Recent case...

[bkell101]

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On call two days ago

54 yo m admitted for syncope
Heavy smoker , drinker, and htn

8.9 cm aaa found on ct scan

Go see him for preop...
Reports good mets and no cardiac symptoms other than his fainting spell

Harsh systolic murmur lusb
No work up for syncope yet but surgeon wants to "get this this fixed before it ruptures"

How would you guys have proceeded?

What else do you want to know?

I'll tell you what we did and how it turned out after a few replies....

 

[drrosenrosen]

First, I'd put in a spinal....



Any previous history on this AAA? Has it been unstable/getting bigger? Any signs it's currently leaking? Pt currently hemodynamically stable? Get a TEE to assess the AS

 

[PainDrain]

First thing, you definitely need an echo. No point in trying to fix that AAA if he crashes on induction. Also, you need to know his cardiac status if, as I am simply guessing, he needs an open repair and considering his open AAA repair will likely produced marked changes in his hemodynamics intraop and post op. He also needs cxr, cmp, CBC, type/cross for 6 units plus products. If it's an endo vascular repair it could be done under MAC but again he needs the Echo and labs. This is my starting point. Game plan depends on echo findings.

 

[bkell101]

First thing, you definitely need an echo. No point in trying to fix that AAA if he crashes on induction. Also, you need to know his cardiac status if, as I am simply guessing, he needs an open repair and considering his open AAA repair will likely produced marked changes in his hemodynamics intraop and post op. He also needs cxr, cmp, CBC, type/cross for 6 units plus products. If it's an endo vascular repair it could be done under MAC but again he needs the Echo and labs. This is my starting point. Game plan depends on echo findings.

Forgot to add...I was sent to pre op the patient at noon, case is scheduled for 1pm

In the sicu pt is chatting up the nurses having a grand ole time

Bp is 90's/60's on axillary Aline
Sats 91 on 4l

Guy hast seen a doc in years
Denies any lung dz
No prior imaging
Per surgeon no sign of leak
Starts just below renal artery Extends into both illiacs
Surgeon says no chance endo vascular

Sicu resident says they got a cards consult but no tte ordered yet

EKG is nsr
Cxr looks like you took it out of a text book section for copd

I tell surgeon we should order and wait on the tte because he has an obvious murmur and is likely the cause of his syncope

He says no case has got to go and it won't change his operative management.....oh and I'm a ca-2 speaking to the surgeon (chair of surgery) ....thoughts on what should be done next?

 

[drrosenrosen]

If surgeon is being this unreasonable, discuss with your attending and get him/her involved. Obviously when you're an attending you just stand up for your patient and say what needs to be done, but you're at a distinct disadvantage in terms of hierarchy here, and it's better to get someone involved to whom the surgeon will listen (maybe?) before he gets his hackles all up arguing with a resident.

 

[IlDestriero]

The AAA isn't causing his syncope if it's not ruptured/leaking. He's lived with it for months to years and it almost certainly won't rupture in the time it takes to properly evaluate the patient with an echo, carotid Doppler, etc. There's no sense doing the open AAA repair if you assassinate him at cross clamp.

 

[IlDestriero]

"It won't change his operative management..." Lol.

 

[Planktonmd]

You need an echo to figure out the cardiac status and make sure he does not have critical aortic stenosis that would kill him the moment you clamp the aorta.
This will not delay the case and should not take more than 10 minutes.
If the Echo shows bad AS you need to have input from CT surgery to formulate a meaningful plan of action.

 

[Ezekiel2517]

Get the echo. There are many things that predict low likelihood of surviving an open AAA repair and severe AS is one of them

 

[Ignatius J]

I'm on the Cowboy end of the spectrum as far as my practice goes, but surgery not getting a TTE is almost defiant to me. You can get a stat echo in just about any hospital within a couple hours.

 

[ThePlockIsHot]

Wow that sounds like a great case. Just trying to think about some of the physiology and curious as to why cross clamp would be so dangerous (assuming tight AS, increase LV afterload after CC, LV has fixed afterload anyway). Wouldn't the really hairy part be the unclamping when you (likely) lose your afterload and your CA perfusion starting the downward spiral?

 

[nimbus]

Agree with everyone that patient needs an echo. Would only take a few minutes to get answers you need.

I'm even more interested in why this patient is not a candidate for a stent graft. Did the surgeon explain why?

Where I am, we stent everything. Haven't done an elective open repair in 5 years at least. Sometimes we do multistage procedure to relocate branch vessels prior to stenting. Other times fenestrated and/or bifurcated devices are deployed.

