Carotid endarterectomy after DES

[seinfeld]

I think the world you practice in also tends to blur your outlook on things. Last night had a lady who was 4 days post STEMI, 3 DES placed, EF 20%, in AFIB, new to dialysis who developed a cold leg on POD 1. Was in and out of IR for thrombolysis and now was coming to the OR for below the knee fasciotomies for early compartment syndrome (i.e. this wasn't a true emergency yet the surgeon was hedging his bets and doing the procedure before she lost sensation and pulses).

My point.....I realize this is not an elective situation , but I guarantee many of the outpatient only anesthesiologists would be weary of this case, where as to me, this is just another walk in the park. 50 mg of prop in divided doses and local by the surgeon, she looked like a peach in the PACU after.

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[GravelRider]

I think the world you practice in also tends to blur your outlook on things. Last night had a lady who was 4 days post STEMI, 3 DES placed, EF 20%, in AFIB, new to dialysis who developed a cold leg on POD 1. Was in and out of IR for thrombolysis and now was coming to the OR for below the knee fasciotomies for early compartment syndrome (i.e. this wasn't a true emergency yet the surgeon was hedging his bets and doing the procedure before she lost sensation and pulses).

My point.....I realize this is not an elective situation , but I guarantee many of the outpatient only anesthesiologists would be weary of this case, where as to me, this is just another walk in the park. 50 mg of prop in divided doses and local by the surgeon, she looked like a peach in the PACU after.

I'm not really sure the case you described is the same thing. It's really not applicable to the original case. Any reasonable anesthesiologist can get any patient through any case at any time. That doesn't mean we should. The case you are talking about is emergent or will soon be. Does that mean we should do more surgeries 1 day post-MI because you were able to guide this patient safely through a procedure 1 day after an MI? Maybe since we have them in the hospital for their post-stent care, we can do that hip replacement they were planning? I'm pretty sure I can get them through that surgery...so long as I have a balloon pump ready to go. That's one less hospital admission, so that is bound to cut costs.

 

[Colba55o]

I think the world you practice in also tends to blur your outlook on things. Last night had a lady who was 4 days post STEMI, 3 DES placed, EF 20%, in AFIB, new to dialysis who developed a cold leg on POD 1. Was in and out of IR for thrombolysis and now was coming to the OR for below the knee fasciotomies for early compartment syndrome (i.e. this wasn't a true emergency yet the surgeon was hedging his bets and doing the procedure before she lost sensation and pulses).

My point.....I realize this is not an elective situation , but I guarantee many of the outpatient only anesthesiologists would be weary of this case, where as to me, this is just another walk in the park. 50 mg of prop in divided doses and local by the surgeon, she looked like a peach in the PACU after.

scratching my head over the point of this self aggrandizing input...oh yeah your point is that you guarantee many outpatient anesthesiologists can't do what you can? Walk in the park? seriously..get over yourself

 

[Dr.Acula99]

Vascular surgeons will always find benefit in doing a CEA. Sounds like this patient needed better counseling from a neurologist or internist regarding the benefits of the decision. Sounds like everyone here is on the same page, if we were in this lady's situation we would delay the operation.

 

[Arch Guillotti]

My point.....I realize this is not an elective situation , but I guarantee many of the outpatient only anesthesiologists would be weary of this case, where as to me, this is just another walk in the park. 50 mg of prop in divided doses and local by the surgeon, she looked like a peach in the PACU after.

If I were an outpatient only anesthesiologist I would be weary AND wary of this case. Of course if you are outpatient only you would never do this case. For the rest of us it isn't a big deal.

 

[pgg]

Seinfeld's case is not a big deal because it's not even remotely elective. Sure you've got to pay attention and be on your game, but the go/no-go decision isn't a decision at all.

I don't object to doing urgent or emergent cases in sick or otherwise high-risk people. That's what I signed up to do and what I trained to do.

Ease or difficulty isn't this thread's issue at all. I don't see how the example of a patient with a cold leg is the least bit relevant to this thread, whether it's an easy or difficult anesthetic. Doing a CEA in an asymptomatic patient who's 3 months out from an MI and DES isn't likely to be hard (unless you're really unlucky and she rethromboses on the table in front of you) ... it's just unwise.

 

[Colba55o]

Seinfeld's case is not a big deal because it's not even remotely elective. Sure you've got to pay attention and be on your game, but the go/no-go decision isn't a decision at all.

I don't object to doing urgent or emergent cases in sick or otherwise high-risk people. That's what I signed up to do and what I trained to do.

