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IP101. Routine Postoperative Cardiac Testing Is Unnecessary Following Carotid Endarterectomy
JOURNAL OF VASCULAR SURGERY June Supplement 2016
88S Abstracts
internal carotid artery (ICA) and degree of carotid stenosis using Doppler ultrasound. Methods: Patients (n ¼ 30) with suspected or previously diagnosed carotid stenosis underwent duplex ultrasounds using a Philips iU22 ultrasound module and a 9-3 MHz probe. A total of 34 carotid studies were analyzed, of which 19 were diseased and 15 were normal. Color Doppler cine loops of the internal carotid artery were recorded and analyzed off-line using customized algorithms written in IDL, a data visualization programming language. The Doppler flow at individual pixels in the image was used to calculate the area of reverse flow (% ARF), reverse mean velocity (RMV), and turbulent flow volume (TFV ¼ %ARF RMV). Results: The TFV correlated with percent stenosis. Diseased ICAs have significantly higher TFV than normal ICAs (P ¼ .0038 by two-tailed t-test; Fig, A). In addition, the post-stenotic TFV correlated with peak systolic velocity (R ¼ 0.47) in the ICA (Fig, B). Conclusions: Duplex imaging and easily implemented computerized image analysis can measure carotid turbulence. These measures correlate with PSV and segregate between normal and diseased carotid arteries in human subjects. This turbulence imaging may allow risk stratification (respective to stroke) of patients with asymptomatic carotid stenosis and may better predict progression of disease. A larger study in patients with both asymptomatic and symptomatic disease is underway and will elucidate the utility of this imaging technique.
Results: The mean age of patients undergoing CEA was 70.9 years (range, 49-89), and 61% were male. Preoperatively, 58% were on b-blocker therapy, 84% on aspirin, 50% were taking both, and 83% were on statin therapy. A total of 19% had prior history of MI; of those, 47% occurred within the last 5 years. A total of 46% of patients had a prior coronary intervention (18% percutaneous, 28% CABG, 8% both). All patients received general anesthesia. A total of 78% of the cases were performed electively. The mean procedure time was 134 minutes (range, 69-258). The mean postoperative length of stay was 2.4 days overall and 1.6 days for the elective procedures. All patients received postoperative cardiac evaluation, including troponin-I and CK-MB. A total of 2% of the patients were judged to have an acute MI; one of which was symptomatic. The asymptomatic patient had a peak troponin-I of 0.52 ng/mL and CK-MB of 14.1 ng/mL. The symptomatic patient had chest pain and bradycardia. The peak troponin-I was 1.59 ng/mL, with CK-MB 11.5 ng/mL. Both patients were treated medically. The cost per troponin-I and CK-MB is $27.78 and $31.44, respectively, in our institution. We estimate that eliminating routine postoperative troponin-I and CK-MB testing alone in postoperative CEA patients would save an estimated $17,766 over the course of the studied population. Conclusions: Routine postoperative MI testing in asymptomatic patients after CEA increases hospital cost without significant benefit. Postoperative cardiac workup is best reserved for symptomatic patients or those with clinical suspicion for myocardial event.
Author Disclosures: J. Davis: Nothing to disclose; R. M. Fairman: Nothing to disclose; P. Foley: Nothing to disclose; J. D. Glaser: Nothing to disclose; B. M. Jackson: Nothing to disclose; K. Koons: Nothing to disclose; C. Sehgal: Nothing to disclose; G. J. Wang: Nothing to disclose.
Author Disclosures: A. Amira: Nothing to disclose; M. R. D’Alessandro: Nothing to disclose; J. Deitch: Nothing to disclose; J. Schor: Nothing to disclose; K. Singh: Nothing to disclose; A. C. Tyson: Nothing to disclose; S. Zia: Nothing to disclose.
IP101.
IP103.
