Time for a Case Discussion

[Noyac]

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So you draw the short straw today.

Your pt is an 80 yo M for a CEA.

HPI: Pt found down 2 weeks ago. Presumed stroke and workup shows L carotid 99% occluded, R carotid 70% occluded, vertebral Arteries with diffuse disease/occlusion (no % given). During work up which included a CT head which showed no acute stroke (is this a good study for for acute stroke?) the pt was found to have BAL 341 and glucose 345. No weakness or deficits.

PMH:
Chronic ETOH abuse
Chronic narcotic abuse/addiction
Essential HTN untreated
DM untreated
Recent UGI bleed
Cervical fusion after MVA with limited ROM
Recent CHF
Smoker
High cholesterol

LABS:
Essentially normal except HA1c-12

ECG - NSR w L axis deviation

Vitals:
170/95, HR 68, Sats 94%, RR 16

Seen by both Vascular surgery and IM who believe the best approach is L CEA in light of "High" risk for stroke due to severe disease. Risks of MI and complications from uncontrolled DM have been addressed with the pt by these docs. Pt is fully aware of these risks (understanding is debatable). Pt and family want to proceed.
IM doc decided not to start BP meds due to severe stenosis and worried of the risk with decreased BP.

Day of surgery:
PT is very excited to have surgery but also very nervous.
BP 210/120 HR 68 RR 16 Sats 94% RA
CBG145

What's your plan?
What's your approach?
Concerns?

 

[vector2]

Recent CHF? Ischemic or from diastolic dysfxn? What's his echo/cath/nuclear stress? Given his risk factors, this guy sounds ripe for a MAC / carotid stent since his odds of post-CEA MI probably outweigh the risk reduction of future stroke. If his anatomy isn't conducive to a stent (or the plaque is unstable) we're doing an awake CEA with a plexus block. I hope pre-op valium and a whiff of methadone has been started and continued for DTs / withdrawal sxs. Duoneb preop. Versed, fentanyl prn, a-line, second IV, 5 lead, insulin, precedex, phenylephrine, and cardene gtts. Titrate SBP to 170-180, keep 140-160 after clamp off or shunt is taken out. Pray he doesn't start tombstoning until he's out of the PACU.

I would also be OK with "hey, you're 80, you've had a good run considering how badly you've abused your body. optimal medical management. laterz"

"
Below is a summary of the results of randomized controlled trials; the 3 earlier studies are omitted because they were performed early in the development of CAS and do not reflect current technique.

Naylor et al, in a prospective, randomized trial of CEA versus CAS for symptomatic patients with greater than 70% internal carotid artery stenosis, found that all 10 of the CEA patients proceeded without any complications, whereas 5 of the 7 CAS patients had an ischemic stroke within 30 days of the procedure.[5] The trial was stopped because of the dramatically bad outcome in the endovascular group.

Brooks et al, in a randomized study of 104 patients presenting with cerebrovascular ischemia related to internal carotid artery stenosis who underwent either CEA (51 patients) or carotid artery stenting (53 patients), reported 1 death in the CEA group and 1 transient ischemic attack in the CAS group.[6] CAS was equivalent to CEA and does not carry an increased risk of major complications (ie, death or stroke). Authors recently published 10-year outcomes for 173 patients. Half of the patients had died from other conditions in this period. They did not find any difference in long-term protection against ipsilateral stroke in either group. Overall, the risk of heart attack was high among patients randomized to CEA.[7]

In the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS), a multicenter clinical trial in which 504 patients with carotid stenosis were randomly assigned to undergo either CEA (253 patients) or CAS (251 patients), there was no substantial difference in the rate of ipsilateral stroke over a 3-year follow-up period.[8] However, the results of surgery were worse as compared to surgical standards for CEA; moreover, cerebral protection devices (CPDs) were used in only 27% of the patients who underwent CAS.

The Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial, an industry-sponsored randomized, controlled trial that included 334 high-risk surgical patients who underwent either CAS or CEA, concluded that CAS was superior to CEA among high-risk surgical patients.[9] The primary end points were combined death, stroke, and myocardial infarction (MI). An asymptomatic rise in troponin levels was regarded as MI, and the higher rate of MI among patients who underwent CEA shifted the balance in favor of CAS.

In the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), which included 2502 patients who were randomly assigned to undergo either CEA or CAS, the combined risk of death, MI, or stroke (the primary end points) was comparable for the 2 procedures (6.8% for CEA vs 7.2% for CAS).[10] However, the incidence of stroke was 2.3% for CEA versus 4.1% for CAS. The incidence of MI was 2.3% for CEA versus 1.1% for CAS. Stroke is a disabling event, and extreme caution should be observed in interpreting the results from CREST.

