Vascular Surgery and Stroke

[Groy]

My understanding is that vascular surgery focuses on pathologies of the peripheral vasculature. I've specifically read it as "all parts of the vascular system except for heart and brain". Many procedures seem to logically align with this description (AAA, limb ischemia, vasculitis, endarterectomy, venous insufficiency, DVT, etc).

I'm now reading that vascular surgery is regularly involved with stroke assessment and management, and I'm wondering to what extent. The phrase I keep coming across is "extracranial cerebrovsacular disease". I understand carotid endarterectomy for stroke prevention, but surely vascular surgeons aren't assessing for stroke foci and doing neurological examinations are they? Just wondering if anyone has any insights as to this. Thanks!

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[TraumaLlamaMD]

I get consulted frequently on patients with vague neurological symptoms and varying degrees of carotid stenosis. Many people who come in with suspected stroke/TIA symptoms get carotid ultrasounds. All those folks need neuro exams to see if their symptoms match with a carotid origin - my assessment will determine if they are offered surgery or not. In some places, the PMD/neurologist might figure this out before placing a consult, but not always.

 

[TypeADissection]

Ditto above. Any patient that comes in with suspected TIA/CVA will be evaluated by Neuro Stroke. If there is sufficient evidence to warrant an admission, then a carotid duplex and ECHO gets thrown in there as well. Our CT stroke protocol here includes a CTA intra-/extra-cranial if their renal function allows for it. If there is anything >50% stenosis in either carotid, I'm going to get a call to evaluate for CEA/CAS. If they're of low surgical risk and can tolerate GA, then they're getting a CEA. If they have a bad heart that puts them at high risk, they're getting a CAS (either TF or TCAR). We're easily cranking 2-3 carotids here a week on average.

 

[Little Green Mensch]

If they're of low surgical risk and can tolerate GA, then they're getting a CEA. If they have a bad heart that puts them at high risk, they're getting a CAS (either TF or TCAR). We're easily cranking 2-3 carotids here a week on average.

Does your institution ever do CEAs awake?

 

[LucidSplash]

Does your institution ever do CEAs awake?

I’m at a high volume center that does 99% CEAs under block and MAC. The only people who get TF stent are those on trial or bad radiation damage. We aren’t really doing TCAR at this point because if you everyone under block it negates the “high risk” argument.

 

[Jolie South]

I’m at a high volume center that does 99% CEAs under block and MAC. The only people who get TF stent are those trial or bad radiation damage. We aren’t really doing TCAR at this point because if you everyone under block it negates the “high risk” argument.

We try under MAC and block and half the time anesthesia does a **** job with the block and it’s impossible.

Attendings that are tired of anesthesia’s garbage routinely shunt because they don’t want to rely on any one. Shunts only rely on our skills, not anesthesia, not a machine.

We also do a fair number of TF stents. Mostly in reop necks.

 

[TypeADissection]

Does your institution ever do CEAs awake?

No. None of my attendings do them awake and therefore, I don't do any of them awake. All of our TF are done w/ local and w/o sedation. As some of my attendings (and their comfort level w/ me) have become more facile w/ TCARs, we have done a few of them awake. I'll tell you what, I hate it. There is so little of that sheath in the carotid and if patients talk or move it makes me nervous. Having said that, doing a TCAR under GA kind of negates the supposed advantage of doing it since they're already undergoing the risk of anesthesia. I'm still trying to formulate what my own style will be when I'm an attending, and most likely it'll be something very conservative and safe like obligate shunting on everybody w/ neuro monitoring + TCDs + the sterile magic monkey that climbs out of his cage to get that perfect feathered distal endpoint for you. Cheers.

 

[filter07]

We do CEA with regional anesthesia and MAC for most cases. Took some getting used to but it works well most times. Stents only for high bifurcation, maybe re-operative neck. I have done CEA without problems on irradiated necks as long as the disease is accessible and they can turn their neck. The scarring hasn't been that bad in my experience. We haven't done TCAR but we will as soon as the VQI requirements are met, and I see TCAR replacing the bulk of stenting and even some CEA. I shunt selectively because we have the benefit of doing CEA awake.

 

[deleted745951]

Tangential here, is vascular involved with ECMO at all in your respective institutions? It seems like it's well within the skill set learned in the specialty.

 

[LucidSplash]

Tangential here, is vascular involved with ECMO at all in your respective institutions? It seems like it's well within the skill set learned in the specialty.

Where I am, we’re only involved for complications and sometimes for assistance decannulating.

For example tonight consulted for a cold leg in a guy on ECMO for massive PE; ischemia in the leg with the arterial cannula. On 3 pressors. Not much I can do about it and they (CT surg) know it, it’s just a consult to cross the T and for the i. Recommend placing an antegrade distal perfusion sheath, wean pressors as tolerated, remove ECMO cannula when able.

I’ve also done some bedside fasciotomies for ECMO patients. It’s not a lot of fun.

But otherwise we don’t get involved much.

 

[Jolie South]

Tangential here, is vascular involved with ECMO at all in your respective institutions? It seems like it's well within the skill set learned in the specialty.

We only get involved for exceptional circumstances. My institution only does V-V with IJ approach when possible so our involvement is minimal.

 

[deleted745951]

Thank you for the responses docs!

 

[deleted745951]

Addendum:

Would I be able to get ECMO privileges as a vascular or trauma surgeon?

 

[LucidSplash]

Addendum:

Would I be able to get ECMO privileges as a vascular or trauma surgeon?

Why would you want it as vascular, we don’t manage it really.

One of my trauma/SCC attendings got ECMO certified and thereafter all the fellows did to, for selective use in patients with bad ARDS. So yes you can as critical care.

 

[Jolie South]

Addendum:

Would I be able to get ECMO privileges as a vascular or trauma surgeon?

At where I did fellowship, that was a trauma/critical care thing.