Routine Postoperative Cardiac Testing Is Unnecessary Following Carotid Endarterectomy Arthelma C. Tyson, MD, Alkhatib Amira, BS, Matthew R. D’Alessandro, DO, Kuldeep Singh, MD, Saqib Zia, MBBS, Jonathan Schor, MD, Jonathan Deitch, MD. Staten Island University Hospital, Staten Island, NY
Endovascular Treatment for Carotid Hemorrhage Secondary to Head and Neck Cancer Erosion Michael Silva, MD, Jennifer Worsham, MD, Charlie Cheng, MD, Zulfiqar Cheema, MD, PhD, Grant Fankhauser, MD. University of Texas Medical Branch, Galveston, Tex
Objectives: Routine laboratory testing to rule out myocardial infarction (MI) after carotid endarterectomy (CEA) is associated with increased cost and is performed in many centers. The utility of routine laboratory testing in this patient population has not been thoroughly investigated. We hypothesize that routine laboratory testing for MI in asymptomatic patients is low-yield and not cost effective. Methods: A retrospective chart review of 101 consecutive CEAs from February 2014 to July 2015 was performed. One patient underwent combined CEA/CABG and was excluded. Patient demographics, medications, medical history, type of anesthesia, and postoperative laboratory results were evaluated. Consistent with the institutional practice, all patients had postoperative cardiac evaluation performed in the immediate postoperative period, including laboratory testing for troponin-I and CK-MB. A patient was judged to have an MI if troponin-I was >0.5 ng/mL, CK-MB was >6.3 ng/mL, and if there were changes on electrocardiogram or echocardiography. The incidence of postoperative MI was recorded and a cost analysis performed.
Objectives: Carotid artery hemorrhage secondary to head and neck tumor invasion and arterial erosion entails significant morbidity and mortality. It is particularly challenging to establish proximal and distal control during open surgical repair while preventing stroke. Endovascular approaches to treatment have increasingly become more used, although further assessment is necessary to not only qualify these interventions but also evaluate their long-term efficacy. Methods: We reviewed our experience with endovascular management of oncologic carotid hemorrhage. Selective arteriogram confirmed extravasation from external or common carotid artery branches. This was controlled with coil embolization and/or covered stent placement using embolic protection devices. Eight cases are reported with outcomes. Technical challenges associated with coil embolization and stent graft placement are outlined as well. Results: Of the eight cases reviewed, we had 100% technical success in placing endovascular coils (6 patients) and stent grafts (7 patients). One patient had asymptomatic,
88S Abstracts
internal carotid artery (ICA) and degree of carotid stenosis using Doppler ultrasound. Methods: Patients (n ¼ 30) with suspected or previously diagnosed carotid stenosis underwent duplex ultrasounds using a Philips iU22 ultrasound module and a 9-3 MHz probe. A total of 34 carotid studies were analyzed, of which 19 were diseased and 15 were normal. Color Doppler cine loops of the internal carotid artery were recorded and analyzed off-line using customized algorithms written in IDL, a data visualization programming language. The Doppler flow at individual pixels in the image was used to calculate the area of reverse flow (% ARF), reverse mean velocity (RMV), and turbulent flow volume (TFV ¼ %ARF RMV). Results: The TFV correlated with percent stenosis. Diseased ICAs have significantly higher TFV than normal ICAs (P ¼ .0038 by two-tailed t-test; Fig, A). In addition, the post-stenotic TFV correlated with peak systolic velocity (R ¼ 0.47) in the ICA (Fig, B). Conclusions: Duplex imaging and easily implemented computerized image analysis can measure carotid turbulence. These measures correlate with PSV and segregate between normal and diseased carotid arteries in human subjects. This turbulence imaging may allow risk stratification (respective to stroke) of patients with asymptomatic carotid stenosis and may better predict progression of disease. A larger study in patients with both asymptomatic and symptomatic disease is underway and will elucidate the utility of this imaging technique.
