Safety and efficacy of concomitant carotid and coronary artery operations

Patients with Polyvascular Disease: A Very High-risk Group

Polyvascular disease (PolyvascDis) with atherosclerosis occurring in >2 vascular beds (coronary, carotid, aortic, visceral and/or peripheral arteries) is encountered in 15-30% of patients who experience greater rates of major adverse cardiovascular (CV) events. Every patient with multiple CV risk factors or presenting with CV disease in one arterial bed should be assessed for PolyvascDis clinically and noninvasively prior to invasive angiography. Peripheral arterial disease (PAD) can be readily diagnosed in routine practice by measuring the ankle-brachial index. Carotid disease can be diagnosed by duplex ultrasound showing % stenosis and/or presence of plaques. Coronary artery disease (CAD) can be screened by determining coronary artery calcium score using coronary computed tomography angiography; further, non-invasive testing includes exercise stress and/or myocardial perfusion imaging or dobutamine stress test, prior to coronary angiography. Abdominal ultrasound can reveal an abdominal aortic aneurysm. Computed tomography angiography will be needed in patients with suspected mesenteric ischemia to assess the mesenteric arteries. Patients with the acute coronary syndrome and concomitant other arterial diseases have more extensive CAD and poorer CV outcomes. Similarly, PolyvascDis in patients with carotid disease and/or other PAD is independently associated with an increased risk for all-cause and CV mortality during long-term follow-up. Treatment of patients with PolyvascDis should include aggressive management of all modifiable risk factors by lifestyle changes and drug therapy, with particular attention to patients who are commonly undertreated, such as those with PAD. Revascularization should be reserved for symptomatic vascular beds, using the least aggressive strategy in a multidisciplinary vascular team approach.

Approach to concurrent coronary and carotid artery disease: Epidemiology, screening and treatment

Summary The concomitance between coronary artery disease and carotid artery disease is known and well documented. However, it is a fact that, despite the screening methods for these conditions and the advances in surgical treatment, little has been achieved in terms of reducing the risk of complications in the perioperative period. Publications are scarce, being mostly composed of reports or case series. There is little agreement on the best initial therapeutic approach (myocardial versus carotid revascularization) or the best technique to be used (surgery with or without extracorporeal circulation, hybrid treatments, etc.). The authors performed a review of the evidence in this clinical scenario, raising pragmatic questions that help in the therapeutic decision.

Carotid endarterectomy for critical stenosis prior to cardiac surgery: Should it be done? A retrospective cohort study

INTRODUCTION

Stroke remains a major cause of morbidity and mortality after cardiac surgery affecting 2% of patients. Extra-cranial carotid artery disease has been implicated in the aetiology of post cardiac surgery stroke. The aim of the study was to evaluate and compare the morbidity and mortality in patients undergoing cardiac surgery with or without staged carotid endarterectomy (CEA) in a tertiary referral centre.

METHODS

A 5 year retrospective study was performed. The primary endpoints were defined as peri-operative stroke and myocardial infarction (MI) with secondary outcome defined as death within 30 days of surgery.

RESULTS

In total 5924 cardiac procedures and 29 staged CEA's were performed. The rate of stroke and MI was significantly higher in patients undergoing staged CEA pre-cardiac surgery compared to patients undergoing cardiac surgery with confirmed or presumed normal carotid arteries (10.34% vs 1.43%; P = .008 and 13.79% vs 0.38%; P < .0001, respectively). There was no significant difference in the stroke and MI rate in those patients undergoing cardiac surgery with confirmed or presumed normal carotid arteries compared to those with significant carotid disease undergoing cardiac surgery with no prior carotid intervention (1.43% vs 3.16%; P > .05 and 0.38% vs 1.05%; P > .05, respectively).

CONCLUSIONS

Carotid disease is associated with an increased risk of stroke post cardiac surgery. Staged carotid intervention cannot be justified based on these results. Increased risk of stroke post cardiac surgery in patients with significant carotid disease needs to be accepted, as the risk of stroke and MI during carotid intervention pre cardiac surgery is significantly higher.