Dissections are another story and we do open those on occasion.

 

[nimbus]

Wow that sounds like a great case. Just trying to think about some of the physiology and curious as to why cross clamp would be so dangerous (assuming tight AS, increase LV afterload after CC, LV has fixed afterload anyway). Wouldn't the really hairy part be the unclamping when you (likely) lose your afterload and your CA perfusion starting the downward spiral?

Both parts can be hairy. But generally infra renal clamping is not so bad.

 

[bkell101]

If surgeon is being this unreasonable, discuss with your attending and get him/her involved. Obviously when you're an attending you just stand up for your patient and say what needs to be done, but you're at a distinct disadvantage in terms of hierarchy here, and it's better to get someone involved to whom the surgeon will listen (maybe?) before he gets his hackles all up arguing with a resident.

I told my attending "I believe this patient has some degree of AS and would like to get an echo"...attending response ,"why can't we just get do an Intraop tee?"...if he has severe as will we cancel the surgery?

 

[bkell101]

You need an echo to figure out the cardiac status and make sure he does not have critical aortic stenosis that would kill him the moment you clamp the aorta.
This will not delay the case and should not take more than 10 minutes.
If the Echo shows bad AS you need to have input from CT surgery to formulate a meaningful plan of action.

This was my feeling exactly...1. how can I be in a major academic institution ad not be able to get a bedside tte in under an hour? (I wanted to just take a look myself). 2. Supra renal clamping and unclamping could kill this guy ...

 

[bkell101]

The AAA isn't causing his syncope if it's not ruptured/leaking. He's lived with it for months to years and it almost certainly won't rupture in the time it takes to properly evaluate the patient with an echo, carotid Doppler, etc. There's no sense doing the open AAA repair if you assassinate him at cross clamp.

I agree completely and this was I my discussion with my attending and the surgical chair .....

 

[bkell101]

So I lose the argument ..16/18 g iv....thoracic epidural ...slow induction with 20 mg of prop at a time...neo inline...Aline shows stable bp...60 of roc ...intubate...cordis in the neck....

I stick the tee probe down and his aortic valve is lit up with calcium , minimum excursion, effective area of .74, gradient over 40 in the face of a crapy lv with Ef 25-30% and the anterior/Lateral walls are barely moving (basically a kinetic)....

So what now?

 

[jwk]

So I lose the argument ..16/18 g iv....thoracic epidural ...slow induction with 20 mg of prop at a time...neo inline...Aline shows stable bp...60 of roc ...intubate...cordis in the neck....

I stick the tee probe down and his aortic valve is lit up with calcium , minimum excursion, effective area of .74, gradient over 40 in the face of a crapy lv with Ef 25-30% and the anterior/Lateral walls are barely moving (basically a kinetic)....

So what now?

Well, it will make a great M&M presentation. 🙂

 

[pgg]

So what now?

Silently think "I told you so" and be grateful that you're a resident and someone else is on the hook.

 

[amyl]

Did your staff not back you up ? In the face of a surgeon like this I say... Ok I'm going to write in the chart that I said wait for the Echo for patient safety and you refused. They usually back down then.
Where I trained they would likely combine the procedures.... Put them on bypass and fix it all

 

[IlDestriero]

What dunce faculty got bullied into not getting an echo? That's beyond ridiculous. Tell the echo tech to get off his ass and walk up to cardiology to get it read. This isn't emergent, it's not 0200. Dangerous decision.

 

[narcusprince]

You cant turn chicken sht into chicken salad.Lets play devils advocate and the surgeon got the echo. To avoid hemodynamic stresses would they fix the valve percutaneously. Then do the aaa open? I have done one of these cases and I believe we did the valve first then the AAA after. We fixed the valve open under cpb.

 

[amyl]

So I lose the argument ..16/18 g iv....thoracic epidural ...slow induction with 20 mg of prop at a time...neo inline...Aline shows stable bp...60 of roc ...intubate...cordis in the neck....

I stick the tee probe down and his aortic valve is lit up with calcium , minimum excursion, effective area of .74, gradient over 40 in the face of a crapy lv with Ef 25-30% and the anterior/Lateral walls are barely moving (basically a kinetic)....

So what now?

