Carotid Artery Disease: treatment

and post-operative care

Jennifer Heise, APN, FNP-BCSeptember 12, 2015

Let’s introduce ourselves…

QUESTION???

Do you like Gray’s Anatomy?

QUESTION???

Did you think I was asking about the television

show?

Learning Objectives

• Review carotid vasculature anatomy • Identify the role of atherosclerosis in carotid

artery disease• Discuss treatment of carotid atherosclerosis– Carotid Endarterectomy (CEA)– Carotid Artery Stenting (CAS)

• Describe nursing management and care for patients pre and post procedure

Carotid Arteries

Carotid arteries

Carotid Artery Disease

• 90% of all extracranial carotid lesions are caused by atherosclerosis

• 10% are caused by:– Fibromuscular dysplasia– Radiation– Takayasu’s arteritis– Carotid artery dissection– Injury

QUESTION???

What are some common risk factors for

atherosclerosis?

Risk Factors for Atherosclerosis

• Diabetes• Tobacco use• Hypertension• Hypercholesterolemia• Family history

Atherosclerosis

• Hardening of an artery due to plaque build up• Complex process, begins at cellular level,

inflammatory process, not fully understood• Chronic, progressive, asymptomatic for years• Stable plaques become unstable, separate

from arterial lumen and rupture

Atherosclerosis

Atherosclerosis

• Plaques can eventually cause stenosis, thrombosis or embolization

• Cause of strokes, myocardial infarctions, extremity arterial occlusive disease

• Most common cause of death in U.S.• Atherosclerosis is the most common

contributing factor for stroke

Carotid Atherosclerosis

Primary Goal of Treatment of Carotid Atherosclerosis is:

Stroke prevention

Patient Evaluation

• Asymptomatic– Plaque may build slowly– Found incidentally– Eventually 3-5% per year become symptomatic

• Symptomatic– Symptoms <24 hours = Transient Ischemic Attack

(TIA)– Symptoms >24 hours = stroke

Patient Evaluation

• Patient history– Neurological changes– Timing of events, duration, frequency– Risk factors

Patient Evaluation

• Patient physical exam– Neurological exam– Temporal artery/carotid artery: pulses, bruits– Cardiac exam– Extremities

Purpose of thorough evaluation:

• Looking for clues or signs of atherosclerosis• Establish

baseline neuro status

Diagnostic Examinations

• Carotid artery ultrasound: shows structural details of carotid arteries, blood clots, and atherosclerotic plaque

• Carotid artery duplex ultrasound: combines standard ultrasound with doppler flow information to show how blood is flowing through the vessels and measures the speed of the flow of the blood.

Carotid artery duplex

ultrasound

MagneticResonance

Imaging

QMRA: Quantitative MRA

Interventions

Carotid Artery Endarterectomy (CEA)Carotid Artery Stenting (CAS)

QUESTION???

Which procedure do you see more in your practice?

Carotid EndarterectomyCarotid Artery Stenting

Carotid Endarterectomy (CEA)

• Most frequently performed non-cardiac vascular surgical procedure in US

• Goal: prevent stroke• First recorded case 1954, safe, lasting• Large studies have shown significant benefit of CEA

if >70% stenosis and symptomatic– CEA is recommended for symptomatic patients with

>50% stenosis– CEA is recommended for asymptomatic patients with

>60% stenosis

Carotid Endarterectomy (CEA)

• Contraindicated: – High surgical risk-general anesthesia– Co-morbidities– Acute major stroke– History severe stroke

Carotid Endarterectomy (CEA)

Carotid Endarterectomy (CEA)Eversion technique

Carotid Endarterectomy (CEA)Transverse Incision

Carotid Artery Stenting (CAS)

• Minimally invasive-endovascular• Goal: prevent stroke• Conscious sedation/local anesthesia• Indications– Unable to tolerate general anesthesia– Previous CEA or neck surgery– Irradiation– Re-stenosis after CEA– High lesions

Carotid Artery Stenting (CAS)

• Contraindications:– Allergy to IV contrast-manageable if

pre-medicated– Unfavorable anatomy– Unstable carotid plaque– Unstable aortic arch plaque– Poor renal function

Carotid Artery Stenting (CAS)

(Medscape.com)

Carotid Artery Stenting (CAS)

(Medscape.com)

