XXV. kongres České společnosti anesteziologie, resuscitace a intenzivní medicíny, Praha 3.-5.10. 2018 Co chce/čeká neurochirug od anesteziologa během karotické endarterektomie? Hejčl A., Orlický M., Sameš M. Department of Neurosurgery, J.E.Purkinje University Masaryk Hospital, Ústí nad Labem, Czech Republic
CEA & Czech Neurosurgical Centers 2013-2016
General Indication Criteria NASCET, ECST, ACAS, ACST and their meta-analyses: degree of stenosis when the CEA is indicated acceptable complication rate. Degree of stenosis Recommendation Acceptable complication rate Symptomatic patients Asymptomatic patients 50-99% 60-99% Class:I Level:A Class: IIa Level: A 6% 3%
Improved prevention and conservative therapy for vascular-risky patients Cessation of smoking Improved hypertension treatment 40% 23% COSS Study Improved cholesterol treatment (statins) Improved lifestyle...
Current situation we progress More selective More conservative (typical patient): 70 year old lady 70% carotid stenosis asymptomatic smooth plaque with no ulcerations More strict on complications
Influence of the type of anaesthesia on the results of CEA GALA 1 study did not show the difference in the incidence of new clinical ischemic lesions of the brain, myocardial infarction, death between CEA in local or general anaesthesia 1 GALA Trial Collaborative Group. 2008. General Anaesthesia versus Local Anaesthesia for Carotid Surgery (GALA): 6 A Multicentre, Randomised Controlled Trial. Lancet (London, England) 372 (9656): 2132 42.
The GALA-DWMR Study Silent brain infarctions can be detected on MR DWI in as many as 34% of cases after carotid endarterectomies 2,3 2 Školoudík et al. 2016. Sonolysis in Prevention of Brain Infarction During Carotid Endarterectomy and Stenting (SONOBUSTER): A Randomized, Controlled Trial. European Heart Journal 37 (40): 3096 3102. 3 Orlický et al. 2015. A Selective Carotid Artery Shunting for Carotid Endarterectomy: Prospective MR DWI Monitoring of Embolization in a Group of 754 Patients. Journal of Neurological Surgery. Part A, (2): 89 92.
Influence of the type of anaesthesia on the results of CEA Will the incidence of new graphical ischemic lesions shown on MR DWI be different in CEA under general and local anaesthesia?
Influence of the type of anaesthesia on the results of CEA Methods 105 CEA surgeries in Local Anaesthesia performed in Ústí n.l. (clinical status monitoring) 105 CEA surgeries in General Anaesthesia performed in Ostrava (Evoked Potentials, TCD monitoring) Detection of new acute ischemic lesions of the brain on MR DWI (app.24h before and after surgery)
Influence of the type of anaesthesia on the results of CEA Results Local General P anaesthesia anaesthesia value New graphic ischemic lesion, n(%) 7 (6.7) 18 (17.1) 0.031 Szabo I-III 0 3 Szabo IV 5 5 Szabo V 2 10 Stroke or TIA, n (%) 2 (1.9) 3 (2.9) 1.000 Death, myocardial infarction, n (%) 0 (0.0) 0 (0.0) 1.000 Local and other complications, n (%) 22 (21.0) 15 (14.3) 0.277
Influence of the type of anaesthesia on the result of CEA Results Local General P anaesthesia anaesthesia value New graphic ischemic lesion, n(%) 7 (6.7) 18 (17.1) 0.031 Shunt used: 13 (LA) vs. 7 (GA) Szabo I-III 0 3 Szabo IV 5 5 Szabo V 2 10 Stroke or TIA, n (%) 2 (1.9) 3 (2.9) 1.000 Death, myocardial infarction, n (%) 0 (0.0) 0 (0.0) 1.000 Local and other complications, n (%) 22 (21.0) 15 (14.3) 0.277
Influence of the type of anaesthesia on the results of CEA - Conclusions Risk of new brain ischemic lesions detected by MR DWI is higher after CEA in GA than after CEA in LA The 30-day mortality and morbidity, including clinical stroke did not differ in both groups (as in the GALA study) Monitoring method used for indication of shunt placement -> predictor of new brain ischemic lesion : SSEP > TCD > clinical monitoring
Influence of intraluminal shunt on the results of CEA Objectives The use of intraluminal shunt: risk of peri-operative ischemic stroke by sustaining of the cerebral blood flow risk of peri-operative ischemic stroke embolization of thrombus/vessel wall fragments during a shunt insertion
Influence of intraluminal shunt on the results of CEA Question of the study Will use of intraluminal shunt increase or decrease the risk of perioperative ischemic stroke?