Ease or difficulty isn't this thread's issue at all. I don't see how the example of a patient with a cold leg is the least bit relevant to this thread, whether it's an easy or difficult anesthetic. Doing a CEA in an asymptomatic patient who's 3 months out from an MI and DES isn't likely to be hard (unless you're really unlucky and she rethromboses on the table in front of you) ... it's just unwise.

It wasn't relevant at all...not to mention his ease with using 50 of prop for such a case speaks more about the surgeon's good local anesthesia than anything.
The case that I originally posted in this thread, was not difficult, the patient looked like a "peach" in PACU and by all accounts was uneventful. Its what happens 2 or 3 days out that I was concerned about. Seinfeld thinks he's a rockstar because he got a sick patient through a MAC case

 

[seinfeld]

scratching my head over the point of this self aggrandizing input...oh yeah your point is that you guarantee many outpatient anesthesiologists can't do what you can? Walk in the park? seriously..get over yourself

I guess i should have more clear in what I was trying to get at and what i saw as the relevant correlations the original thread.

1. When i asked the surgeon if the case was emergent or even urgent he said NO. He was hedging his bets based upon what he felt would be the natural history. So technically, based on some opinions here, I could have said no to the case and made him wait until the patient lost pulses or sensation and it was truly limb threatening. To the original threads point, I am not a vascular surgeon and I could not make a judgment call like he was regarding the anticipation of this becoming limb threatening. We had a discussion about the risks ( the cardiologist involved in the care wrote a great note also deferring judgement to the surgeon ackowledging the higher risk) based on his knowledge and experience he felt best to do now electively then risk what he thought would become a limb threatening situation. Like the CEA case presented, i had to defer to the judgment of the surgeon, I feel i was in no position to cancel or delay the case as I would be projecting my judgement in an area where i was not the expert on risk/benefit.

2. To the Original point of the thread....It is common for me to accept higher risk profiles based upon the types of cases I get on a regular basis. In my shop if this case was scheduled in such proximity to the MI and stents I would assume it was deemed urgent. Sometimes the environment you work in alters your biases. Having said that, my original post in this thread did mention that I would have discussed with the surgeon and cardiologist regarding the risk benefit, and then document.

3. Stop trolling for an online argument, no need to be so brash and childish in your responses. We are all trying to learn from each other on this forum. You assume way too much about my motivations from simple posts. Am I happy that I didn't have to provide a full GA and the surgeon was able to give a great block, hell yeah. Was i worried about how she will do for the rest of her life, hell yeah. I took from the case the little amount of personal satisfaction that I did the best I could and she looked better than I anticipated postop. As an ICU DOC I always believe that our success is not measured solely based on PACU d/c appearances.

Its responses like yours that make me fade away from this forum for months at a time, not because i cant handle the immaturity but rather i choose not to. When PGG or Arch posted comments that were in opposition they did so without assigning antagonistic nicknames, that I can respect

How many people have read your response and are now unlikely to give there input? As it stand now this forum is usually a discussion between a handful of people. We all loose from such behavior.

Cheers

 

[Colba55o]

I guess i should have more clear in what I was trying to get at and what i saw as the relevant correlations the original thread.

1. When i asked the surgeon if the case was emergent or even urgent he said NO. He was hedging his bets based upon what he felt would be the natural history. So technically, based on some opinions here, I could have said no to the case and made him wait until the patient lost pulses or sensation and it was truly limb threatening. To the original threads point, I am not a vascular surgeon and I could not make a judgment call like he was regarding the anticipation of this becoming limb threatening. We had a discussion about the risks ( the cardiologist involved in the care wrote a great note also deferring judgement to the surgeon ackowledging the higher risk) based on his knowledge and experience he felt best to do now electively then risk what he thought would become a limb threatening situation. Like the CEA case presented, i had to defer to the judgment of the surgeon, I feel i was in no position to cancel or delay the case as I would be projecting my judgement in an area where i was not the expert on risk/benefit.

2. To the Original point of the thread....It is common for me to accept higher risk profiles based upon the types of cases I get on a regular basis. In my shop if this case was scheduled in such proximity to the MI and stents I would assume it was deemed urgent. Sometimes the environment you work in alters your biases. Having said that, my original post in this thread did mention that I would have discussed with the surgeon and cardiologist regarding the risk benefit, and then document.

3. Stop trolling for an online argument, no need to be so brash and childish in your responses. We are all trying to learn from each other on this forum. You assume way too much about my motivations from simple posts. Am I happy that I didn't have to provide a full GA and the surgeon was able to give a great block, hell yeah. Was i worried about how she will do for the rest of her life, hell yeah. I took from the case the little amount of personal satisfaction that I did the best I could and she looked better than I anticipated postop. As an ICU DOC I always believe that our success is not measured solely based on PACU d/c appearances.

