Preop Eval

[WholeLottaGame7]

In pre-op clinic this month. 56yM comes in for robot-assisted lap partial nephrectomy for presumed RCC, surgery is in a week. PMHx sig for a couple of right-sided CVAs from a 100% occluded right ICA 2 years ago w/ some left-sided extremity deficits. Left carotid w/ <50% occlusion. EF of 45% w/ mild global hypokinesis and a positive bubble study at time of CVA 2 years ago. DM2 and HTN which actually appear pretty well-controlled given that he hasn't taken any meds in months. Was only on baby ASA for his CVA and stopped that as well.

<4 METS, just limps around the house all day. But, no CP, no orthopnea, PND, peripheral edema, rales, any other signs/symptoms for CHF. EKG best I've seen in weeks. Labs unremarkable.

Will share my thought process and decision-making but curious to get others' opinions as well.

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[beepbloop]

Awake retrograde wire, double stick the neck.

 

[bcat85]

Preop I don't think I would do much more than what's already been done. I would certainly advocate for continuing his aspirin through his periop course. He does have some risk factors for CAD and has less than 4 METs of activity, but it doesn't sound like this warrants any further cardiac w/u. Anesthetic plan would be modestly straightforward--tube with an a-line and 2 big PIV's. I think the tougher question is whether he is a good candidate for a robotic case with his cerebrovascular disease. I would worry about a long run of steep trendelenberg position in a guy with marginal cerebral vasculature. Would the surgeon be up for a different approach?

 

[WholeLottaGame7]

Yeah, so despite his functional status and mildly depressed EF, I'm not super concerned about his heart. He doesn't have any active cardiac conditions (recent MI, arrhythmia, valvular dz, decomp HF) and he's having an intermediate-risk surgery. It's semi-elective, but it is probably cancer, so I doubt we'd want to take the time to revascularize him even if we did stress him and find something.

I am more concerned about his noggin, especially the medication non-compliance. Though short of providing him a bottle of baby ASA, I don't know that he's going to take anything. I mean, it doesn't get any cheaper than baby ASA or metformin or a statin. I think the best we can hope for is getting him on something postoperatively while we have him in-house. Fortunately, the surgeon knows what he's doing so hopefully the screwing around will be cut to a minimum.

I realized while investigating this, there's plenty of data on asymptomatic carotid stenosis, but not a lot of literature on management of 100% occlusion.

 

[bawer234]

So essentially 56yM for robot-assisted lap partial nephrectomy for presumed RCC; Untreated DM and HTN with prior CVAs from ICA occulsion +/- positive bubble study.

Intermediate risk surgery with low METs usually means pt gets a stress test. He's aSx but in the setting of untreated DM he could be having silent ischemia, in addition to that, he's not exerting himself enough to show any angina/DOE so your ROS questions are of limited value in this setting. Usually global hypokinesis has an etiology (i.e. CAD, EtOH, ect) so it would be interesting to know why his heart is suboptimal in the first place. That being said, having surgery for a possible malignancy pretty cancels out the possibility of getting this guy a stress test as you wouldn't want to post-pone a potentially life saving surgery for the next 6 months. The bubble study indicates the possibility of a PFO which could be problematic in the sense that RCCs can have tumor thrombus associated with them. When the surgeon manipulates the tumor, they could embolize any clot present sending it across a potential R->L shunt and causing an additional stroke. I would want to get an opinion from cardiology regarding any possible closure of the PFO prior to clearing him. From what I've read, it seems like these percutaneous PFO closure patients only require 6 months of either coumadin (obviously not going to happen) or ASA (much more feasible) s/p closure.

 

[deleted9493]

You shouldn't need steep trendelenburg for a robotic-assisted nephrectomy. I have done these often with partial lateral, table flex and kidney bump. Yeah, you've got to maintain a good MAP during insufflation in this patient, so I think an arterial line is justifiable. Otherwise, I'm just underscoring the risk of perioperative CVA with the patient/family and proceeding.

56 is simply too young to have an occluded ICA. Paradoxical embolus is a concern but this guy needs his tumor out, if he's going to have his years on earth optimized. Again, underscore the risk.