Vascular D&C

Sundeep Guliani

• 61 yo lady with episodic arm and facial numbness

• Carotid artery duplex: Occluded Right internal carotid (known), High grade stenosis left internal carotid (~75%)

• PMH: CAD, A Fib, COPD, DM,

• Meds: Coumadin, Plavix, Inhalers

OR• Left carotid endarterectomy w patch– Shunt used

• PACU – Right complete hemiparesis– System heparinization

• Re-exploration– Patent carotid artery– Angio: Small irregularity in common carotid artery ->

Endarterectomy extended proximally

Post op• CTA neck/head: No embolus or bleed• POD 1– Extubated– ~50% of strength

• POD 3– Neuro exam normal

• POD 5– D/C Home

Peri-operative/Post-operative CVA after CEA

• Etiology: – Carotid artery occlusion – Embolus – Cerebral hypoperfusion during clamping

• Management strategies:– Expectant management of stroke– Emergent re-exploration– Carotid duplex/CTA neck to eval vasculature

• Retrospective study of 13 (out of 24) patients with “major” hemispheric deficits after CEA (hemiplegia/Hemiparesis)

• The time of stroke onset in relation to surgery, the investigations and actions performed, the angiographic/operative results, and outcomes were recorded

• Attribute neurological improvement to carotid reopening when affected muscle strength increased to antigravity power (Grade 3/5) within 6 hours of reoperation

The 13 patients

• 5 patients (38%) displayed deficits when they awakened from anesthesia,

• 7 had deficits that occurred within 12 hours of surgery (all except one of these within 4 h of surgery)

5 patients – Awoken w neuro deficits

• all underwent urgent reoperation without carotid angiography• In two patients carotid occlusions at the endarterectomy site

were found and removed• In one patient persistent stenosis with intraluminal thrombus

was found and repaired• In one patient, mural thrombus without a stenosis or flaw in

the arterial repair was found and repaired• In one patient, intra-arterial TPA

• All of these reoperations were undertaken within 1.5 hours of stroke recognition

7 patients – Neuro deficits within 12 hrs

• all underwent urgent cerebral angiography as the first step

• Two carotid occlusions and one residual stenosis with thrombus were found; these patients were returned immediately to the operating room for carotid rerepair

• All reoperations in this group were undertaken within 4 hours of stroke onset

Cont

• 8/13 patients total underwent re-operation• reopening of occluded carotid arteries:– was followed by early improvement 2/4 patients– another patient improved after correction of a

stenosis with thrombus

• 11/13 patients had new ischemic lesions revealed by head CT within 48 hours of surgery

Etiology of stroke

• The causes of major strokes in this series were – CEA site occlusion 4/13 pts– Thromboembolism 4/13 pts– cross-clamp ischemia 4/13 pts

• Overall 50% of patients had surgically correctable lesion– Half of these improved after repair

Teaching points

• Controversial issue• Study advocated aggressive policy toward

immediate post-op CVA’s after CEA