Patient Education is Key

Patient education

• Pre-op– Carotid artery disease is result of atherosclerosis– CEA is surgical procedure to remove plaque from

carotid artery to prevent stroke– CAS is minimally invasive, angioplasty/stent to

prevent stroke – MD/APN to explain risks/benefits– Discuss pre/post op routines– Assess neuro status

Patient care: pre-op CEA

• Patient education• Labs: CBC, CMP, PT/INR• CXR, EKG• Consider cardiac clearance• NPO after midnight• Baseline neuro exam, (cranial nerve assessment)

Patient care: post-op CEA

• Admit-step down unit• Vital signs per routine-call MD for abnormals• Neuro exam, including cranial nerves

• every 4 hours for 24 hours• Routine nursing neuro check

– Alert/oriented/speech clear/swallow –gag reflex– Pupils– Visual fields– Smile, frown, stick tongue out– Shoulder shrug, motor drift, hand grasps

• Diet– Advance diet as tolerated (4 hours post-op)

Patient care: post-op CEA

• Nursing interventions– Ice to incision, 20 minutes/hour, PRN– Keep dressing in place, will be changed by MD– Foley catheter (rarely ordered)-discontinue in

PACU, post-op, midnight– No labs/tests unless ordered by vascular surgeon– HOB to 30 degrees

Patient care: post-op CEA

• Medications– IV fluids– Aspirin suppository, 300mg, rectal, once, PACU– Aspirin 325 mg, oral, daily, starting post-op day 1– Labetalol, hydralazine, clonidine, nitroprusside prn

to help maintain systolic BP <140– Prophylactic antibiotics (ancef, vanco, cleocin)– Antiemetics (zofran, reglan, nausea protocol)

Patient care: post-op CEA

• Pain management– No narcotics/sedatives/sleeping agents– Acetaminophen

• VTE prophylaxis– SCDs– Do not give chemoprophylaxis due to high risk of

bleeding- (no Lovenox or heparin)• Activity– Bedrest, or bedrest with bathroom privileges– Ambulate TID, starting post-op day 1

Patient education: post-op CEA

• Post-op– Activity: return to normal activity as tolerated– No heavy lifting >10 pounds for 1 month– May shower 2-3 days post op, cleanse incision

gently with mild soap/water, pat dry– Bruising and minimal swelling is normal– Men should shave gently with electric razor until

swelling decreases, numbness is common– May drive when able to turn neck freely

Patient education: post-op CEA

• Notify MD of any new or recurrent symptoms– Swallowing/breathing issues– Unusual redness/swelling– Temperature over 100.5– Sudden weakness, numbness of one side

• Follow up:– 2 weeks-MD visit (no scan- too tender)– 6 weeks-US duplex scan– 6 months-US duplex scan– Every 6-12 months

Patient education: post-op CEA

• Medications– Aspirin-enteric coated- 81 mg daily– Acetaminophen 500 mg 1-2 tabs every 4 hours as

needed for pain

Patient care: pre-op CAS

• Patient education• Consent: Cerebral angiogram with possible

stenting of carotid artery stenosis• Labs: CBC, BMP, PT/INR• CXR, EKG• Consider cardiac clearance• NPO after midnight• NIH stroke scale (pre-procedure and prior to

discharge)

Patient care: pre-op CAS

• Aspirin and Plavix for 5-7 days prior• P2y12 function (Plavix) and aspirin function

levels• Hold betablockers for 2 days prior• Hold proton pump inhibitors-start H2 blockers• Space timing of Plavix and statin therapy

Patient care: post-op CAS

• Outpatient: If diagnostic cerebral angiogram only, asymptomatic, low grade stenosis, and low risk for stroke

• Admit to ICU: if stent placed (if symptomatic, and greater than 80% stenosis)

• Discharge post-op day one from ICU

Patient care: post-op CAS

• Vital signs per routine-call MD if abnormal• Routine neuro exam (NIH at discharge)• Groin access site care– Femstop/leg immobilizer, frequent groin checks

• Ambulate after groin is stable• Regular heart healthy diet

Patient care: post-op CAS

• Medications– Aspirin for life, 81mg or 325mg– Plavix for minimum of 6 months

• Follow up:– 30 days-US carotids– 5-6 months-US carotids and QMRA– Annually- US carotids and QMRA

Post-op complicationsfor CEA or CAS

• Perioperative stroke– Embolization of atheromatous debris or low blood

flow– Surgeon will assess in OR and PACU– Be aware of neuro changes, Code BAT

• Hypertension/hypotension– Hypertension can threaten arterial anastomosis– Hypotension can cause thrombosis– Either can complicate existing cardiac issues