Influence of intraluminal shunt on the results of CEA Methods Selective use of shunt (neurological status) Detection of new acute ischemic lesions on MR DWI of the brain (app. 24h before and after the surgery) Data studied Rate and Etiology of the new ischemic lesions of the brain in shunted and non-shunted carotid endarterectomies
Selective use of shunting during CEA CEA in cervical block New DWI lesion 46 (6%) shunts used in 754 patients operated for ICA stenosis 32.6% vs. 4.2% A new ischemic stroke was detected in 45 (6%) on DWI. 80% were neurologically asymtomatic 15 (32.6%) of new DWI lesions in shunted patents shunt vs. no shunt 30 (4.2%) of new DWI lesion in non-shunted patients Orlický, et al. J Neurol Surg Part A. 2015
Endovascular procedures for brain ischemia in the region Ústí nad Labem 160 140 120 100 80 60 40 20 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 LT LO MO TP CH DC UL
2014/2015 MR CLEAN ESCAPE EXTEND-IA SWIFT PRIME REVASCAT THRACE THERAPY
Influence of the timing of surgery on the results of CEA Rothwell, Lancet 2004 Rothwell, Neurology 2005 Rothwell Lancet Neurol 2006 Risk of recurrent stroke after TIA: 1st Day...17% 14 Days...46% The median of symptoms-to-surgery period (StS; in days) for AF (dashed line) and hemispheral TIA (full line) for consecutive years
Influence of the timing of surgery on the results of CEA Methods 187 patients who underwent CEA after TIA Data studied 1. Period from beginning of symptoms until carotid endarterectomy (symptoms-to-surgery, abbr.: StS) 2. Complication rate and type in relation to the time of surgery
Influence of the timing of surgery on the Complications results of CEA Table: Complication rate (up to 3 days post op) in relation to timing of the surgery - StS StS Major n (%) Minor n (%) Till 1 st day 0 7 (3,5) 2 nd -3 rd day 1 (0,5) 3 (1,5) 4 th -7 th day 2 (1) 2 (1) 8 th -14 th day 0 6 (3) Over 14 th day 2 (1) 14 (7) All 5 (2,5) 32 (16) Note: "major" complications: Stroke, Myocardial infarction, Hyperperfusion sy., death "minor" complications: vocal cord palsy, marginal branch of facial n. palsy, wound hematomas
CEA under local anesthesia (cervical block) No intubation No general anesthetics No urinary catheter No interruption of peroral medication Immediate peroral intake Selective indication of shunting (shunt = risk of embolisation)
NIRS monitoring Perioperative monitoring carotid endarterectomy lumbar spine knee and hip replacement aortic surgery cardiac surgery ICU monitoring Emergency medicine Singh et al. 2016
Study Design Awake patients (cervical block) Application of bifrontal NIRS skin probes (Foresight oximeter (CAS Medical Systems Inc., Branford,CT, USA) Application of SEP monitoring Invasive arterial pressure monitoring Selective ECA clipping Selective ICA clipping Neurological evaluation (60 seconds) Shunt insertion in case of clinical deterioration No shunt insertion in case of a clinically stable patient Evaluation of NIRS data with respect to clinical deterioration DWI before and after surgery
Cohort characteristics 50% symptomatic 3 pts contralateral ICA occlusion 47% diabetics 79% hypertension 10% coronary heart disease 52% dyslipidemia 42% smokers
NIRS monitoring during CEA Data based on 58 patients 49 clinically stable 9 clinical deterioration (7 shunted) Easy to implant Reliable data collection (..sweating, restless patients) Online evaluation by the operating neurosurgeon
Regional cerebral oximetry in a shunted patient ICA clipping - clinical testing ICA occlusion shunt insertion shunt extraction, ECA reverse flow ICA flow restoration
Percentage of NIRS change The difference in the NIRS% values after ICA clipping between patients with and w/out clinical deterioration 18 16 NIRS% * 14 12 10 8 6 4 2 0 clin. stable clin. deterioration * p < 0.001 NIRS%...10% 100% sensitivity 87% specificity
Conclusions Changing scenario Acute timing of CEA for symptomatic stenosis People are healthier with better medication Safer and more effective CEA Very early CEA for symptomatic carotid stenosi Complex solutions (LA,GA)
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