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

49-year-old lady for complete endovascular reconstruction of Aortic bifurcation, endoluminal graft, and reconstruction of aorto-iliac segment.

Background

• Significant peripheral vascular disease – intermittent claudication, limiting all exercise.
• Wheelchair bound outside home
• Morbid obesity
• NIDDM. HbA1c = 5.8%

Issues

• Recurrent episodes of angina on minimal exertion over the last 3 months
• Exercise stress echocardiogram performed – submaximal test due to leg pain. Exercised 3-4 METs and reached 69% of predicted heart rate
• Chest pain during test, normal ECG and no exercise-induced Regional Wall Motion Abnormalities or reduction in end-systolic volumes
• CTCA recommended by treating cardiologist
• CTCA – Left main disease. ‘Extensive CAD with at least 50-69% stenosis in left main and mid RCA.’ Calcium score 439 (above 95^th percentile)
• Discussed at cardiology meeting. Plan to postpone and perform coronary angiogram

Discussion

CTCA

• Discussion as to the value of the test in this patient
• Young patient but high calcium score not unexpected given existing vascular disease
• Coronary CTA VISION study – evaluated role of CTCA in perioperative risk stratification.
• Results showed patients were x 5 times more likely to have an inappropriate over-estimation of surgical risk based on RCRI after coronary CTA
• Coronary angiogram likely to be a better test in this patient

LM disease

• CABG vs PCI discussed
• Traditionally, left main disease was an indication for CABG
• Extensive area of myocardium involved with increased potential for morbidity and mortality
• Evolution of practice, newer generation of DES, and improved adjuvant drug therapy has created better outcomes for PCI in LMCA
• 2 recent RCT’s EXCEL and NOBLE compared revascularization with PCI to surgical techniques with conflicting results.
• Both trials showed similar long‐term survival rates to CABG surgery, particularly in those with low and intermediate anatomic risk. 
• However, patients undergoing PCI had higher need for repeat revascularization in the future.
• Which patients are suitable for PCI? Current guidelines from AHA state they ‘strongly recommend surgical revascularization for LMCAD (class IA) with PCI considered a reasonable alternative (class II) in select patients with less complex anatomy and clinical characteristics that predict an increased risk of adverse surgical outcomes.’
• https://www.ahajournals.org/doi/10.1161/JAHA.117.008151

Plan

• Discussed at cardiology meeting – to proceed to coronary angiogram
• Patient and surgeon aware of plan.

72-year-old man for gastroscopy and colonoscopy

Background

• Surveillance colonoscopy for previous benign polyps
• Gastroscopy for chronic GORD symptoms
• BMI 57
• NIDDM, good control
• PAF, on Apixaban
• Pulmonary Hypertension, routine echo in 2017

Issues

• Recent Bilateral PE’s (April 2021) with significant clot burden
• Admission with sepsis and AKI 2 months previously and DOAC ceased
• No investigations for OSA; STOPBANG 8 and Epworth Sleepiness Score 12
• Not known to respiratory physician and no follow-up in place from hospital admission

Discussion

Should procedure be postponed?

• Yes. Elective procedure. No red flags.
• Surgical team in agreement.
• Postpone until 6 months post PE.
• Postponement of 3 months is usually adequate. A longer timeframe was selected in this patient due to the severity of his disease and complex comorbidities.

Optimisation

• Referral to respiratory physician; significant clot burden, should he have repeat imaging before interruption of anticoagulation?
• Clinical suspicion of OSA (and possibly OHS) given multiple risk factors, ESS, and long-standing pulmonary hypertension.
• Plan to discuss with respiratory physician

Plan

• Postpone for at least 3 months
• Repeat echocardiogram
• Referral to respiratory team

PIG Notes 15th July 2021

• Bronchial Thermoplasty
• Carotid endarterectomy v. stent
• Bilateral TKR
• Frail patient for e/o SCC and craniectomy
• ? Cardiac amyloid
• HOCM and PAF for hernia repair
• Trifascicular block and urological stent

85-year-old man for cystoscopy and stent change

Background

• Metastatic prostate cancer
• IDDM – HbA1c = 11.7%
• Increased BMI
• OSA
• Asthma

Issues

• Recent admission with AKI and obstructive uropathy, thought to be caused by pelvic metastatic disease
• AKI ongoing despite stent
• Trifasicular block on ECG – 46bpm
• Asymptomatic, present on ECGs from admission last year
• History of unexplained falls attributed to postural hypotension and resolved with cessation of antihypertensives

Discussion

Management of trifasicular block perioperatively

• Discussed at cardiology meeting – Not for pacemaker therapy at present; asymptomatic, multiple co-morbidities, increased risk of infection, but does present uncertain risk of developing complete heart block intraoperatively
• Consensus that there should be a clear management pathway for patients at risk of perioperative bradyarrhythmia that are unsuitable for PPM therapy
• Increasing numbers of similar presentations

Risk of perioperative complete heart block

• Difficult to define
• Literature is contradictory at best
• Recent case of perioperative bradycardia with difficulty in obtaining temporary pacing. Not first line therapy but some concern that this issue be resolved before we decide to proceed with cases at known risk of perioperative CHB?