Its responses like yours that make me fade away from this forum for months at a time, not because i cant handle the immaturity but rather i choose not to. When PGG or Arch posted comments that were in opposition they did so without assigning antagonistic nicknames, that I can respect

How many people have read your response and are now unlikely to give there input? As it stand now this forum is usually a discussion between a handful of people. We all loose from such behavior.

Cheers

Seinfeld your reasoning doesn't hold water so at the risk of sounding brash and childish I still assert your ego was the main motivation behind your post about the leg case.

If a patient had a cold leg and early compartment syndrome,..I would think the threat to limb would be more likely to occur over the next 180 days than the patient having a perioperative MI. In my case, was the risk of an asymptomatic patient stroking out over the same time period more likely to occur than a periop MI? Not so sure..the urgency of your case is clearly more apparent than mine. The vascular surgeon was just "hedging his bets"? You mean no evidence based medicine went into his decision?

I was not trolling for an argument..the 2nd paragraph of your post is nothing but hubris. Who are you to "guarantee" what many outpatient only anesthesiologists would be weary of? Last I remember we all did the same residency and passed the same boards. And what relevance does that have to the subject at hand which is basically dealing with situations where you may disagree with surgeons and cardiologists? This was not a thread about how to do a case, or who is comfortable doing a case but rather when it's appropriate to do one.

 

[RxBoy]

Cardio here and I found this thread very interesting and a lot of great points made by all here. I agree in that this isn't a black and white issue and honestly I don't think there is one absolute/correct answer.

I DO agree in that there needs to be a frank discussion between all involved, and notable between the surgeon and patient regarding all the risks. Obviously just going by guidelines we should hold off and wait ideally after 1 year, though probably 6 months is sufficient as risk of MACE seems to level off then.

That said, a lot of these studies (certainly up until the mid-late 2000's) that looked at risks of stent thrombosis involved BMS and the 1st-gen DES. The newer 2nd Generation DES (which I'm assuming she had received) have even better/lower rates of late stent thrombosis (I've seen <1% at 12 months in some studies, outside of needing non-cardiac surgery of course).

There's still on-going debate in our literature on not only how long to keep patients on DAPT, but on the minimum DAPT time needed, with some even advocating that DAPT <6 months for those receiving the 2nd Gen DES as sufficient and allowing non-cardiac surgery 4-6 weeks after PCI. In the past if we knew someone needed surgery in the upcoming few months it was thought that we should implant a BMS, keep on DAPT for 4-6 weeks then let them have surgery. Though now with 2nd Gen DES there is some data that even tailored therapy as short as 30 days in patients with a higher bleeding risk/high thrombotic risk with a Zotarolimus-eluting stent is superior to BMS. (ZEUS Trial, JACC 2015)

I do agree that surgery at this point after her ACS event increases her overall risk and many other factors would need to be factored in here.... urgency of the CEA as deemed by the vascular surgeon, location of her stent (distal RCA vs a proximal LAD stent) and extent of her CAD/atherosclerotic burden overall, continued smoking, and frankly her wishes as well as which problem she is going to be worried about more (risk of a periop cardiac event vs risk of sitting there with a significant carotid stenosis) regardless of what the actually percentages may be.

While I'm not in practice quite yet, if I were seeing her in the office for a pre-op visit and she was 3 months out from an ACS event with PCI, I would certainly have a discussion on the above and officially say she is at an increased cardiac risk (though likely not prohibitive) and probably just give the surgeon a call as my preference would be to wait an additional 3 months, though if the surgeon and patient both perceive it as needing to be done sooner than so be it, while continuing DAPT of course.

Most informative response of the bunch. Thank you nlax30 for that post.

I've seen a couple of these less than 6 month DES "clearance" for semi-urgent cases. I had a cardiologist give me a very similar explanation. I had no clue that there were 2nd gen DES with decreased in stent thrombosis rates. Turns out the cardiologist knew a little more about his stents than I thought he did. It also turns out Im not as smart as I thought especially after I told the patient in PAT that his cardiologist probably didn't fully understand the surgical risk.

So if the OP's case was indeed a 2nd gen DES... This entire debate ultimate boils down to 2 camps:
*Cancel the case because it goes against the "guidelines", even though they probably dont apply to this case. This is mostly malpractice protection.
vs.
*Proceed with the case after a proper discussion/documentation takes place with all parties knowing the inherent risks of proceeding.

Its a grey region and neither side is truly right. Im of the latter camp. However, Ive never been sued (knock on wood). Im sure one lawsuit could totally change my perspective.