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