Etomidate? When it was in back order I mixed neo right in my propofol on sickos like this. No bolusing the epidural. I'd probably float the swan if you haven't.... Want as much fill as the sh-tty ef will tolerate and swan will help in post op management - otherwise typical AS management... Sinus, slow end of normal, maintain preload. Call the cards guys.... Can they fix the valve first? Look at surgeon with that quiet I told you so look bc you are a resident - and take away the lesson.... Sometimes the most powerful lesson is a negative example and your anes staff was wrong not to back you up. One of my very smart attending school told me "there are four horsemen of the apocalypse that will kill your patient on induction - severe pulmonary Htn, severe left main disease or its equivalent, kissing tonsils, and critical AS. These things, you don't f--- around with." Good luck with the clamping and unclamping, you have gotten this far, realistically I doubt anyone is going to abort this now. How'd it go?

 

[deleted171991]

I don't want to be rude, but the cowboys who approved going to surgery while bypassing the TTE (and syncope/systolic murmur workup) do not deserve their board cert. This is a patient who can't even get CPR if anything happens (that AAA will burst - besides the fact that one may not CPR properly a critical AS), and yet they just went ahead playing games in a non-emergent high risk case.

 

[PainDrain]

I don't want to be rude, but the cowboys who approved going to surgery while bypassing the TTE (and syncope/systolic murmur workup) do not deserve their board cert. This is a patient who can't even get CPR if anything happens (that AAA will burst - besides the fact that one may not CPR properly a critical AS), and yet they just went ahead playing games in a non-emergent high risk case.

Agreed. Not getting an echo and having a plan for the valve is bordering on incompetence and would never hold water in court.

 

[Noyac]

My thoughts are:
1) syncope in the face of AS is a 5yr death sentence usually
2) echo is mandatory
3) endovascular repair is doable, if not by your people then send him someplace that can do it
4) someone mentioned that this would be an infrarenal clamp but I don't think so since surgeon says it's not repairable endovascularly. This will be a suprarenal clamp with a longer repair.
5) the hemodynamic changes affecting the AS will be both during x-clamp and at release. The release may be somewhat easier to manage if adequately tanked up but this LV may not tolerate any increased volume. Surgeon will need to reapply clamp multiple times as you slowly tank the pt up. Swan will help here and postop. X-clamping will be difficult because this heart has no reserve. Have drips running (not just at the ready).
6) if truly not EVAR candidate then repair both AV and AAA in one case. AVR first then AAA.
7) not a candidate for percutaneous AVR due to AAA unless access is through radial/brachial artery.

That's it so far.

 

[Docuronium]

Silently think "I told you so" and be grateful that you're a resident and someone else is on the hook.

My plan usually too... the best is when the surgeon looks back at you and says "Why you gotta be such a jerk about it" like 10 seconds before they weren't trying to bull you into a surgery you didn't feel comfortable doing without the relevant data.

 

[urge]

7) not a candidate for percutaneous AVR due to AAA unless access is through radial/brachial artery.

They can replace your aortic valve through the radial artery?

 

[pgg]

Good luck with the clamping and unclamping, you have gotten this far, realistically I doubt anyone is going to abort this now.

The guy's asleep and has had an art line, central line, and TEE at this point. They absolutely could wake the guy up and say "golly we took a closer look at your heart and decided you'd be better off getting a different procedure from a different surgeon" ... no harm, no foul.

Of course they wouldn't really have done that. 🙂

My prediction here is that pent-sux-tube worked out because the anesthesiologist (resident) brought his A game and the surgeon got away with one.

 

[Noyac]

They can replace your aortic valve through the radial artery?

I have no idea since I haven't done one but I wouldn't be going thru a AAA.

 

[bcat85]

I have no idea since I haven't done one but I wouldn't be going thru a AAA.

I am not aware of anyone doing a TAVR through the radial artery--that seems really difficult given the size of the sheath typically required. I do know that they can be done transapically, so the patient doesn't absolutely have to have the procedure done through the groin.

Other thoughts on this case. I would echo (no pun intended) what the other folks here said--it would have been great to have the echo preop, if for no other reason other than you could actually consent the patient for the TAVR that he clearly needs. In the situation you're currently in, I think his operative mortality is extraordinarily high if you proceed with the AAA repair. I would be tempted to wake him up, leave the lines in, consent him for the TAVR, do that, and then do the AAA later. Of course that isn't how this went down, because the train had sort of left the station by the time he was asleep and lined up in the OR. My guess--same as the above. The surgeon got away with it because you guys brought your a-game. How'd it go?

 

[pjl]

Ummm...If it went horribly, please lie to us, this is a public forum, and based on dates this information can quickly become rather identifiable if there were a lawsuit 🙂

 

[PainDrain]

Bump. What happened with this case?

