internal jugular fistula(?). would place an echo and make sure that there is no proximal aortic dissection. im kind of worried about how narrow that internal carotid looks and would probably delay until i could find some way to assess degree of stenosis. also could review cath films if available
 
Mr. Surgeon look what we have here. Mrs. Cardiologist look what we have here.
Probably not gonna jam that introducer in after all. Do we really "need" a PAC for this case anywho? TEE like the idio recommends.
 
I don't want want to spoil it.
 
Edit: realized the last question might have been poorly worded. Is the instrument oriented superior/inferior?
 
Last edited:
periopdoc said:
Induce and fight with the pressure for a few minutes then get set up for your usual double stick right IJ CVP and PAC.
Click to expand...

Why would you want a PAC for this case?
I don't think it's pulsating from a communication with the carotid it's just the membrane floating in the vessel. Some sort of IJ aneurysm.
I believe the surgeon would like to get an angi or mri prior to fixing this.
 
dhb said:
Why would you want a PAC for this case?
I don't think it's pulsating from a communication with the carotid it's just the membrane floating in the vessel. Some sort of IJ aneurysm.
I believe the surgeon would like to get an angi or mri prior to fixing this.
Click to expand...

Or some other anomaly. Duplication of the Jugular? Somebody who looks at vascular u/s routinely needs to look at this. Radiology? Vasular surgeon in the next room? Either way, I aint puttin no needle and certainly no 8.5 Fr introducer into that.
 
How's the left look? Any other imaging on file you could reference? Maybe a pre-op carotid duplex that you could steal a peek of the jugs? I'm on board with getting someone else to look at that.

If you're pressed, on that's not really an option how does the left look?
 
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For those that are wondering, this is a true short axis cross section of the IJ as evidenced by the short axis cross section of the carotid artery. It seems huge doesn't it?

When I talk about superior/ inferior, I mean that I am moving the probe cephalad and caudad while maintaining a short axis orientation to the IJ.

For those that might be thinking of a communication between the carotid and the IJ, look closely at the timing of the movement of the flap. It seems more like an a-c-v CVP type waveform than a typical arterial waveform.

- pod
 
periopdoc said:
For those that are wondering, this is a true short axis cross section of the IJ as evidenced by the short axis cross section of the carotid artery. It seems huge doesn't it?

When I talk about superior/ inferior, I mean that I am moving the probe cephalad and caudad while maintaining a short axis orientation to the IJ.

For those that might be thinking of a communication between the carotid and the IJ, look closely at the timing of the movement of the flap. It seems more like an a-c-v CVP type waveform than a typical arterial waveform.

- pod
Click to expand...

Thanks! Have very little experience with US and the abnormal anatomy made it a little too much to be sure
 
RocurWorld said:
Its a valve. sometimes the IJ has them. Place the line. proceed with case.
Click to expand...

Ding Ding Ding!

I have to admit it has been entertaining reading all the bizarre responses.
 
periopdoc said:
Induce and fight with the pressure for a few minutes then get set up for your usual double stick right IJ CVP and PAC. Prep, drape, and start surveying the IJ with U/S which reveals the following as you scan from superiorly to inferiorly,
Click to expand...

Do you have a CRNA or somebody to help you if the blood pressure tanks while you are placing the line?
 
dhb said:
Why would you want a PAC for this case?.
Click to expand...

I don't, the surgeon and intensivist do. They want them for all hearts so I place them. I get paid better for floating a PA than I do for doing TEE so I am not complaining too loudly.

urge said:
Do you have a CRNA or somebody to help you if the blood pressure tanks while you are placing the line?
Click to expand...

Nope, no CRNA's here, but I am fairly good with my toes. Before I induce, I hook up the drips to a peripheral line. I do a quick initial resuscitation after inducing and start drips if necessary. If I need to start or adjust the drips while placing the line I can do it with my toes. If I need a quick pressor bolus, a tug or two on the ETT tends to work pretty well and since it is covered with the drape, I can manipulated it and remain sterile. Worst case scenario, I break, resuscitate, and regown to finish the procedure.

- pod
 
periopdoc said:
Nope, no CRNA's here, but I am fairly good with my toes. If I need to start or adjust the drips while placing the line I can do it with my toes.
Click to expand...

smelly_feet_remedies-300x200.jpg
 
I think it looks like a valve in the vein.

I would scan the other side and probably put the line in there.

Incidentally there seems to be a significant knuckle of atheroma in the carotid in the first video (at the 5 second mark) that doesn't look at all friendly.
 
dhb said:
Could be a valve but i'm surprised by the size of that vein, never seen one like it. I still think in the first video the vessel isn't perfectly anechogenic although it could be an artifact.
Click to expand...

I thought the carotid was a little smallish in size. My own IJ is that size... maybe even bigger with a valsalva.
 