Post-op complicationsfor CEA or CAS

• Hyperperfusion syndrome– Rare– Can occur 2-3 days post-op– Severe unilateral headache, seizure, stroke– Due to increased blood pressure in brain

capillaries because vessels have chronically lost the ability to autoregulate and vasoconstrict

Post-op complicationsfor CEA or CAS

• Cranial nerve injury (CEA)– May have decreased sensation or movement– Can be misinterpreted as a stroke– Caused by traction during surgery or accidental

transection– Most injuries resolve with time

Post-op complicationsfor CEA or CAS

• Groin site complications (CAS)• Hematoma/respiratory distress (CEA)– Wound complications are infrequent– Bleeding and wound hematoma could

compromise airway, cause tracheal compression– Possible return to surgery, drain placement

QUESTION???

What would be the MOST important assessment finding to notify the provider about post procedure?A. Slight oozing at incision/groin siteB. Complaints of hungerC. Hypo/hypertensionD. Pain at incision/groin site

Post-procedure

Patient education• Risk factor reduction– Diet: Low fat/low cholesterol diet– Smoking: accelerates atherosclerosis, increases

blood pressure, and decreases heart rate– Hypertension: resume previous blood pressure

medications, follow up regularly with primary MD or cardiologist

• Notify MD of any new or recurrent symptoms• Attend follow up visits and repeat duplex scans

QUESTION???

What acronym do we use to teach the public to recognize signs of stroke?A. PASSB. RACEC. FASTD. RICE

Neuro assessment-cranial nerves

• Alert/oriented/speech clear/swallow-gag reflex

• Pupils: PEARL, EOM• Visual fields• Smile, frown, stick tongue out• Shoulder shrug, motor drift, hand grasps

Cranial Nerves in Relation to Carotid Artery

Neuro assessment post CEA:Pupils- CN III, IV, VI

Pupils: PEARL Extraocular movements: EOM

Neuro assessment post CEA:Visual fields and facial symmetry-

CN II, III, IV, V, VII, XIIVisual fields Facial symmetry

Neuro assessment post CEA:Accessory -CN XI

Shoulder shrug Motor drift

Summary of cranial nerves• I - Smell • II - Visual acuity, visual fields and ocular fundi • II,III - Pupillary reactions • III,IV,VI - Extra-ocular movements, including opening of the eyes • V - Facial sensation, movements of the jaw, and corneal reflexes • VII - Facial movements and gustation • VIII - Hearing and balance • IX,X - Swallowing, elevation of the palate, gag reflex and gustation • V,VII,X,XII - Voice and speech • XI - Shrugging the shoulders and turning the head • XII - Movement and protrusion of tongue

CEA vs CAS?

• CEA-has been standard of care for significant carotid artery disease

• CAS-less invasive alternative• SAPPHIRE trial proved the noninferiority of CAS vs.

CEA in high-risk patients with carotid artery disease.• CREST trial showed no significant differences in

death, stroke or MI• Rates of CAS are slowly increasing with

improvements in technology and experience

Interesting thought…???

• Are CEA and CAS even necessary?• Perhaps, asymptomatic carotid artery

disease can be effectively treated with current pharmacologic guideline driven treatments for HTN, hyperlipidemia, diabetes and smoking cessation.

• Announcing CREST-2: stay tuned!• http://www.crest2trial.org/

QUESTIONS?

jennifer.heise@cadencehealth.org

References

• Assessment: Musculoskeletal and neurologic. (2006-2013). Mosby’s Skills. St. Louis,

MO:Elsevier• Fahey, Victoria. (2004). Vascular nursing. St.

Louis, MO: Saunders. • www.medscape.com• www.svnnet.org • www.vascularweb.org• Gray’s Anatomy

References

• Bates ER, Babb JD, Casey DE, Cates CU, Duckwiler GR, Feldman TE, Gray WA, Ouriel K, Peterson ED, Rosenfield K, Rundback JH, Safian RD, Sloan MA, White CJ. ACCF/SCAI/SVMB/SIR/ASITN 2007 clinical expert consensus document on carotid stenting: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (ACCF/SCAI/SVMB/SIR/ASITN Clinical Expert Consensus DocumentCommittee on Carotid Stenting). J Am Coll Cardiol 2007;49:126 –70.