 

[deleted162650]

I am not aware of anyone doing a TAVR through the radial artery--that seems really difficult given the size of the sheath typically required.

TAVR req. a sheath that is 18fr-24fr depending on valve size. Dude's gotta have a pretty massive radial for that to work.

 

[cchoukal]

I am not aware of anyone doing a TAVR through the radial artery--that seems really difficult given the size of the sheath typically required. I do know that they can be done transapically, so the patient doesn't absolutely have to have the procedure done through the groin.

Can be done transapically and, i'm told, a new-ish approach is trans-aortic, from somewhere up above. Haven't seen one.

 

[bkell101]

Bump. What happened with this case?

It was an supra renal clamp, clamp time was pretty quick, only one application, slow on and off, 2500 ebl , bunch of cell saver , no major hemodynamic changes with clamping, dropped off in pacu still intubated requiring 60% fio2 and low dose noreppy.....I haven't looked through details of post op course yet but unfortunately suffered Stemi 48 hrs post op and had emergent baloon pump placed and showed up in the OR for cabg /avr unstable and had to crash onto pump....I've been out of town for Mother's Day weekend so haven't followed up the final result yet

 

[bkell101]

It was an supra renal clamp, clamp time was pretty quick, only one application, slow on and off, 2500 ebl , bunch of cell saver , no major hemodynamic changes with clamping, dropped off in pacu still intubated requiring 60% fio2 and low dose noreppy.....I haven't looked through details of post op course yet but unfortunately suffered Stemi 48 hrs post op and had emergent baloon pump placed and showed up in the OR for cabg /avr unstable and had to crash onto pump....I've been out of town for Mother's Day weekend so haven't followed up the final result yet

Sounds like most people agree that tavr would have been the best next step prior to the aaa repair? (After some sort of echo was performed either asleep or awake)

 

[deleted171991]

Sounds like most people agree that tavr would have been the best next step prior to the aaa repair? (After some sort of echo was performed either asleep or awake)

What do you think, now that you have the hindsight?

Did that STEMI had anything to do with his almost critical AS and crappy coronaries? 🙂

I stick the tee probe down and his aortic valve is lit up with calcium , minimum excursion, effective area of .74, gradient over 40 in the face of a crapy lv with Ef 25-30% and the anterior/Lateral walls are barely moving (basically a kinetic)....

 

[Brookstacular]

?..unfortunately suffered Stemi 48 hrs post op and had emergent baloon pump placed and showed up in the OR for cabg /avr unstable and had to crash onto pump...

So, attempted murder by the surgeon? Time to start writing all the details that exonerate you.

 

[urge]

It was an supra renal clamp, clamp time was pretty quick, only one application, slow on and off, 2500 ebl , bunch of cell saver , no major hemodynamic changes with clamping, dropped off in pacu still intubated requiring 60% fio2 and low dose noreppy.....I haven't looked through details of post op course yet but unfortunately suffered Stemi 48 hrs post op and had emergent baloon pump placed and showed up in the OR for cabg /avr unstable and had to crash onto pump....I've been out of town for Mother's Day weekend so haven't followed up the final result yet

Balloon pump on the new graft anastomosis? Guess it can be done.

 

[urge]

Sounds like most people agree that tavr would have been the best next step prior to the aaa repair? (After some sort of echo was performed either asleep or awake)

I wouldn't say that. I think it is easier to manage AS than an aneurysm.

A tavr is anything but stable. The aneurysm would have popped. Can't he get a good old AVR?

My guess is they dropped the ball post op letting him become hypotensive.

 

[chmd]

Sounds like most people agree that tavr would have been the best next step prior to the aaa repair? (After some sort of echo was performed either asleep or awake)

Not necessarily tavr. Needed a cath and avr of some sort. I would have been fine with doing aaa prior to avr or avr/cabg if ct surg had been consulted and they deferred, or combined surgs

 

[PainDrain]

The ideal sutuation for this patient is one of two courses. You either find a damn good endovascular guy and fix the AAA with an endo graft then proceed with open valve repair. Alternative to this case would be put him on pump and fix both at the same time. It would be tricky to manage both simultaneously so I think the valve would go first followed by AAA repair.

You know what they say about hindsight and all but this outcome was so friggin obvious. He was very lucky to have made it through the AAA repair. How the events unfolded are beyond ridiculous. If I was the attending anesthesiologist and I saw that valve after induction the case would have been over then, but I never would have let go to the OR anyway.