The Effects of Near-Infrared Spectroscopy on the Neurocognitive Functions in the Patients Undergoing Coronary Artery Bypass Grafting with Asymptomatic Carotid Artery Disease: A Randomized Prospective Study

PURPOSE

The purpose of this study was to research the use of near-infrared spectroscopy (NIRS) on the neurocognitive functions in the patients undergoing coronary artery bypass grafting (CABG) with asymptomatic carotid artery disease.

METHODS

The study design was carried out with the participation of 79 patients in a prospective, randomized and double blind control method. The patients were separated into two groups as NIRS (n = 43) and no NIRS (n = 36). A neurocognitive test was applied preoperatively and postoperatively to all patients before discharge. Cognitive functions were evaluated by applying the Montreal Cognitive Assessment test (MoCA).

RESULTS

The decrease in the postoperative score of mean MoCA in no NIRS group was statistically significant when compared to preoperatively (p <0.001). Postoperative mean MoCA score was found to be significantly higher in NIRS group (NIRS: 26.8 ± 1.9 vs. no NIRS: 23.6 ± 2.5, p <0.001). It has been determined that there was a moderately positive significant correlation between the increase in the NIRS used patients (%) and increase in the MoCA score of the patients (r = 0.59, p <0.001).

CONCLUSION

Intraoperative NIRS usage in the patients undergoing CABG with carotid artery disease might be useful due to its postoperative positive effects on the cognitive functions.

Simultaneous coronary artery bypass grafting and carotid endarterectomy can be performed with low mortality rates

Introduction

There is controversy over the best approach for patients with concomitant carotid and coronary artery disease. In this study, we report on our experience with simultaneous carotid endarterectomy (CEA) and coronary artery bypass graft (CABG) surgery in our clinic in the light of data in the literature.

Methods

Between January 1996 and January 2009, a total of 110 patients (86 males, 24 females; mean age 65.11 ± 7.81 years; range 44–85 years), who were admitted to the cardiovascular surgery clinic at our hospital, were retrospectively analysed. All patients underwent simultaneous CEA and CABG. Demographic characteristics of the patients and a history of previous myocardial infarction (MI), hypertension, diabetes mellitus, hyperlipidaemia, peripheral arterial disease and smoking were recorded.

Results

One patient (0.9%) with major stroke died due to ventricular fibrillation. Peri-operative neurological complications were observed in seven patients (6%). Complications were persistent in two patients. Four patients (3%) had postoperative major stroke, whereas three patients (2%) had transient hemiparesis. No peri-operative myocardial infarction was observed.

Conclusion

Simultaneous CEA and CABG can be performed with low rates of mortality and morbidity.

Staged carotid endarterectomy under local anaesthetic in patients requiring cardiac surgery

INTRODUCTION

There is no clear guidance as to the management of carotid stenotic disease prior to cardiac surgery. We aimed to review the results of a single centre performing carotid endarterectomy (CEA) under local anaesthesia prior to cardiac surgery.

PATIENTS AND METHODS

All patients referred for cardiac surgery in our tertiary referral unit between January 1998 and August 2008 were identified and data relating to those 100 undergoing CEA prior to cardiac surgery were reviewed. Eighty had coronary artery bypass grafting (CABG) alone, 15 combined valve surgery and CABG and three underwent isolated valve surgery. Two patients died prior to cardiac surgery.

RESULTS

One hundred patients were prospectively identified after screening by clinical features and carotid duplex scanning to require CEA from a total of 11,394. The stroke rate was 1% between CEA and cardiac surgery, 2% following cardiac surgery and 3% in total. Ninety-eight patients proceeded to cardiac surgery (two deaths post-CEA). The cumulative event rate (stroke, myocardial infarct [included in view of the nature of the patients in our cohort] and/or death) was 10.2% following all cardiac surgery (CABG and valve). In 80 patients undergoing CABG only, the cumulative event rate was 7.5% after CABG. Including the two deaths pre-cardiac surgery, the rates were 12% and 8%. The risk of peri-operative stroke and 30-day mortality were reduced to that of patients undergoing cardiac surgery without significant carotid arterial disease, 3% versus 3.3% and 5.1% versus 6.5%, respectively.

CONCLUSIONS

This study demonstrates that a policy of selective screening for significant carotid artery disease in cardiac surgical patients combined with a strategy of CEA under local anaesthesia prior to unselected cardiac surgery (CABG with or without valve surgery) leads to rates of peri-operative CVA, myocardial infarction and death comparable to rates published for CEA prior to isolated CABG surgery. Furthermore, it reduces the risk of peri-operative stroke and 30-day mortality to that observed in patients undergoing cardiac surgery without significant carotid arterial disease.