Results: The mean age of patients undergoing CEA was 70.9 years (range, 49-89), and 61% were male. Preoperatively, 58% were on b-blocker therapy, 84% on aspirin, 50% were taking both, and 83% were on statin therapy. A total of 19% had prior history of MI; of those, 47% occurred within the last 5 years. A total of 46% of patients had a prior coronary intervention (18% percutaneous, 28% CABG, 8% both). All patients received general anesthesia. A total of 78% of the cases were performed electively. The mean procedure time was 134 minutes (range, 69-258). The mean postoperative length of stay was 2.4 days overall and 1.6 days for the elective procedures. All patients received postoperative cardiac evaluation, including troponin-I and CK-MB. A total of 2% of the patients were judged to have an acute MI; one of which was symptomatic. The asymptomatic patient had a peak troponin-I of 0.52 ng/mL and CK-MB of 14.1 ng/mL. The symptomatic patient had chest pain and bradycardia. The peak troponin-I was 1.59 ng/mL, with CK-MB 11.5 ng/mL. Both patients were treated medically. The cost per troponin-I and CK-MB is $27.78 and $31.44, respectively, in our institution. We estimate that eliminating routine postoperative troponin-I and CK-MB testing alone in postoperative CEA patients would save an estimated $17,766 over the course of the studied population. Conclusions: Routine postoperative MI testing in asymptomatic patients after CEA increases hospital cost without significant benefit. Postoperative cardiac workup is best reserved for symptomatic patients or those with clinical suspicion for myocardial event.
Author Disclosures: J. Davis: Nothing to disclose; R. M. Fairman: Nothing to disclose; P. Foley: Nothing to disclose; J. D. Glaser: Nothing to disclose; B. M. Jackson: Nothing to disclose; K. Koons: Nothing to disclose; C. Sehgal: Nothing to disclose; G. J. Wang: Nothing to disclose.
Author Disclosures: A. Amira: Nothing to disclose; M. R. D’Alessandro: Nothing to disclose; J. Deitch: Nothing to disclose; J. Schor: Nothing to disclose; K. Singh: Nothing to disclose; A. C. Tyson: Nothing to disclose; S. Zia: Nothing to disclose.
IP101.
IP103.
Routine Postoperative Cardiac Testing Is Unnecessary Following Carotid Endarterectomy Arthelma C. Tyson, MD, Alkhatib Amira, BS, Matthew R. D’Alessandro, DO, Kuldeep Singh, MD, Saqib Zia, MBBS, Jonathan Schor, MD, Jonathan Deitch, MD. Staten Island University Hospital, Staten Island, NY
Endovascular Treatment for Carotid Hemorrhage Secondary to Head and Neck Cancer Erosion Michael Silva, MD, Jennifer Worsham, MD, Charlie Cheng, MD, Zulfiqar Cheema, MD, PhD, Grant Fankhauser, MD. University of Texas Medical Branch, Galveston, Tex
Objectives: Routine laboratory testing to rule out myocardial infarction (MI) after carotid endarterectomy (CEA) is associated with increased cost and is performed in many centers. The utility of routine laboratory testing in this patient population has not been thoroughly investigated. We hypothesize that routine laboratory testing for MI in asymptomatic patients is low-yield and not cost effective. Methods: A retrospective chart review of 101 consecutive CEAs from February 2014 to July 2015 was performed. One patient underwent combined CEA/CABG and was excluded. Patient demographics, medications, medical history, type of anesthesia, and postoperative laboratory results were evaluated. Consistent with the institutional practice, all patients had postoperative cardiac evaluation performed in the immediate postoperative period, including laboratory testing for troponin-I and CK-MB. A patient was judged to have an MI if troponin-I was >0.5 ng/mL, CK-MB was >6.3 ng/mL, and if there were changes on electrocardiogram or echocardiography. The incidence of postoperative MI was recorded and a cost analysis performed.
Objectives: Carotid artery hemorrhage secondary to head and neck tumor invasion and arterial erosion entails significant morbidity and mortality. It is particularly challenging to establish proximal and distal control during open surgical repair while preventing stroke. Endovascular approaches to treatment have increasingly become more used, although further assessment is necessary to not only qualify these interventions but also evaluate their long-term efficacy. Methods: We reviewed our experience with endovascular management of oncologic carotid hemorrhage. Selective arteriogram confirmed extravasation from external or common carotid artery branches. This was controlled with coil embolization and/or covered stent placement using embolic protection devices. Eight cases are reported with outcomes. Technical challenges associated with coil embolization and stent graft placement are outlined as well. Results: Of the eight cases reviewed, we had 100% technical success in placing endovascular coils (6 patients) and stent grafts (7 patients). One patient had asymptomatic,