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Austin D. Williams, MD MSEd Hospital of the University of Pennsylvania Vascular Surgery Grand Rounds

Vascular Grand Rounds

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Case report and vascular grand rounds (carotid)

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Vascular Surgery Grand Rounds

Austin D. Williams, MD MSEd Hospital of the University of Pennsylvania

Vascular Surgery Grand Rounds

1Case Presentation72 year-old femaleCC/HPIProblems with word finding for several monthsDyspnea on exertionOccasional chest pain and palpitationsROSNo vision changes, weakness, loss of sensationNo claudication

Case PresentationPMHRight carotid stenosis - - R CEA (2002)CVA (2010) - - no residual symptomsCAD with NSTEMI - - PCI with DES in RCA/OM (12/12)HLDHTNPSHL mastectomy and reconstruction (1995)SHFormer smoker, quit 1969Social EtOH

Case PresentationEKG NSR, LVH

CXR wnl

Echo LVEF 70%, severe AS (valve area 0.6 cm2)Nuclear stress test small area of lateral wall ischemia

CTA neckLICA 82% stenosisRight and internal carotids with minimal stenosisAssessment72 year-old femaleHistory of coronary artery and cerebrovascular diseaseConcominant aortic stenosis and (?) symptomatic carotid stenosis PLAN?Operative SequenceCardiac morbidity and mortality in carotid surgery

Risk: Patients with AS fare worse than those without

Risk: stenting not inferior to endarterectomy (SAPPHIRE)Kertai et al. 2002. Aortic stenosis: an underestimated risk factor perioperative complications in patients undergoing noncardiac surgery. Am J Med.

Operative SequenceCerebrovascular morbidity and mortality in cardiac surgery

Risk: 3-11%, severityRisk: 3-fold increase with CABG

Risk: 20%, bilateral high grade stenosis

Naylor et al. 2002. Carotid artery disease and stroke during coronary artery bypass: a critical review of the literature. Eur J Vasc Endovasc Surg 23:283-294. AHA Cardiology Guidelines, 1999 Etiology of Cerebrovascular EventsHypoperfusionBypass hypotensionImpairment of autoregulation

Plaque embolizationCarotid vs. ??Off-pump + CAS

High CV M/M predictor

Operative SequenceSynchronous

Staged