1. VCU DEATH AND COMPLICATIONS CONFERENCE

2. Complication  Complication  STROKE  Procedure  CEA  Primary Diagnosis  SYMPTOMATIC CAROTID STENOSIS

3. Clinical History  HPI  67 yo male with severe left sided carotid Stenosis >90% with symptoms (visual floaters, transient blindness) was admitted for heparin infusion and urgent CEA.

4. Clinical History  PMH  COPD, HTN, PVD  PSH  S/P angioplasty and stent in left common iliac and SFA  MEDS :  Clopidogrel/statin/diltiazem/inhalers.

5. Overview of Case  Chest x-ray  LABS: within normal level  EKG reviewed-non ischemic  Echo reviewed-normal LV function and no valvular lesion  CT head  Intracranial vascular calcifications involving bilateral vertebral and internal carotid  Cardiology and anesthesia evaluated patient and deemed him moderate risk

6. CEA WITH SHUNTING

7. Overview of Case  OR  we were unable to place a shunt  Proceeded with out a shunt  Post-op patient was hemiplegic  Carotid Angio  Good flow with no flaps or filling defects  CT negative  MRI infarction involving the cerebral cortex of the left frontal, parietal, and occipital lobes

8. Circle of Willis

9. Broca's Aphasia

10. Supporting Data/Conclusions Shunting, non shunting and selective shunting during CEA.

11. Selective shunting  Transcranial Doppler (TCD)  Electroencephalogram (EEG) monitoring  Carotid stump pressure (SP)  Cervical block anesthesia (CBA)  Somatosensory evoked potential (SSEP).

12. In this study, the available evidence supporting shunting, nonshunting, and selective shunting during CEA were analyzed.

13. Methods  An electronic PubMed/MEDLINE search was conducted  Identify all published CEA studies between January1990 and December 2010, that analyzed the perioperative outcome of routine shunting, routine nonshunting, and selective shunting based on EEG,TCD, SP, CBA, and SSEP.

19. Results:  The mean reported perioperative stroke rate for CEAs with routine shunting was 1.4%.  Routine nonshunt was 2%.  The mean perioperative stroke rates for selecting shunting were  1.6% using EEG, 4.8% using TCD,1.6% using SP, 1.8% using SSEP, and 1.1% for CBA.

20. Analysis of Complication Was the complication potentially avoidable? – YES, IF SHUNTING WAS ESTABLISHED Would avoiding the complication change the outcome for the patient? – YES What factors contributed the complication? Stroke likely related to hypoperfusion due to inability to put a shunt and likely poor collateral circulation.

21. Argyle shunt