 

[Noyac]

The ideal sutuation for this patient is one of two courses. You either find a damn good endovascular guy and fix the AAA with an endo graft then proceed with open valve repair. Alternative to this case would be put him on pump and fix both at the same time. It would be tricky to manage both simultaneously so I think the valve would go first followed by AAA repair.

You know what they say about hindsight and all but this outcome was so friggin obvious. He was very lucky to have made it through the AAA repair. How the events unfolded are beyond ridiculous. If I was the attending anesthesiologist and I saw that valve after induction the case would have been over then, but I never would have let go to the OR anyway.

This is the best post in this thread.
In my experience, the above is exactly how things should have gone. Endovascular repair with sedation or gentle GA. Or open AVR then on to the AAA. Some might say why not do the AAA first but I've done it both ways and the problem with doing a AAA or even CEA before going on bypass is that those repairs bleed like stink the entire time on bypass being fully anticoagulated. You will find yourself pumping in large amounts of PRBCs while on pump and this all makes for a very bloody difficult case that doesn't need to be this way.

Nice post, paindrain!

 

[Noyac]

Also, is anyone surprised that this guy had an MI postop? The writing was on the wall. Yes, nobody mentioned it earlier but if anyone was asked if it was possible we would have all said that it was more than possible, it was likely.

When are post op MI's most likely? Day 3ish

Who is most susceptible? This guy.

I did a case as a rookie anesthesiologist in my first gig. It was a colon resection on a guy with severe (not critical) AS. He had a large tumor in his colon and the surgeon wanted to get it out "now". He didn't want to wait for AVR/CABG and the recovery time. So I placed an epidural and did the case. It went fine and for three days the guy had zero pain. He started PO's and I removed the epidural. His pain increased as expected and the next day he had an MI.

The funniest part of all this (not that any of this is funny) is that the surgeon asked me if my epidural caused his MI since it is relatively contraindicated in AS. WTF?

 

[urge]

1 When are post op MI's most likely? Day 3ish


2 epidural caused his MI since it is relatively contraindicated in AS. WTF?

1 That's very old teaching. Intraop MIs are more common now (kind of old by now too)

2 Don't know why people still talk about neuroaxial contraindicated in AS. Can't people start phenylephrine drip in the 21st century?

 

[Noyac]

1 That's very old teaching. Intraop MIs are more common now (kind of old by now too)

2 Don't know why people still talk about neuroaxial contraindicated in AS. Can't people start phenylephrine drip in the 21st century?

1) I have not seen an intraop MI. All have been 3days or so

2) that's why I said "relatively".

 

[urge]

1) I have not seen an intraop MI. All have been 3days or so

2) that's why I said "relatively".

1 I'm only pointing it out for the residents.

2 General frustration of mine. I'm sure you provided a great anesthetic.

 

[bkell101]

What do you think, now that you have the hindsight?

Did that STEMI had anything to do with his almost critical AS? 🙂

The ideal sutuation for this patient is one of two courses. You either find a damn good endovascular guy and fix the AAA with an endo graft then proceed with open valve repair. Alternative to this case would be put him on pump and fix both at the same time. It would be tricky to manage both simultaneously so I think the valve would go first followed by AAA repair.

You know what they say about hindsight and all but this outcome was so friggin obvious. He was very lucky to have made it through the AAA repair. How the events unfolded are beyond ridiculous. If I was the attending anesthesiologist and I saw that valve after induction the case would have been over then, but I never would have let go to the OR anyway.

yes this outcome was obvious from the get go, to me at least , I was shocked to have made it through the aaa repair without major issues

This is the best post in this thread.
In my experience, the above is exactly how things should have gone. Endovascular repair with sedation or gentle GA. Or open AVR then on to the AAA. Some might say why not do the AAA first but I've done it both ways and the problem with doing a AAA or even CEA before going on bypass is that those repairs bleed like stink the entire time on bypass being fully anticoagulated. You will find yourself pumping in large amounts of PRBCs while on pump and this all makes for a very bloody difficult case that doesn't need to be this way.

Nice post, paindrain!

You mentioned you did an open combo procedure....How did the avr then triple aaa repair go? Good outcome?

 

[Noyac]

The worst one I remember was a CEA and then CABG/AVR. It was a bloody mess as the neck was left open till the end to check hemostatsis and then close after the chest was closed. So the neck was packed with gauze and the surgeon had to change the gauze a couple times during the case. The bleeding was secondary to full heparinization and there was little we could do about it. I was giving blood the entire time. It was awful. At the end the surgeon looked up at me and said, "if I ever book a combo like this again ou have the right to slap the **** out of me". I said, "thanks, I will."

Pt did well.