AW: [HSF] a carotid and coronary case

[Tea Acuff]

I stopped using a shunt after my first few cases in private practice because I do not believe that flow occlusion is the most commom cause of stroke if one can rountinely accomplish the closure in around twenty minutes or so (often less). For the first decade approximately I did not patch, but gradually began patching everything as I thought it compensated for distal plague that did not taper well and my technique speeded up. In a case like this a shunt might be reasonable if easy to place, and I would have have no fear in sewing up without a patch to decrease ischemia (with or without a shunt) to hopefully around ten to fifteen minutes...which still may be a lifetime. This is clearly high risk by any approach. I have done a (small) number of totally occluded contralateral carotids without shunt and with patch and likely will continue to.
tea


----- Original Message ----
From: prasannasimha <prasannasimha at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Friday, August 3, 2007 9:12:02 PM
Subject: Re: AW: [HSF] a carotid and coronary case


Then a 4 vessel MR angio would be in order.. (The cases I was referring 
to actually had 3 of 4 vessels occluded) with antegrade cerebral 
malperfusion induced by even by posture change.
Incidentally what are your indications for patching ?
What size shunts do you use and what is the size of the carotid when you 
would not place a shunt ?
Prasanna
Edward Bender wrote:
> The reasons that a shunt could not be placed are usually due to the 
> small size of the distal internal carotid or, less commonly, severe 
> tortuosity.   In the presence of only one patent internal carotid 
> artery feeding the contralateral side, the arterial size is usually 
> quite large.  I have not had a problem with hemispheric ischemia with 
> 4 or 5 minutes of no flow in the heparinized patient.  I would also 
> hazard a guess, and have anecdotes,  that you could safely do the case 
> without a shunt.  In rare cases the vertebral system will not feed the 
> anterior circulation and this would be a problem.  Where I have run 
> into problems with post-op cerebral ischemia is due to either 
> embolization of material or air, or a distal shunt injury to the 
> carotid intima raising a flap.. I think that the committee that 
> designed the brain's vascular anatomy got it right.
>
> Ed Bender, MD
>
>
> On Aug 3, 2007, at 8:45 PM, prasannasimha wrote:
>
>> What  would your strategy be in the no flow period ? (between 
>> arteriotomy and shunt introduction) and if the shunt for some reason 
>> cannot be placed ?
>> Prasanna
>>
>> Jbflegejr at aol.com wrote:
>>> I would do a left carotid endartectomy and a couple of days later do 
>>> the CABG. John Flege
>>>
>>>
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