55-year-old lady for Right Carotid Endarterectomy
- Bilateral carotid artery stenosis: Right 99%, Left 90%
- Symptomatic – multiple TIAs with left hemiparesis.
- Right temporoparietal watershed infarct on MRI
- Vertebral artery disease – possible small dissection on imaging
- NIDDM. HbA1c = 6.7%
- IHD with multiple previous PCI’s
- Ischaemic cardiomyopathy, LVEF 45%
- Recent NSTEMI (in WA)
- Significant triple vessel disease on angiogram
- Treating team felt CVA risk too high for CABG, opted for PCI
- PCI in June 2021: 1x DES to prox RCA, 1x DES to Mid-Cx, 3x overlapping DES to LAD
- Now on Ticagrelor
- Recent echo showed hypokinesis of inferior and septal walls
- Complex and high-risk cardiac and cerebrovascular disease!
Management of anti-platelet therapy
- Ticagrelor – oral, reversible, direct-acting P2Y12 inhibitor. Ticagrelor has a more rapid onset and more pronounced platelet inhibition than clopidogrel. See attached PLATO trial.
- Vascular surgeon happy to perform CEA on Aspirin/Clopidogrel but not on Ticagrelor due to increased bleeding risk.
- Current plan to cease Ticagrelor 3 days preoperatively
- Unclear if patient was on DAPT when had recent NSTEMI
- If had NSTEMI on Clopidogrel, should we consider performing platelet function studies?
- Discussed at Cardiology meeting – DAPT would be ideal solution
Timing of Procedure
- Booked for September, 3 months post-PCI
- Consensus is that it would be acceptable to proceed earlier given significant disease and ongoing risk of CVA
- Shunt – bilateral disease along with possible vertebral artery dissection, would the proceduralist opt to shunt prophylactically?
- Majority felt that shunt would be most likely performed in this case but should be discussed further with proceduralist
- Postoperative ICU for strict BP control and haemodynamic monitoring
- Should we consider postoperative troponins?
- Further discussion required with proceduralist and cardiologist regarding timing of surgery and management of antiplatelet medications
- Postoperative ICU bed