technical adjuncts in high risk patients undergoing endarterectomy joseph p. archie jr
TRANSCRIPT
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Technical Adjuncts in High Risk Patients Undergoing
Endarterectomy
Joseph P. Archie Jr.
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Risk Factors
• Systemic Co-morbidity (cardiac, pulmonary)• Combined CEA-CAB• Contralateral Internal Carotid Occlusion• Hostile Neck - Prior Irradiation, Prior CEA• High Internal Carotid Lesion
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Cardio-Pulmonary Risk Technical Adjuncts
• Bradycardia - carotid sinus, vagal
Block carotid sinus with xylocain
Give atropine
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Combined CEA - CABTechnical Adjuncts
• Combined risk = CEA risk + CAB risk
• Prep & drape for combined operations
• CEA done while vein harvested
• Saphenous vein patch
• Drain
• Added time about 45 minutes
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Contralateral ICA Occlusion
• NASCET 6/43 (14 %) stroke or death, versus 86/737 (6 %), P = 0.84
• ASAC 2/86 (2 %) stroke, versus 17/737 (2 %)
• Pooled stroke rate for 8 studies 1992-2001 26/592 (4.4%) versus 87/3,392 (2.3%)P = 0.013
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Contralateral ICA OcclusionTechnical Adjunct
• SHUNT - SHUNT - SHUNT
• Approximately 50 % of patients with contralateral occlusion meet selective shunt criteria
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Prior Irradiated NeckTechnical Adjuncts
• Cranial nerve protection - nerve stimulator
• Carotid exposure - friable internal carotid
• Autologous vein patch or bypass
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Prior CEA
• Pooled outcomes from 10 studies 1995 to 2001
Stroke 24/847 (2.8 %)
Death 6/847 (0.7%)
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Prior CEATechnical Adjuncts
• Old operative note
• Expose common carotid proximal to and internal carotid distal to prior dissection (CW Doppler probe)
• Nerve stimulator
• Patch or bypass (outcomes similar)
• Material: vein and synthetics have similar outcomes for both patch and bypass