vcu death and complications conference. complication complication stroke procedure cea primary...
TRANSCRIPT
VCUDEATH AND COMPLICATIONS CONFERENCE
Complication
Complication STROKE
Procedure CEA
Primary Diagnosis SYMPTOMATIC CAROTID STENOSIS
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.
Clinical History
PMH COPD, HTN, PVD
PSH S/P angioplasty and stent in left
common iliac and SFA
MEDS : Clopidogrel/statin/diltiazem/inhalers.
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
CEA WITH SHUNTING
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
Circle of Willis
Broca's Aphasia
Supporting Data/Conclusions
• Shunting, non shunting and selective shunting during CEA.
Selective shunting
Transcranial Doppler (TCD) Electroencephalogram (EEG)
monitoring Carotid stump pressure (SP) Cervical block anesthesia (CBA) Somatosensory evoked potential
(SSEP)
.
In this study, the available evidence supporting shunting, nonshunting, and selective shunting during CEA were analyzed.
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.
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.
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.
Argyle shunt