A recently published subanalysis of the CREST trial[11] showed that restenosis and occlusion rates were similar up to 2 years after CEA and CS."

 

[Noyac]

CHF from diastolic dysfunction.
EF 55%
Cath? You want a cath? What if it shows CAD? You still need to fix the carotid before the coronaries. What if they put a stent in the LAD? Now what are you gonna do?

Personal question for you vector2. How many awake CEA's have you done?

Can a 99% stenosis be "safely" stented?

I like your methadone/Valium plan sort of. Not gonna do it tho. Why would you give such long acting meds here?

 

[PainDrain]

99% can't be stented and this guys biggest risk with a CEA contract considering his current BP is post-CEA hyperperfusion syndrome. With his hypertension being currently untreated I would opt to admit him overnight and bring him down slightly, maybe to around 170-180/90 range. He is also at significant risk of post-op cardiovascular events.

 

[Noyac]

99% can't be stented and this guys biggest risk with a CEA contract considering his current BP is post-CEA hyperperfusion syndrome. With his hypertension being currently untreated I would opt to admit him overnight and bring him down slightly, maybe to around 170-180/90 range. He is also at significant risk of post-op cardiovascular events.

Absolutely!
But his baseline BP is what your target is. He seems to be anxious now.
So do you cancel for BP control? Or do you see if it is controllable with some meds? What meds?

 

[vector2]

CHF from diastolic dysfunction.
EF 55%
Cath? You want a cath? What if it shows CAD? You still need to fix the carotid before the coronaries. What if they put a stent in the LAD? Now what are you gonna do?

Personal question for you vector2. How many awake CEA's have you done?

Can a 99% stenosis be "safely" stented?

I like your methadone/Valium plan sort of. Not gonna do it tho. Why would you give such long acting meds here?

I want a cath just to make sure he doesn't have left main or left main equivalent. If he does, there is absolutely no way I'm doing asleep CEA considering he's already sporting so many major risk factors. If it's just non-obstructive CAD or something stentable then we're back to the original problem, which is to say there's not really a good answer between stent and CEA. That being said, I would feel pretty good about EF 55%, normal PAPs, and grade I-II diastolic dysfunction. However, if the first time I see the guy he's dyspneic, he sounds wet, his CXR looks wet, and I'm attributing the aforementioned 94 sat to pulmonary edema/HTN urgency/horrible diastology and not COPD, case gets delayed for 3-5 days while his BP is slowly brought down in the hospital and he gets diuresed. If the guy is having an acute stroke/TIA, then we should do it within a couple days, but from the sound of your OP (clear CT, no deficits, no recent TIA sxs) I think the guy can wait 2+ weeks.

I've sat two awakes, although I didn't do the blocks. They were a PITA compared to neo/prop/sux/tube, but the patients did fine.

If the guy is a real deal alcoholic and narcotics abuser then I would absolutely start valium (or ativan) the day of admission and either continue his home narcs or start equianalgesic methadone. I'm assuming that he's had a day or two on the floor to detox and get the dosages to a sweet spot. If he's walking in day of surgery and his last boones farm/oxy binge was 6 hrs ago I'm not doing the case.

And yes, a 99% stenosis can be stented assuming it's in a relatively non-tortuous stretch of artery and there's not horrible calcification or a mobile, wacky waving arm inflatable tube man plaque booger just waiting to embolize the second you get near it.

http://circ.ahajournals.org/content/113/16/2021.full
"Although some lesion characteristics (eg, degree of stenosis and length) indicate potential technical difficulties, the 2 most important anatomic findings portending an increased procedural risk are vascular tortuosity and heavy concentric calcification. Excessive tortuosity is defined as ≥2 bend points that exceed 90°, within 5 cm of the lesion, including the takeoff of the ICA from the CCA (Figure 2). Excessive tortuosity increases the difficulty of access to the lesion, may not permit device delivery, and can prevent distal positioning of an EPD with a “landing zone” sufficient for stent placement. These factors expose the patient to the risks of atheroembolism from the arch, air embolism, excessive contrast administration, bifurcation plaque disruption, and ICA dissection. Importantly, tortuosity should be assessed after the sheath (or guide catheter) has been placed in the CCA, because forces by the catheter directed toward the unyielding base of the cranium tend to exaggerate ICA tortuosity (Figure 3). Finally, heavy calcification is an important predictor of complications. This is defined as concentric calcification, ≥3 mm in width and deemed by at least 2 orthogonal views to be circumferentially situated around the lesion (Figure 4)."

 

[Noyac]

I've sat two awakes, although I didn't do the blocks. They were a PITA compared to neo/prop/sux/tube, but the patients did fine.