The other thing it could be- a septated communication between an abnormal EJ and the IJ.
 
periopdoc said:
Friday morning with just one quick heart case before the big weekend off. Scheduled for LIMA to LAD and one or two vein grafts all of which you know your CT surg buddy can do with a 20 min pump run or so if you even have to go on pump. There is a good chance you are going to make it out by noon today.

Of course the A-line doesn't go, won't thread blah blah blah. Call for U/S and drop it in, but your usual 1-3 min procedure took 15 min. Blech.

Induce and fight with the pressure for a few minutes then get set up for your usual double stick right IJ CVP and PAC. Prep, drape, and start surveying the IJ with U/S which reveals the following as you scan from superiorly to inferiorly,

[YOUTUBE]IsOnmr-cwCY[/YOUTUBE]

[YOUTUBE]TLtNZXvGrJ4[/YOUTUBE]

Your next move?

- pod
Click to expand...
Commenting kind of late in the game. I have seen this before in my residency. Although, with the history of difficult aline placement a dissection flap is on the list. However the vessel in question is not the internal carotid its definitely a venous waveform. We consulted vasc surgery they came by looked at it and made the diagnosis of a valve. We scanned the LIJ where the valve was not present and placed an IJ. I would have my vascular colleagues come by take a look placed an IJ on the L side. No PA catheter TEE in the goose and lets get on pump. Also, most of our hearts the patients often have carotid dopplers. May run my pump flows a little higher than normal with the smallish carotid.
 
Im pretty certain its a valve. Urge agrees :) but i havent seen Pods official answer. If it is a valve, canceling the case, or calling a consult would make you look silly.

By the way, a 20 minute pump run? I dont think ive ever seen less than 40! for a single vessel! We did a 53 minute pump run the other day just to scrape a small tumor of a valve. Didnt even need to repair it!
 
Sorry I don't have a nice long axis view saved to show you, but this is indeed a IJ valve.

The reason it looks so odd is that it is an incompetent IJ valve. Color flow revealed normal venous flow pattern lateral to the valve and some swirling medially, but clearly venous flow.

The IJ is enlarged due to chronic valvular incompetence.

This is typically associated with COPD or pulmonary HTN.

Difficulty with central line placement has been reported although there is no clear cut contraindication to placing a line in that vein that I am aware of.

I asked the CT surgeon to have a look in case it altered his approach at all, then I elected to place lines on the left side to avoid any potential problems being blamed on cannulation of the right side.

As expected from the large size of the right IJ, the left IJ was minuscule, but I was able to place a triple lumen CVP into it with U/S guidance.

I placed a PA introducer into the left subclavian and floated the Swan through that.

Probably un-necessary, but a good excuse to practice a different technique.

- pod
 
Didn't read anything after the first post and didn't watch the videos sinc rim aon an iPad and can't access them. But my question is, if your CV guys are so good (can do a couple vein grafts in 20 min) then why are you doing a double stick?
 
7454417120_ed988a0573_m.jpg
[/url]
mail-1 by Sevo', on Flickr[/IMG]

7454417090_7f26f99a3a_m.jpg
[/url]
mail-2 by Sevo', on Flickr[/IMG]

Well, I should be a pretty easy stick for my CABG if I ever get one. :)

Same goes for my ISB for my shoulder scope... which I KNOW I will get sometime in the next 5-10 yrs. :(
 
Noyac said:
Didn't read anything after the first post and didn't watch the videos sinc rim aon an iPad and can't access them. But my question is, if your CV guys are so good (can do a couple vein grafts in 20 min) then why are you doing a double stick?
Click to expand...

I'm going to guess that the introducer/swan come out pretty quickly. Triple lumen thereafter.

Our routine here is RIJ introducer Swan. No triple lumen.... we just go off a good 18G after the introducer comes out.
 
I'd say we average about 15min. per graft. Of course... the sneaky ones buried in fat take a little longer to find sometimes.
 
sevoflurane said:
7454417120_ed988a0573_m.jpg
[/url]
mail-1 by Sevo', on Flickr[/IMG]

7454417090_7f26f99a3a_m.jpg
[/url]
mail-2 by Sevo', on Flickr[/IMG]

Well, I should be a pretty easy stick for my CABG if I ever get one. :)

Same goes for my ISB for my shoulder scope... which I KNOW I will get sometime in the next 5-10 yrs. :(
Click to expand...
With such excellant anatomy next time ur on the table I will grab a med student to put in your mac. Without ultrasound :)
 
proman said:
What's up with Friday CABs? Found this yesterday:

[YOUTUBE]http://www.youtube.com/watch?v=SpXLRxe2TUc&feature=plcp[/YOUTUBE]
Click to expand...

Did you call vascular for dissection, fistula, svc syndrome....... or did you do :"saw that at sdn last week, move along"
 
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