Fast-track CEA: a 3-year experience

Transcription

1 Fast-track CEA: a 3-year experience Giorgio L. Poletto, MD Milano, Italy 6th ACST-2 Collaborators Meeting, Palau de Congresos, Valencia. 24th and 25th September 2018.

2 Stroke prevention Primary prevention: prevent carotid disease from ever developing Secondary prevention: reduce the clinical impact of asymptomatic carotid disease (i.e. stenoses are present and the aim is to prevent them from causing a TIA or stroke). Tertiary prevention: reduce the risk of recurrent TIA or stroke in patients secondary to carotid stenoses A.R. Naylor et Al. ESVS Guidelines Eur J Vasc Endovasc Surg (2018)

3 Imaging Recommendation Class Level Duplex ultrasound (as first-line), CT and/or MR angiography are recommended for evaluating the extent and severity of extracranial carotid stenoses When CEA is being considered, it is recommended that Duplex ultrasound stenosis estimation be corroborated by angio CT/MR angio, or by a repeat Duplex ultrasound performed by a second operator I I A A A.R. Naylor et Al. ESVS Guidelines Eur J Vasc Endovasc Surg (2018)

4 Anaesthesia general deep cervical block

5 Local anaesthesia

6 Clinical monitoring

7 Surgical access

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12 Eversion CEA

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15 Eversion CEA

16 Eversion CEA

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18 Completion angiography

19 Selective drainage

20 Early discharge No pain No electro-cardiogram changes Hemodynamic stability No neck hematoma/swelling No cranial nerve injury Easy access to hospital re-admisson Phone call on POD 2nd

21 Our experience FAST-TRACK period Apr 15 - Feb 18: 223 patients ESVS Recommendation Class Level CEA in patients symptomatic within the preceding 6 months and who have a 7099% carotid stenosis I A CEA in patients symptomatic within the preceding 6 months and who have a 5069% carotid stenosis IIa A CEA in patients with an asymptomatic 60-99% stenosis, in the presence of one or more imaging characteristics that may be associated with an increased risk of late ipsilateral stroke IIa B CAS may be considered in selected asymptomatic patients who have an 60-99% stenosis at high-risk for surgery in the presence of one or more imaging characteristics that may be associated with an increased risk of late ipsilateral stroke IIb B

22 High-risk patients clinically significant cardiac disease (congestive heart failure, abnormal stress test, or need for open-heart surgery) severe pulmonary disease contralateral carotid occlusion age >80 years contralateral laryngeal nerve palsy radical neck surgery/radiation voluminous goiter recurrent stenosis after CEA Yadav JS, et al. (SAPPHIRE study). N Engl J Med 2004

23 High-risk patients clinically significant cardiac disease (congestive heart failure, abnormal stress test, or need for open-heart surgery) severe pulmonary disease contralateral carotid occlusion age >80 years contralateral laryngeal nerve palsy radical neck surgery/radiation voluminous goiter CAS 26 cases recurrent stenosis after CEA

24 Patients Patient Data STANDARD FAST-TRACK Sept12-April15 Apr15-Feb patients 223 patients P value Age mean ± SD (range) 73 ± 8 (44-93) 74 ± 8 (42-90) Age 80 years, number (%) 52 (21) 52 (23) Male 175 (72) 148 (66) Hypertension 199 (82) 192 (86) Diabetes mellitus 68 (28) 69 (31) COPD 25 (10) 30 (13) Dislipidemia 133 (55) 153 (69) Chronic renal failure 20 (8) 21 (9) Current smoker 45 (18) 44 (20) ASA score (1) 118 (48) 123 (50) 0 1 (<1) 126 (57) 93 (42) 3 (1)

25 Indications STANDARD FAST-TRACK 76 ± 8 75 ± %-69%, number %-94% (82) 191 (86) Patient Data Stenosis (%) mean ± SD >95% Asymptomatic, number (%) Symptomatic, number (%) 45 (18) 32 (14) P value Hemispheric TIA 30 (67% of Sxic pts) 20 (63% of Sxic pts) Retinal TIA 8 (18% of Sxic pts) 5 (16% of Sxic pts) Stroke 7 (16% of Sxic pts) 7 (22% of Sxic pts) 0.864

26 Surgical procedure Anaesthesia Local anaesthetic General anaethesia Eversion 1% Direct suture Patch angioplasty Eversion STANDARD FAST-TRACK < <0.001 Patch angiopast y 16% Direct suture 41% Patch angioplasty 58% P value Direct suture 0% Eversion 84%

27 Surgical procedure 125% STANDARD FAST-TRACK 100% 100% 75% 50% 27% 25% 18% 13% 16% 3% 0% Use of shunt p: Drain placement <0.001 ICU admission <0.001

28 Results STANDARD Outcome FAST-TRACK P value Death + Major stroke + MI 3 (1.2) 1 (0.4) C Mortality * 0 0 n/a Stroke 4 (1.6) 1 (0.4) C Minor stroke 1 (0.4) 1 (0.4) C Major stroke* 3 (1.2) C Post-op Troponin elevation 2 (<1) 2 (<1) C Myocardial infarction* 0 1 (0.4) C 3 (1.2) C 12 (4.9) 3 (1.3) C Respiratory failure (requiring ICU)* Bleeding requiring reoperation

29 Length of stay Outcome Postoperative LOS (range) STANDARD FAST-TRACK P value 2 (1-71) 1 (1-7) <0.001 M Number of patients discharged (%) 70% STANDARD FAST-TRACK 56% 42% 28% 14% 0% Postoperative day discharge

30 Conclusions CEA is still the gold standard Risky procedure - well trained team - high volume centers High risk patients may undergo CEA Traditional approach can be implemented Fast track protocol is safe and effective giorgio.poletto@humanitas.it