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Technical Adjuncts in High Risk Patients Undergoing Endarterectomy

Technical Adjuncts in High Risk Patients Undergoing Endarterectomy. Joseph P. Archie Jr. 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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Technical Adjuncts in High Risk Patients Undergoing Endarterectomy

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  1. Technical Adjuncts in High Risk Patients Undergoing Endarterectomy Joseph P. Archie Jr.

  2. Risk Factors • Systemic Co-morbidity (cardiac, pulmonary) • Combined CEA-CAB • Contralateral Internal Carotid Occlusion • Hostile Neck - Prior Irradiation, Prior CEA • High Internal Carotid Lesion

  3. Cardio-Pulmonary Risk Technical Adjuncts • Bradycardia - carotid sinus, vagal • Block carotid sinus with xylocain • Give atropine

  4. 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

  5. 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

  6. Contralateral ICA OcclusionTechnical Adjunct • SHUNT - SHUNT - SHUNT • Approximately 50 % of patients with contralateral occlusion meet selective shunt criteria

  7. Prior Irradiated NeckTechnical Adjuncts • Cranial nerve protection - nerve stimulator • Carotid exposure - friable internal carotid • Autologous vein patch or bypass

  8. Prior CEA • Pooled outcomes from 10 studies 1995 to 2001Stroke 24/847 (2.8 %)Death 6/847 (0.7%)

  9. 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

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