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Management of the Endovascular Patient and Acute Emergencies in the Angio Suite
June 9, 2015
Bridget Cantrell, APN, CNP
Endovascular Neurosurgery
Advocate Medical Group
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No Disclosures
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The human brain is estimated to have about a hundred billion nerve cells, two million miles of axons, and a million billion synapses, making it the most complex structure, natural or artificial, on earth. – Tim Green, Stephan F. Heinemann and
Jim F. Gusella (from a paper in Neuron, vol. 420, p. 427, 1998)
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Peri-Procedural Complications
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Getting to know one another…. Pre-procedural considerationsMedical, surgical, and social history
-Medication or contrast allergies
-Anxiety, coping capabilities
-Elective vs. emergent procedure
-Sedation/anesthesia considerations
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• Sedation/anesthesia considerations– Primary goals of sedation in the interventional
suite. 1. Provide to the patient the level of sedation that
provides them comfort but that permits prompt neurological assessment when needed.
2. Render the patient physiologically stable and immobile.
3. Manipulate systemic blood pressure optimally as dictating by needs of procedure.
4. Provide emergent management in catastrophic complications.
(Management of Therapeutic Interventional Procedures, 2010)
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-Comorbidities
-Cardiac : rhythm, rate, blood pressure
-Kidney function: elevated serum creatinine (1.5 mg/dl or greater) or estimated glomerular filtration rate (60mL/1.73m2)
Acetylcysteine (Mucomyst) – is a thiol compound with antioxidant and vasodilatory properties. Since agent is potentially beneficial, well tolerated, and relatively inexpensive is often administered to high risk patients. The American College of Cardiology/American Heart Association do not recommend as it is an unproven therapy.
If there are no contraindications to volume expansion, isotonic intravenous fluids prior to and continued for several hours after contrast administration is recommended (Grade 1B).
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-Comorbidities
-Skin: breakdown, positioning
-Chronic pain: positioning, sedation
-Vascular: pedal pulses pre and post
-Informed consent
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“The brain is a monstrous, beautiful mess.” -William F. Allman, Apprentices of Wonder: Inside the Neural Network Revolution
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Intra- procedure complications
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D.D. , 70 year old Caucasian male
PMH: CAD, CVA (with residual aphasia and right sided weakness), seizure disorder, DM, HTN, HLD, dementia
PSH: CABG (on Aspirin and Coumadin)
Allergy: Simvastatin
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CT head demonstrated extensive SAH with moderate hydrocephalus.
CTA brain demonstrated an irregular, wide neck 5mm aneurysm arising from the right lateral wall of the proximal basilar artery.
Exam: Drowsy, orientated x 2, follows commands,
4/5 motor on right, 5/5 motor on left. Hunt Hess 1
Cerebral angiogram confirmed CTA finding with a severe focal stenosis of the V4 vertebral artery just proximal to the aneurysm.
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.
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Anticipate potential problemsKept patient intubated, EVD was placed
Plavix 300mg per ng and Aspirin 300mg suppository
Informed consent with family
In order to access and treat aneurysm, the proximal stenosis was treated with placement of 3mm x 8mm balloon mounted stent
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Intra-procedure rupture• Reversal of heparin (Protamine 1mg for every
100 unit of Heparin)• Coils/embolization glue• EVD open, EVD placement• Mannitol (Osmitrol)- osmatic diuretic, not
compatible with most other medications, use IV filter, can cause renal failure if dehydration status persists, know dosage
• Hypertonic saline, osmotic agent
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Intra-procedure ruptureAneurysm was treated immediately with stent assisted coil embolization.
CT head post procedure demonstrated increased subarachnoid hemorrhage.
Post procedure, patient not responsive, withdrawing all extremities
EVD clotted a few hours post procedure
Withdrew care and patient expired 3 days later
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R.A., 44 year old Caucasian maleNo medical or surgical history
Presented with severe headache and photophobia
CT head demonstrated subarachnoid hemorrhage
Hunt Hess 1
CTA head demonstrated 3.5mm anterior communicating artery aneurysm
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Thrombus formation• ReaPro (Abciximab) - platelet aggregation
inhibitor, bolus intra-procedure 0.25mg/kg, followed by infusion post CT head 0.125ug/kg/min
• Heparin – anticoagulant, dosage per physician, IA bolus or infusion
• Mechanical thrombectomy
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Coil Migration• Reapro or Heparin bolus• Snare devices• Potential stenting (Aspirin and Plavix
considerations)
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Vessel dissection• Heparin infusion• Possible stenting• Initiate Aspirin therapy
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Post procedure complications• Femoral hematoma
– Apply manual pressure– Monitor vital signs– Outline with marker and monitor for progression– Strict bed rest– Notify physician– Can form immediately, hours, or days later
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• Femoral pseudo aneurysm – Is a bleeding track into the tissue with flow– Pulsatile mass, +thrill/bruit, pain, diagnosed with
ultrasound– Can rupture, cause nerve compression and
damage– Management similar to hematoma but can
require thrombin injection, surgical repair
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• Femoral occlusion– Assess vitals, distal pulses, color/temperature of
extremity– Surgical intervention
• Retroperitoneal hemorrhage– Hypotension, tachycardia, pallor, abdominal/low
back/pelvic pain, decrease in Hgb(rapid), anxious– Hold pressure, CT abdomen, transfusion, fluid
resuscitation
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• Hemorrhagic conversion– Blood pressure control– Monitor for cerebral edema
• Infection– Sterile techniques, groin care providing
instructions upon discharge
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Post procedure considerations• Blood pressure control
– Goals of therapy
• Swallow evaluation– Place NG for medications if not completed– Start nutrition within 24 hours
• Emotional support– Patient and family education
• Follow up
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