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Vascular D&C M. Uchiyama02/01/2013
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Introduction Complication R MCA distribution embolic stroke Procedure R carotid angiography with planned, but aborted R carotid stent, carotid endarterectomy Primary Diagnosis Asymptomatic R carotid 70-79% re-stenosis 13 yrs s/p carotid endarterectomy
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Clinical History HPI: 73 yr old female s/p bilateral CEA’s & re-stenosis of R common & internal carotid 13 yrs postop PMHx: CAD, HLD, OSA requiring CPAP, TIA, DM, cutaneous lupus, depression, fibromyalgia PSHx: R CEA (1999, Chippenham), L CEA (2008, VCU), CABGx3 (2008, VCU) Relevant Meds: ASA, plavix & pravastatin (continued through perioperative period) Social: Lives with husband, no history of smoking/EtOH/drug use
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Preoperative History Seen 4/2012 in neurology clinic with multiple episodes of headache, presyncope & syncope MRI Head/Neck: Bilateral vertebral & basilar artery stenosis High grade common and moderate internal carotid artery stenosis Posterior communicating arteries not visualized R carotid dissection could not be excluded Carotid duplex 12/11/12: R ICA 70-79% stenosis RCCA50-80% stenosis L ICA 50-59% stenosis L CCA <50% stenosis
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Perioperative/Operative Period Patient seen in vascular clinic 12/18/12 and was sent to ED with hypertensive urgency (systolic 214, headache) Re-evaluated 1/8/12, non-focal neurologic examination documented & plans made for carotid stenting OR 1/11/2012: Carotid angiography converted to carotid endarterectomy
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Vascular Surgery M&M Conference VCUHS 1/31/2013 Ayo Akinrinlola, MD PGY 7
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Procedural Steps of CAS – Access – Aortic Arch Angiogram – Selective Common Carotid Cannulation – Crossing the Internal Carotid Stenosis – Predilatation – Stent Delivery – Postdilatation – Retrieval of the Cerebral Protection Device and Completion Angiography – Access Hemostasis
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– Access – Aortic Arch Angiogram – Selective Common Carotid Cannulation – Crossing the Internal Carotid Stenosis – Predilatation – Stent Delivery – Postdilatation – Retrieval of the Cerebral Protection Device and Completion Angiography – Access Hemostasis Procedural Steps of CAS
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Rescue techniques during CAS Mechanical removal of an embolus Aspiration of an embolus/thrombus Fragmentation techniques Intra-arterial thrombolysis
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Immediate Postoperative Period Patient extubated, transferred to STICU Patient sleepy, but arousable, no facial droop and LUE/LLE motor intact but weaker than RUE/RLE Imaging ordered CT Head, CTA head/neck MRI head
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Imaging CT Head, CTA head/neck Evolving infarction of R parietal and temporal lobe in posterior R MCA distribution Dissection of mid R common carotid with 50% reduction of true lumen Abrupt cutoff M2 Branch of R MCA resembling acute thrombus Hypoplastic R vertebral artery
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MRA Head Posterior division R MCA infarction including posterior R frontal lobe and most of R temporal lobe Separate areas consistent with embolic infarction of R frontal lobe and posterior R frontal lobe
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Outcome Due to increasing somnolence, patient was intubated pod#0 Hypertension requiring nipride drip & NSTEMI pod#3 Remains intubated pod#20 due to slowly resolving angioedema of tongue likely related to ACE inhibitor (lisinopril) Can move RUE/RLE, withdraws to pain LUE/LLE Tracheostomy/PEG 1/30/12 Plans for long term rehab
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Analysis of Complication Was the complication potentially avoidable? – Possibly Would avoiding the complication change the outcome for the patient? – Yes What factors contributed the complication? – Embolization after manipulation of wires in carotid artery from dissection site or friable existing plaque – Inability to complete cerebral angiogram during endovascular procedure
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CREST Trial “Carotid Revascularization Versus Stenting Trial” Stroke, 2010
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Before CREST NASCET Trial (1995): 2,226 patients with symptomatic stenosis randomized to either medical management or endarterectomy Endarterectomy was superior to medical management & decreased stroke rate 65% in patients with 70% stenosis, to a lesser extent in those with 50-69% stenosis and there was no difference with <50% stenosis
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Before CREST ACAS Trial (1995): 1,662 patients without symptoms & with 60% stenosis were randomized to either medical management or endarterectomy Endarterectomy was superior to medical management in patients with stenosis >60%
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CREST Trial Largest randomized prospective study comparing CEA to carotid artery stenting CEA and stenting were shown to be equivalent in 30 day composite outcomes of stroke, MI or death Stenting had higher rates of periop stroke, but that majority of these were nonmajor CEA was associated with higher periop MI CEA and stenting were shown to be equivalent in 4 year outcomes of stroke
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CREST Trial 2,522 Symptomatic & asymptomatic patients were included Inclusion criteria: Symptomatic (TIA, amaurosis, ipsilateral minor stroke) with >70% stenosis by US or asymptomatic with >70% stenosis by US with favorable anatomy for both procedures Exclusion criteria: evolving stroke, h/o major stroke, atrial fibrillation on anticoagulation, MI within 30 days, unstable angina
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CREST Trial 1,271 were assigned to stenting and 1,251 were assigned to CEA Only statistically significant difference between groups was higher incidence of dyslipidemia in CEA group Endpoints: Stroke (either perioperatively or up to 4 years postop), MI, death
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CREST Trial Outcomes: Perioperative Stroke, MI, Death (Combined): 5.2% (stenting) v. 4.5% (CEA) HR 1.18, 95% CI 0.82–1.68, P =.38 Major ipsilateral stroke: 0.9% vs 0.3% HR 2.67, 95% CI 0.85–8.40, P =.09 MI: 1.1% vs 2.3% R 0.50, 95% CI 0.26–0.94, P =.03 Cranial nerve palsy: 0.3% vs 4.8% HR 0.07, 95% CI 0.02–0.18, P <.0001
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CREST Trial Outcomes at Four Years Stroke, MI, death, or ipsilateral stroke: 7.2% (stenting ) v. 6.8% (CEA) HR 1.11, 95% CI 0.81–1.51 Ipsilateral stroke: 2.0% v. 2.4%, HR 0.94, 95% CI 0.50–1.76, P =.85
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CREST Trial Findings Risk of ipsilateral periprocedural minor stroke higher with stenting, although risk of long-term stroke was nearly equal (2.0 v. 2.4%) MI slightly more likely in CEA group Patients over 70 yrs did better with CEA, while younger patients did better with stenting Compared to previous studies, rate of stroke and composite outcomes after CEA was lower Embolic protection devices were used in 96.1% of stenting cases Participating surgeons were more experienced with low documented complication rates Improved medical therapy Less wound complications in stenting group
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CREST Trial Limitations Study design altered midway to include asymptomatic patients Lesion length, calcification and lesion location were not accounted for Study design only included experienced operators
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