Towards Short Stay Carotid Endarterectomy

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Towards Short Stay Carotid Endarterectomy?

• Louis FligelstoneRachel Havard, Ganeshen
  Chinien, Nicola Power,
• Swansea Vascular Unit

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Background

• Stroke has become the 3rd leading cause of death
  in developed countries following heart disease
  and cancer.
• Every year in the UK, carotid artery occlusive
  disease kills 1 in 100 of the population aged
  more than 75 yrs.

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Background

• NASCET and ECST trials showed that CEA is of
  proven benefit in symptomatic patients with
  severe (70-90)stenosis and even with
  moderate(50-69) stenosis.
• ACAS group has suggested that CEA may be
  beneficial in asymptomatic patients with 60
  stenosis.

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ACST

• ACST CEA beneficial
• 70 stenosis
• Age lt75yrs
• Comorbidity allowing
• Surgical results allowing

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Carotid Endarterectomy

• First CEA performed
• ? Felix Eastcott - St Marys Hospital in UK in
  1954.
• ? William DeBakey Baylor Medical College/Texas
  Heart Institute 1953
• Traditionally
• GA
• Catheterisation, arterial line, use of drains
• ITU/HDU post-operatively for 24 hours
• Discharge 24 hours after drain removal

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NHS Pressures

• HDU/ITU bed crisis
• Ward bed reductions
• Need to develop integrated care pathways

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Study

• Determine if short stay CEA is feasible
• Procedure general or local anaesthesia
• Whether there is need for HDU/ITU, if prolonged
  stay in recovery
• Avoid use of drains
• Avoid use of catheters

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Theatre set up
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Exposure of Vessels
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Mobilising Atheromatous Plaque
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Endarterectomy completed
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Skin Closure(subcuticular monocryl suture)
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Training Unaffected
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Happy Grateful Patient
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Methods

• Retrospective study reviewing patients undergoing
  CEA from October 2004 to November 2005 under 1
  surgeon.
• Patients assessed in clinic and offered options
  of regional or general anaesthetics.
• Continue all antiplatelet therapy
  perioperatively.
• Explain likely early discharge.

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Methods

• Standard local practice - patient admitted day
  before surgery for Duplex assessment marking
• CEA next day GA/LA standard techniques
• Patient observed closely for 2 hrs in recovery.
• If stable , transferred to ward otherwise
  HDU/ITU.
• Patient discharged following day if appropriate.

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Results

• Sample size 38
• Male Female 27 11
• Average age 70 ( 49 to 86)
• LA GA 1721.

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Indications
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Co morbidity
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ASA class
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Antiplatelet / Anticoagulant Therapy
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Results

• Shunt insertion 6 GA, 1 LA
• 35 patients had angioscopy (3 cases not
  documented).
• 6 patients were catheterised GA group
• 6 patients had drain inserted.

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Results

• Planned length of stay in recovery is 2 hrs
• 2.0 hrs in LA group
• 1.9 hrs in GA group.
• Average length of stay for all patients was 2.5
  days.
• Length of stay in regional anaesthesia group was
  2.0 days.
• Length of stay in general anaesthesia group was
  2.8 days.

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Events In Recovery

• 10 patient events in recovery.
• Hypertension- 3 patients.
• Hypotension-2 patients.
• Transient neurological deficit-2 patients
• Cranial nerve traction injury
• Temporary worsening of weakness from previous
  stroke
• Haematoma-1 patient.
• Confusion- 1 patient
• Shortness of breath- 1 patient.

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HDU

• 3 patients were admitted to HDU
• One planned - Previous MI and stroke
• 2 Unexpected
• Hypotension
• Observation for labile blood pressure.

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Conclusion Future Plans

• Safe feasible technique
• Increased confidence should lead to shorter stays
• Admit on day of surgery
• Duplex on day of surgery
• Feasibility of 23 hour stay CEA for the majority
  of patients
• Refinement of ICP

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End