Brain Surgery Information:

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CHAPTER 15: THE ENDOVASCULAR SURGICAL PROCEDURE AND EARLY POSTOPERATIVE PERIOD

Just as for the perioperative period, the periinteventional period refers to the few days before and after endovascular treatment of the lesion. The endovascular surgeon will meet with the patient to discuss the benefits, risks, alternatives, team approach and technical and recovery aspects of endovascular surgery. An anesthesiologist may meet with the patient to make sure the patient is medically cleared for the procedure, even if it is not an open surgical one and even if the patient is not required to be in deep anesthesia for the procedure. For some brain lesions being treated with microcoils and/or stents, the endovascular surgeon may make a recommendation for the patient to be placed on some form of blood thinner such as Plavix for the procedure. The rationale for this is that having a blood thinner on board prior to the placement of microcoils and/or a stent will prevent the arteries around the lesion from suddenly blocking off or thrombosing, which can cause a stroke. Thrombosis happens because microcoils and stents are intrinsically thrombogenic in that they slow blood flow around them enough to cause blood to clot. The endovascular surgeon will tell a patient if he or she wants the patient to be “loaded” with a blood thinner before the procedure. The load, if recommended, is usually administered as an oral medication the night before the procedure, but sometimes is administered as an oral or IV medication at the very time of the procedure.

The preinterventional period involves a patient eating and drinking nothing from midnight before the morning of the procedure, and checking with his or her doctor beforehand regarding taking any medications. Most endovascular surgeons will want to carry out such procedures earlier in the day rather than later, and after reporting to the patient registration area of the hospital at the specified time, the patient will be directed to the angiography suite in which the procedure will be carried out.

Generally, endovascular treatment is free of pain. There may or may not be a requirement for deep or general anesthesia, depending on the brain condition, the patient, and the type of endovascular treatment. If no deep anesthesia is required, it is likely that a modified attended anesthesia routine will be used, where oxygen is administered via face mask or nasal cannula and mild IV sedating medications used to make the patient drowsy and settled but still somewhat cooperative. Just as for cerebral angiography (Figure 14), local anesthetic is administered at the catheter entry site typically in the groin region and the thin catheter tubing is advanced painlessly through the aorta and into the arteries of the neck and brain. When the contrast dye is injected into the patient’s circulation through the catheter itself, there may be a warm rushing sensation felt by the patient, but there should be no other significant discomfort. As the dye is injected, the X-ray machines are operative, rapidly taking multiple X-rays and forming a roadmap of the patient’s brain circulation. The lesion is identified, and the microcoil or stent or glue is introduced or deployed through the catheter into the lesion (Figure 27). The lesion is then shut down or occluded, hopefully completely and without complication. The devices are withdrawn and manual pressure is held over the femoral “puncture” site for about 20-30 minutes to allow a suitable clot to form. An arterial closing device may be used instead. The endovascular procedure itself may take anywhere between 1-3 hours. Additional time may be taken for appropriate anesthesia and post-procedural recovery. The patient may be kept flat in bed for about 4-6 hours after the catheter is removed to allow the femoral clot to form, so that no hemorrhage occurs at or from this site. A hemorrhage or hematoma at this site is usually marked by an expanding and often painful thigh clot. The patient should report this to the nursing staff who, in any case, should be checking for its occurrence regularly after the patient returns to Recovery and then the ICU area.

Figure 27 (above). Endovascular coiling and stenting.

Most endovascularly treated patients are taken to the ICU for one night. Many are dismissed from the ICU directly to home the next morning. Exceptions to early dismissal include: (1) A ruptured aneurysm patient, whose postprocedural care may be complex; (2) a patient who suffered a complication during the endovascular procedure; and (3) a patient whose endovascular procedure was the first of a multi-stage treatment plan where, say, the second stage involves open surgery a day or two after the first stage. For most patients who have undergone uncomplicated elective endovascular treatment, the night of the procedure is generally unremarkable. They should be awake, talking and appropriately interactive early after the procedure, and are frequently encouraged to get out of bed to a chair after a brief period of postprocedural bed rest. There is very little by way of pain. The two pain issues are some degree of headache, which is common after coiling of aneurysms particularly in the posterior circulation, and the occurrence of minor thigh aching pain from the puncture site. The endovascular surgeon should make recommendations regarding the treatment of the headache, which usually involves oral medications for a few days. This dull or throbbing headache, if it occurs at all, usually subsides within a few days, and is not like the severe thunderclap headache of aneurysmal rupture. If the latter happens at any time after the procedure, the patient should seek medical attention immediately. Sometimes higher doses of a nonsteroidal anti-inflammatory medication such as Motrin, Advil, or ibuprofen can be used regularly for a few days till the headache subsides, but a patient should check with the endovascular surgeon first. On the day of dismissal, usually the day after the procedure, patients should be given clear contact and followup instructions. If not, they should check with their physician and nursing care givers. It is vital that the patient returns for followup after endovascular treatment of his or her lesion, because there may be a significant chance of the lesion’s recurrence or regrowth depending on its size and/or its degree of obliteration following the initial procedure. The timing of future angiograms should be communicated to the patient before leaving the hospital.