Ok, that's probably 2 more observations than the vast majority of the people on this board have seen. So you want to proceed with a HIGH risk CEA under local/regional with some sedation after watching 2.
I have done them this way. I don't do them this way any longer. Any ideas why?
Or better yet, tell us what makes this a good option. Assume we all know the usual, insantaneous cerebral perfusion monitoring. Now what?

 

[Noyac]

And personally, I don't want a cath!

 

[vector2]

Ok, that's probably 2 more observations than the vast majority of the people on this board have seen. So you want to proceed with a HIGH risk CEA under local/regional with some sedation after watching 2.

In order of what I "want" :
1. Don't do anything (other than write a script for coreg, lipitor, and plavix) considering he's 80, has DHF, COPD, drug/alcohol abuse, severely uncontrolled HTN, uncontrolled DM, contralateral carotid stenosis, and likely CAD. And let's not forget you said he has poor insight into his condition and likely doesn't have informed consent vis a vis risks/benefits.
2. Do an awake stent.
3. Do an awake CEA.
4. Do an asleep CEA.

I have done them this way. I don't do them this way any longer. Any ideas why?

Nope. Do tell.

 

[fakin' the funk]

Awake CEAs can be elegantly done and not a PITA assuming
a) patient is coachable and chill, in English
b) you can do the block with a low risk of vertebral artery or subarachnoid injection
c) RLN and phrenic block in your pt is OK
d) your surgeon understands what's blocked and what's not and is willing to supplement
e) your OR team understands they need to STFU and refrain from gabbing about the upcoming Christmas party, etc.

IMO point #a is the biggest dealbreaker to do awake vs asleep.

I've done these with "intermediate" cervical plexus block (IJ perivascular block) with 2% lidocaine and 1:400000 epi 20ml, then dilaudid + precedex for very light sedation. Remi might be a decent option too, HR allowing.

 

[pgg]

The deal breaker for awake CEAs most places I've been is surgeons who can't get the case done in less than 3 hours.

The last dozen or 20 I've done were under GA. Most got shunted. Used cerebral oximetry if it was available.

This patient I'd like to see better BP control before surgery but whoever admits him to control it needs to move gently, lest they stroke him before he even gets to the OR.

 

[itwasalladream]

Assuming UGIB isn't recent enough to cause concern with heparinization...
Even if I was comfortable with awake I'd still choose to go to sleep: RA sats 94%, smoker, ETOH and narcotic abuse, limited neck ROM. Sounds like a big pain when it comes to sedation/cooperation. But it's a moot point because I am doing it asleep regardless.
Lower BP in holding to a goal 180SBP (I like labetalol) then do the case with an art-line and 2 good PIV, neuromonitoring of choice. Pt is aware of cardiac risks and not in active failure. I think the most recent ACC/AHA guidelines have changed their wording, but the previous ones billed CEA as an intermediate risk procedure. It doesn't appear that testing further than his CVA workup will add anything.
Pain control with remi intraop, local.
Careful with fluids given diastolic dysfunction.
The usual careful BP control after carotid is opened up.

 

[Mman]

I did about 20 awake CEAs as a resident. I've never done one as an attending. They can be nice, but the biggest issue is patient selection and surgeon selection. The patient has to be very motivated and cooperative. I'd probably do the case GA with cerebral oximetry. It's not perfect but it'd sure be nice to see what the baseline numbers are and follow trends during the case.

 

[Noyac]

I think awake CEA's are for pts that are a low risk for stroking during the procedure in addition to the other reasons mentioned here. It is a very ugly scene when they start to stroke out and you are trying to manage the airway keep them from moving and their neck is wide open.

 

[Noyac]

Ok so people want better BP control. I get the. What is your target and why do you think his BP is so high?

Anyone have any concerns with the HA1c?

 

[pgg]

If the 220/120 is just preop anxiety or "didn't take routine meds this AM" and his true baseline is the 170/90 from the preop visit vitals, then I'd just gently control it myself and go ahead with the case. Otherwise you can make a compelling argument that 220/120 is a hypertensive urgency or crisis and then you've got no business doing an elective case, full stop.


There's lots and lots of data that a terrible A1C predicts complications, and all of us would love to see it at 6 vs 12, but you have to weigh the benefit of delaying for the (unlikely!) hope that he'll suddenly start to give a **** about it and get it better controlled, vs his nontrivial ongoing risk of stroke while you delay. I wouldn't delay this patient for better glucose control, that's a fool's errand. Ain't going to happen. His A1C is 12 now and it'll be 12 when he dies, whenever that day comes.

