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NB: also see chapter 104 on CEA in Neuro section for more details

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Endovascular Procedures
Carotid proceduresAortic proceduresPeripheral/other vessel procedures
TypesCarotid artery stenting and angioplastyEndovascular repair of abdominal (AAA), thoracic (TAA), or thoracoabdominal (TAAA) aortic aneurysmsAngiography, percutaneous transluminal angioplasty (PTA) ± stenting, intra-arterial thrombolytic therapy, embolectomy or stenting for subclavian, renal, iliac, femoropopliteal, or mesenteric arteries as well as venous procedures (TIPS,1 inferior vena cava (IVC) stenting, etc.)
IndicationsRevascularization for stroke prevention; endovascular is alternative to open CEA (e.g., if history of neck radiation)Exclusion of aneurysms to prevent rupture or rupture repairRevascularization from atherosclerotic or thromboembolic etiology to treat limb claudication, peripheral vascular disease, congestion, and organ hypoperfusion
Open vs. endovascularSimilar long-term risk of major stroke, slightly higher risk of minor stroke in endovascular; therefore, CEA still considered standard-of-careEndovascular compared to open surgical approach may offer advantage of reduced postop pain, recovery time, and morbidity related to cross-clamping and large incisions; however, device failure and complications from device placement are unique complications; especially superior when significant comorbidities are present
Morbidity and mortalityTypically secondary to cardiac, renal, and neurologic insults

1Transjugular intrahepatic portosystemic shunt.

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Preoperative Assessment for Endovascular Procedures
Carotid proceduresAortic proceduresPeripheral/other vessel procedures
History and physicalAsk about exercise tolerance, comorbidities, preexisting neurologic deficits, iodine/contrast allergies; examine heart, lungs, and nervous system
Cardiac risk assessment
  • Review workup of clinical risk factors increasing perioperative morbidity and mortality (ischemic heart disease, cerebral vascular disease, Cr > 2, heart failure, etc.) and pulmonary function
  • Request additional workup if patient has limited functional capacity with >1 risk factor, information would change management, if data are missing or not updated since functional decline
  • Prophylactic coronary revascularization prior to surgery not superior to perioperative maintenance of medical therapy of CAD (β-blockers, statins, aspirin) in all patients; wait 6 weeks if pt underwent recent revascularization
Labs
  • Coagulation—pts may be on anticoagulants and will receive heparin intra-op
  • Creatinine—assess presence of acute or chronic renal insufficiency; also keep in mind the possibility of contrast-induced nephrotoxicity during the procedure
  • Hemoglobin/Hematocrit—to determine maximal allowable blood loss, especially if aneurysm rupture is suspected. Transfusion threshold of Hb 10 g/dL for patients with IHD (ischemic heart disease) or suspected CAD
  • Activated clotting time—need a baseline prior to heparinization
  • Type and cross—ensure active; may need 2 units available for larger procedures or if preop anemia
RadiographyCerebral angiography and duplex ultrasonography should be reviewed to assess for patency of Circle of Willis, contralateral carotid disease, and lesion characteristicsReview to appreciate size, location, involved branches, and plaque burdenOften does not change anesthetic management but assessment of disease extent and plaque burden may be of use if severe
RxContinue CAD therapy, except angiotensin-converting enzyme inhibitors (ACEI), hold oral hypoglycemic agents; insulin glargine dose should be halved the night before. ...

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