CEA and triple vessel disease

Gabrielle Morris

55-year-old lady for Right Carotid Endarterectomy

Background

  • 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%

Issues:

  • 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

Discussion

  • 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

Procedural Issues

  • 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

Disposition

  • Postoperative ICU for strict BP control and haemodynamic monitoring
  • Should we consider postoperative troponins?

Plan:

  • Further discussion required with proceduralist and cardiologist regarding timing of surgery and management of antiplatelet medications
  • Postoperative ICU bed