Larry King Recovers from Cartoid Surgery

When it rains, it pours. And this week it was pouring 70-something talk show hosts with serious vascular issues. First Regis and now Larry King. Charles Grodin and Charlie Rose better pack a bag.

While Reege is hopefully thinking about discharge, the 73 yo King is fresh out of a carotid endarterectomy (CEA) and his camp says he'll be back by Monday to interview Sen. Barack Hussein Obama (that name is like a SNL joke - he couldn't have worse luck if his name was Stalin Bitler).

Larry King is no stranger to vasculopathy and has a history of 4-vessel CABG way back in 1987. Which also implies that he has probably had subsequent cardiac caths to open of some grafts or possibly even an ancient native vessel. King's propensity for vascular disease makes one wonder what risk factors he wields.

It is very likely he is hypertensive and most certainly takes a statin for high cholesterol. Is he diabetic, too? Probably not - all those years of poorly controlled blood pressure, cigarettes, drugs?, and booze is most certainly enough to give you the old coronary-carotid double feature.

Prior to surgery King definitely had a carotid ultrasound to assess the degree of stenosis. The question is, did symptoms prompt this vascular study or was it a smart doc who knew the talk show host's propensity for vascular atherosclerosis? Either way, he had enough of a lesion to dictate that medical therapy, compared with surgical revascularization, would be more likely to result in a stroke or even death.

What about his outcome? Well, all of the following characteristics have been associated with an increased risk of poor outcome (stroke, myocardial infarction, or death) at 30 days after CEA:

• Age 80 or older
• Severe heart disease
• Severe pulmonary dysfunction
• Renal insufficiency or failure
• Stroke as the indication for endarterectomy
• Anatomical issues including limited surgical access, prior cervical irradiation, prior ipsilateral CEA, and contralateral carotid occlusion

Surgical Methods

Carotid endarterectomy (CEA) is most often done through a neck incision either bordering the sternocleidomastoid muscle, or more esthetically, with a horizontal incision in a skin crease at the level of carotid bulb. Either way, the scar will be small and discrete enough to be covered by a good layer of pancake, so don't expect to see it on Monday unless King wants you to.

The underlying platysma (muscle) and sub-Q tissues are dissected and the carotid artery is isolated, from the common carotid to well beyond the bifurcation of its internal and external branches. After proximal and distal control of the artery is obtained, the patient is given anticoagulated. The internal, common, and external arteries are then clamped sequentially and a the artery is opened at the level of the bifurcation and extended proximally and distally. Some surgeons use a cerebral shunt which is inserted at this time.

The carotid plaque, consistently found at the carotid bifurcation and the origin of the internal carotid artery, is dissected out and removed through a dissection plane developed between the media and intima. Surgeons take great pains to create a smoothly tapered transition between the endarterectomized portion of the artery and its normal distal extent. This maneuver avoids intimal flaps which might lead to arterial dissection after flow is reestablished or perhaps become a nidus for platelet adhesion and thrombogenesis.

After careful inspection of the now clot-free surface, special attention is directed at repair. Some surgeons choose to repair primarily, while others patch the artery with saphenous vein or prosthetic material such as Dacron or polytetrafluoroethylene (PTFE).

Before the artery is closed, the internal carotid artery (ICA) is unclamped distally and flushed free of debris in a retrograde fashion. This vessel is then reclamped and the common and external arteries are opened. This way, all the left over aretreial "gunk" is jettisoned via the external carotid artery prior to restarting antegrade flow, i.e. that blood which goes to the brain. This technique is based on prior experience showing that patients were coming out of surgery with new neurologic events despite the best efforts of the surgeons to remove all the plaque adhered to the wall of the artery. [Interestingly, when carotid stenoses are done percuatneously, i.e. by catheter, interventionalists use a distal occlusion device to prevent embolic events. However, the interventional community is having a tough time showing benefit, or even equivalence to CEA.]

Once hemostasis is achieved, a Jackson Pratt drain is left in the wound to minimize neck hematomas and the muscle and skin are closed. when King was waking from his anesthesia, a neuro check was performed and repeated probably every 10 mins for the first hour and then every hour during recovery to make sure the talking head wasn't slurring as a result of the arterial manipulation.

Below is a sweet slide presentation we found that provides a step-by-step approach to carotid surgery.

http://www.pvss.org/Cases/CartEnd/car3.htm

Notre Dame Head Coach Sues for Botched Bypass

Charlie Weis, head coach of the Notre Dame Fighting Irish and former Super Bowl winning offensive coordinator, testified yesterday in his lawsuit against two surgeons from prestigious Massachusetts General, who he claims were negligent following his gastric bypass surgery.

According to ESPN.com, the now svelte Weis said he spent more than a month in various hospitals, and following his release, had problems walking and could get around only with the help of a wheelchair or electric cart. His lawyer, Michael Mone, told the jury during opening statements Tuesday that Weis still suffers nerve damage in his legs.

How was his ambulation when he tipped the scales at 400 lbs? And his diabetes? And HTN? And obstructive sleep apnea, etc etc?

I am astonished that someone who signed a contract for $30-40 million over 10 years and is now healthy enough toWeis2.jpg walk the sidelines and handle a high-stress job like his, would sue doctors who are at the top of their field and clearly did not mean any harm.

Gastric bypass is inherently a complicated procedure and when a morbidly obese individually undergoes the surgery, this is explained to him or her. If the physicians made a erred during the surgery and corrected their error enabling him to successfully drop weight and return to coaching, what is he suing for?

Obviously, we are not privy to the details of the case but we do know he is coaching and that hey are Harvard surgeons who want the bet for their patients - especially high-profile ones like Weis.

Can the Fighting Irish fans sue Weis every time he makes a bad call or for their pitiful performance in Bowl games?

Doctors explained to Weis the risk of the surgery and he, in fact, waived a psychological assessment period so that he could be ready in time for football season. Now he is suing them?

Weis, as a head football coach, and a man who is familiar with risk-benefit analysis, whould recognize the complications inherent in such an invasive procedure - particularly in such an unhealthy individual. Big rewards can be gained form big risks - but like the deep pass and the double reverse, catastrophe can also occur. Weis is lucky that he is alive, healthier than before, and actively coaching a marquee program. And who does he have to thank for that? His team? His family?

No. His doctors.