AW: [HSF] a carotid and coronary case

Sat Aug 4 12:57:51 EDT 2007

I would not be comfortable knowing that the patient had a 95%  ICA stenosis preop and doing nothing. That is why we do CEA and particularly before CABG because we know it is a marker and a partially reversible marker for post op stroke. I do not care if some other doctor or surgeon was not concerned any more than I would if they weren't concerned with the 3 vessel disease either and I was.

Yes I would operate on any 95% ICA stenosis that was technically doable and the patient had reasonable expection of need for prophylaxis from stroke in the indeterminate future, eg already stroked or severe other limitations.

No as to the OPCAB question as stroke is clearly multifactorial with aortic manipulation being only one factor.

As to Hal's 20 minute retort, I do not offer 20 minutes as a guideline per se, but to better let the surgeon considering my technique think about whether that is something that would be transferrable to his practice. I am not particularly interested in having a shunt placed in my carotid artery either...unless I need a carotid CEA and Hal is doing it. In offering many teaching experiences for OPCAB, it becomes clear that some techniques are doable if the skills are appropiate for the surgeon in question. If the surgeon rountinely takes 30-45 minutes for each distal coronary on pump and often redoes them to make them "perfect", that surgeon must shunt for off pump and probably should not do off pump at all. (Maybe that surgeon would be better off learning CTA to see what "perfect" grafts look like verses his partners imperfect ones.) Likewise, if a surgeon can not hope to do a transfer of coronaries for switch for TGA in less than 40-60 minutes of circ
 arrest then the surgeon should think of another option no matter what the literature or other physicians says about arterial switch.

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Saturday, August 4, 2007 12:06:15 AM
Subject: RE: AW: [HSF] a carotid and coronary case

To Tea, Hal, Tom, Ed and other cardiovascular surgeons amongst us,

I think it was Ben who asked the question how remote the stroke was - I am sure Roberto will answer, but assuming the stroke was remote (years) and patient has not had any recent neurological event would any do the CABG alone and ignore the Carotid? Assume also that he had been known to have carotid disease for some years and that a conscious decision had been made that carotid surgery was not indicated on its own merit. 

Assuming again the stroke was remote and he did not have cardiac disease would this count as a symptomatic indication for carotid surgery?

Would any OPCAB surgeons do a case like this anaortic and ignore the cerebrovascular disease?

Ani

> Date: Fri, 3 Aug 2007 21:24:33 -0700> From: tacuff at swbell.net> Subject: Re: AW: [HSF] a carotid and coronary case> To: OpenHeart-L at lists.hsforum.com> CC: > > 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
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