Plan

• Proceed with surgery in conjunction with procedural anaesthetist
• Optimise glycaemic control without postponing procedure
• Discuss at departmental M&M with reference to recent case

66-year-old man for open left inguinal hernia repair       

Background:

• Reducible inguinoscrotal hernia. Causing intermittent pain but no hospital admissions.
• Hyperthyroidism
• Epilepsy
• Anxiety/depression

Issues:

• HOCM – stable disease on medical therapy
• AICD in situ
• PAF – Associated increased dyspnoea, haemodynamically stable, severely dilated LA on echo, booked for AF ablation in coming months
• Commenced on amiodarone but recent device check showed an AF burden of 100%
• DC Cardioversion recently

Discussion:

Timing of surgery

• High risk of AF intraoperatively
• Recent cardioversion and need to cease DOAC perioperatively
• Should we wait until ablation is performed?
• Discussed at cardiology meeting and cardiologist feels it would be suitable to proceed but there is a risk of perioperative AF. Ablation success is uncertain in the settling of HOCM, and patient will be more likely to redevelop AF in the 3 months post-ablation
• On optimal medical therapy
• Elective surgery – consensus that it would be better to have ablative therapy preoperatively

Plan:

• Expedite ablation if possible
• Postpone hernia surgery until 3 months post-ablation

56-year-old man for a Radical prostatectomy for prostate cancer

Background:

• Asthma – well-controlled
• Lifelong smoker – 30 pack years
• Active, goes to the gym daily >4METS

Issues:

• Inferior TWI noted on perioperative ECG
• No history of symptoms
• Echocardiogram showed ‘moderately hypertrophic LV with marginally reduced systolic function, Grade 1 diastolic dysfunction, infiltrative process cannot be excluded, and ASD with small left>right shunt.’

Discussion:

• Discussed at cardiology meeting regarding need for further investigations preoperatively. Cardiologist recommended that surgery proceeds, cancer surgery.
• Differential diagnosis:
• Ischaemic Heart disease – relatively normal LV systolic function is reassuring.
• Infiltrative process – E.G. Amyloidosis, unlikely but at present it is not significant. Not obvious on echo and voltages preserved on ECG. Recommends post-op outpatient cardiology review and cardiac MRI
• AHA guidelines would support proceeding without further cardiac investigations
• Normal sestamibi would be reassuring but abnormal result would likely cause delay and not change intraoperative management

Plan:

• Proceed with planned procedure
• Refer to GP for postoperative cardiology referral and consideration of cardiac MRI and stress test.

85-year-old lady for extensive excision of SCC from scalp, transposition flap grafting and craniectomy

Background:

• Severe COPD documented in notes
• Stable disease for past 2 years
• Normal spirometry in clinic
• Walks 1km on flat

Issues

• T4N0MO SCC scalp
• 45kg, concern regarding frailty and extensive surgical procedure
• Albumin 42, 4 on Clinical Frailty Scale

Discussion

• Patient very keen to proceed with surgery, fully informed of risks
• Alternative treatment option – radiotherapy, patient feels this would significantly impact on her QoL
• Surgery is likely to be long and involves craniectomy
• Increased risk of postoperative pulmonary complications and delirium
• Consensus is that it is suitable to proceed with planned surgery
• Disposition – transpositional flap, will have special nurse on ward for observations

Plan:

• Proceed with planned surgery
• ICU 3

73-year-old man with bilateral knee OA for consideration of single/bilateral knee replacements

Background

• OSA – home CPAP. Compliant
• BMI 37
• IDDM – Hba1c = 7.5%
• Asthma – not known to respiratory physician. Uses salbutamol 5-6 times per day, including overnight.
• Ex-smoker – 10 pack years

Issues

• Noted to have NYHA class-4 dyspnoea at periop clinic
• Spirometry performed which showed: FEV 1 = 1.1 (46%) FVC = 1.9 (56%)
• Confirmed with formal spirometry – moderate restrictive defect with no significant BD response
• Seen at Rapid-access respiratory clinic – advised a short course of steroids and triple inhaler therapy

Discussion

Bilateral joint replacements

• Patients often referred for consideration of bilateral joints
• Surgical team usually requesting procedure to be guided by anaesthetic assessment
• No formal guideline for patient selection but consensus would be an ASA 1/2 patient who is normally fit and active
• This patient would not be suitable for bilateral joint replacements. Increased risk of postoperative pulmonary complications, infection, and MACE.

Optimisation

• Suitable to proceed with single joint replacement
• Optimised from respiratory perspective.

Plan

• Proceed with single joint replacement

62-year-old man for consideration of Right carotid Endarterectomy vs Stent

Background

• Left CEA 2001
• Adult polycystic kidney disease – Haemodialysis dependent
• Hypertension
• NIDDM – Diet only
• Recent normal sestamibi

Issues

• Asymptomatic high-grade right internal carotid artery stenosis – 80%
• Previous TIA and left CEA
• On clopidogrel

Discussion

CEA vs Stent

• Patient suitable for either procedure as per surgical decision
• Minimal anaesthetic required for carotid stent
• Stent often performed by interventional neuroradiologist

Plan

• Inform surgical team of meeting outcome
• Proceed with either procedure