Case Presentation

Sean David Johnson, MDGeneral Surgery Residency

Kendall Regional Medical Center

CC/HPI• 74y/o female presents with dizziness to KRMC ED.

She was recently admitted to Homestead hospital for carotid surgery but desired surgery to be done at KRMC by her previous Vascular surgeon. Patient denies fever, chills, nausea, vomiting, diarrhea or any other complaint.

• PMH: HTN, DM, HLD, previous CVA, GERD• PSH: s/p R CEA (2013), cardiac cath/stents, c-section• Meds: plavix, nifedipine, clonidine, insulin, folic acid • Allergies NKDA • SH: No tobacco or alchol use • FH: heart disease

Physical examination• VS T 98.5 P 98 R 14 BP 168/54 SpO2 100% R/A• General: NAD• Head/Eyes: atraumatic, • Neck: no JVD• Respiratory/Chest: CTAB• Cardiovascular: regular rate and rhythm, normal heart

sounds, normal cap refill, • Abdomen: soft, non-tender, no distention, normal

bowel sounds• Skin: no abrasions, warm, dry• Neurologic – Gross sensation WNL, strength 5/5

Operative Note

• Pre-operative diagnosis: L ICA Critical Stenosis with ulcerated plaque

• Post-op diagnosis: same• Procedure: L Carotid Endarterectomy• Anesthesia: Local block*• EBL: 100cc• Complications: intra operative CVA

PACU

• Stroke Alert called• Critical Care team consulted• Patient intubated• STAT Brain MRI 10/20 :

– Cortical restricted diffusion within the left frontal lobe, parietal lobe, left temporal lobe, left superior occipital lobe and left subinsular cortex from an acute infarct which is in the left anterior– cerebral artery and middle cerebral artery distribution.

– Old bilateral basal ganglia, left pontine and left cerebellar infarcts.

• Neck CTA 10/20– Postsurgical changes of the left neck with multiple foci of dissections involving the left carotid bulb, proximal and mid cervical internal carotid artery.

– Previous right endarterectomy.

– Hypoplastic left vertebral artery with a non enhancement in the left

– Occluded left intracranial vertebral artery which is hypoplastic.

– Left hemisphere sulcal effacement from acute ischemia.

Hospital Course

• CT brain (10/21) – ischemic changes• Neurology consulted (re: CVA, AMS)• GI consult (dysphagia) –placed PEG tube• Poor prognosis• Transferred to hospice care

LITERATURE REVIEW

• Journal of Vascular Surgery• Volume 19, Issue 2, February 1994, Pages 206–216• The cause of perioperative stroke after carotid

endarterectomy Presented at the Forty-seventh Annual Meeting of the Society for Vascular Surgery, Washington, D.C., June 8-9, 1993.

• Thomas S. Riles, MD, Anthony M. Imparato, MD, Glenn R. Jacobowitz, MD, Patrick J. Lamparello, MD, Gary Giangola, MD, Mark A. Adelman, MD, Ronnie Landis, RN,

• From the Division of Peripheral Vascular Surgery, Department of Surgery, New York University Medical Center, New York.

• Purpose: The purpose of this study was to examine the cause of perioperative stroke after carotid endarterectomy.

• Methods: The records of 2365 patients undergoing 3062 carotid endarterectomies from 1965 through 1991 were reviewed. Sixty-six (2.2%) operations were associated with a perioperative stroke. The mechanism of stroke was determined in 63 of 66 cases. Patient risk factors and surgeon-dependent factors were analyzed.

• Results: More than 20 different mechanisms of perioperative stroke were identified, but most could be grouped into broad categories of ischemia during carotid artery clamping (n = 10), postoperative thrombosis and embolism (n = 25), intracerebral hemorrhage (n = 12), strokes from other mechanisms associated with the surgery (n = 8), and stroke unrelated to the reconstructed artery(n = 8). Dividing the operative experience approximately into thirds, during the years 1965 to 1979, 1980 to 1985, and 1986 to 1991 the perioperative stroke rates were 2.7%, 2.2%, and 1.5%, respectively. This, in part, is associated with a better selection of patients (more symptom free, fewer with neurologic deficits). There has been a notable decrease in perioperative stroke caused by ischemia during clamping and intracerebral hemorrhage, but postoperative thrombosis and embolism remain the major cause of neurologic complications.

• Conclusions: Although patient selection seems to play a role, most perioperative strokes were due to technical errors made during carotid endarterectomy or reconstruction and were preventable.

• Br J Surg. 2005 Mar;92(3):316-21.• Sequential cohort study of Dacron patch

closure following carotid endarterectomy• Ali T, Sabharwal T, Dourado RA, Padayach TS,

Hunt T, Burnand KG.

METHODS: A cohort of 236 patients undergoing carotid endarterectomy at a single centre was studied; 117 patients had primary closure of the arteriotomy and 119 patients in a sequential series had closure with a Dacron patch. A standard endarterectomy with completion intraoperative duplex imaging and digital subtraction angiography was used throughout.RESULTS: Patch closure was associated with a significant reduction in the 30-day combined death, stroke and TIA rate: 10.3 per cent for primary closure versus 2.5 per cent for patch closure (P = 0.017). The risk of any cerebral event (stroke or TIA) was also significantly reduced (7.7 versus 1.7 per cent; P = 0.033). Residual stenosis on completion angiography was more common after primary closure (24.6 versus 7.4 per cent; P = 0.003).CONCLUSION: Dacron patch closure had a higher technical success rate on completion imaging and was associated with a significant reduction in the risk of perioperative stroke, TIA and death.

•THANK YOU