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