 

[Mman]

If the 220/120 is just preop anxiety or "didn't take routine meds this AM" and his true baseline is the 170/90 from the preop visit vitals, then I'd just gently control it myself and go ahead with the case. Otherwise you can make a compelling argument that 220/120 is a hypertensive urgency or crisis and then you've got no business doing an elective case, full stop.

Can probably safely assume in this uncontrolled hypertensive that his BP is just all over the place. Preop anxiety probably not helping it. Also worth pointing out this case isn't exactly elective given his presentation. Personally I'd just use 170/95 as his baseline for my management in the OR and go from there. I mean you already have the IM docs deciding to not even treat his BP preoperatively in light of his tight stenosis. It's not like if you cancel the case they are now going to start him on some meds for it.

 

[Planktonmd]

Blah Blah...... /horrible diastology and not COPD, case gets delayed for 3-5 days while his BP is slowly brought down in the hospital and he gets diuresed. If the guy is having an acute stroke/TIA, then we should do it within a couple days, but from the sound of your OP (clear CT, no deficits, no ..............Blah Blah (Figure 4)."

We need more people in this specialty who use words like Diastology

 

[Planktonmd]

Here is my plan: A line, Smooth induction GA with some sort of pressor running in the background to maintain BP at a mean of 100-110.
If brain oxymetrty is available I would use it but otherwise just another day at the office!

 

[Noyac]

Here is my plan: A line, Smooth induction GA with some sort of pressor running in the background to maintain BP at a mean of 100-110.
If brain oxymetrty is available I would use it but otherwise just another day at the office!

That was my plan exactly but with some remi running as well.

Here how it went down though. I did a preinduction Aline which I rarely do. Went to the OR and slowly started my induction. Remi started at 0.1 and planned to have neo infusion started before induction but obviously didn't in this guy. Propofol boluses in small amounts until he dozed off. BP went to 160/65 and stayed there. Perfect induction, I thought. About 10 min later his BP fell to 70/30. I got it back to 120/50 before the vitals trend on the monitor could ever record it ( less that 5min). Neo was adjusted throughout the case btw 30-50mcg/kg/min. BP was a train track of 165/65 MAP 100. Surgeon who was obviously nervous about the pts wellbeing asked if I thought we should proceed and I said sure, What have we got to lose? He starts the case and works his way down to the carotid. Then he realizes that the plaque extended too far up the internal carotid and that he wasn't going to be able to safely remove it so we abandoned the case. I would have thought that this might have been discerned before surgery. Not my issue. I woke him up and brought him to PACU. POOR GUY.

 

[deleted162650]

The deal breaker for awake CEAs most places I've been is surgeons who can't get the case done in less than 3 hours.

The last dozen or 20 I've done were under GA. Most got shunted. Used cerebral oximetry if it was available.

This patient I'd like to see better BP control before surgery but whoever admits him to control it needs to move gently, lest they stroke him before he even gets to the OR.

Man that's painful pgg. I guess I didn't realize how spoiled I was with our vascular guys. All 3 do carotids in just under an hour skin to skin with clamp times all right around 7 min. Can't think of a single one that's been shunted in the last 2.5 years. Haven't had one stroke out yet (fingers crossed).

 

[Noyac]

I follow up with the pt today. Can anyone guess what went on over the course of the evening?

 

[PainDrain]

He developed a water-shed infarct? Or he was perfectly fine because he is the type of protoplasm that can't be killed.

 

[Noyac]

Close. He had a TIA. I'm sure he has been having them but never really was aware what it was since he was drunk or high. But IM doc and surgeon took his word for it.

 

[Ignatius J]

That was my plan exactly but with some remi running as well.

Here how it went down though. I did a preinduction Aline which I rarely do. Went to the OR and slowly started my induction. Remi started at 0.1 and planned to have neo infusion started before induction but obviously didn't in this guy. Propofol boluses in small amounts until he dozed off. BP went to 160/65 and stayed there. Perfect induction, I thought. About 10 min later his BP fell to 70/30. I got it back to 120/50 before the vitals trend on the monitor could ever record it ( less that 5min). Neo was adjusted throughout the case btw 30-50mcg/kg/min. BP was a train track of 165/65 MAP 100. Surgeon who was obviously nervous about the pts wellbeing asked if I thought we should proceed and I said sure, What have we got to lose? He starts the case and works his way down to the carotid. Then he realizes that the plaque extended too far up the internal carotid and that he wasn't going to be able to safely remove it so we abandoned the case. I would have thought that this might have been discerned before surgery. Not my issue. I woke him up and brought him to PACU. POOR GUY.

Sounds like you did your job. Needed a better surgeon it sounds like.