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