Preoperative screening and management of carotid artery disease in patients undergoing cardiac surgery

BACKGROUND

Carotid artery stenosis (CAS) is a well-known risk factor for perioperative stroke in cardiac surgery. It is unclear whether preoperative carotid screening should be applied to all patients. Carotid intervention concomitantly with cardiac operations is also controversial. Our objective was to identify the prevalence of significant CAS and its related risk factors by applying a protocol of preoperative carotid screening to all patients undergoing cardiac surgery.

METHODS

We studied 307 patients who were primarily screened preoperatively by duplex Doppler ultrasonography. Catheter carotid angiography or transcranial Doppler was performed on equivocal cases. Univariate and multivariate analyses were applied across selected parameters to identify risk factors for significant CAS (> 70%). The prevalence of CAS and perioperative stroke rates were determined.

RESULTS

Twenty-two patients with severe and 18 with moderate carotid stenosis were identified. Further radiological evaluation with catheter carotid angiography and transcranial Doppler confirmed the presence of significant CAS in 20 patients who underwent carotid stenting or endarterectomy before the open heart surgery. The cardiac surgeon was free to modify the surgical technique according to the preoperative assessment. No patient had major stroke perioperatively, while two minor strokes with complete neurologic recovery have been documented. The history of stroke and the presence of bruit on clinical examination were the only significant predictors of severe carotid disease.

CONCLUSION

Careful clinical examination together with detailed previous history taking can identify the majority of patients with CAS. Further data are required for the construction of a scientifically valid policy as a guideline.

Early results of combined and staged coronary bypass and carotid endarterectomy in advanced age patients in single centre

Aim:

In present study, we aimed to compare the staged and combined surgery in patients with severe carotid stenosis and coronary atherosclerosis and detect the factors affecting mortality and morbidity.

Material and method:

Between 2004 and 2008, 120 patients with predominant ischemic heart disease were enrolled to study. Patients were divided into three groups on basis surgery procedure. Group 1 (n=40) includeed patients had coronary artery disease without carotid disease underwent coronary artery by-pass graft (CABG) operation. Group 2 (n=40): included patients underwent combined surgery procedure including CABG and carotid endarterectomy (CEA). Patients underwent staged CABG and CEA were enrolled to Group 3 (n=40). All patients were in advanced aged and were had the same risk factors atributable atherosclerosis

Results:

Mean age of the patients in all groups were 68±6, 69±3, 71±2 respectively, and 83% were male. Eight patients died in all groups at follow-up(seven in group 2 and 3, and one in group 1) and the difference between both groups was statistically significant (p<0.001). The follow-up period in the intensive care unit, and hospitalization period were not statistically different between CABG group and combined CEA plus CABG group.

Conclusion:

We think that the results of staged or combined CABG plus CEA surgery are satisfactory in patients with severe carotid disease and advanced coronary artery disease. However, the mortality and morbidity in both procedures are higher than those of alone.

Screening for carotid artery disease before cardiac surgery: is current clinical practice evidence based?

BACKGROUND

There is no clear consensus as to the correct screening procedure to identify patients undergoing cardiac surgery and who are at greatest risk of stroke because of the presence of significant carotid artery stenosis. Such screening is important because some patients benefit from combined carotid and cardiac surgery and, regardless of this, the information gained puts the cardiac surgeon in a position to provide an accurate assessment of surgical risk. Our objective was to examine current clinical practice of carotid artery investigation prior to urgent cardiac surgery and to review this illustrative practice in the context of the world literature.

HYPOTHESIS

The study aimed to establish that current typical practice for screening cardiac surgical patients for carotid artery disease is illogical according to the evidence in the world literature.

METHODS

The study consisted of a retrospective assessment of all patients undergoing urgent cardiac surgery and a Medline-derived literature review, and included all patients undergoing urgent cardiac surgery at a tertiary cardiothoracic center between January 1 and December 31, 1997.

RESULTS

Of 529 patients undergoing urgent cardiac surgery, 44 (8%) were screened preoperatively by duplex Doppler ultrasonography for carotid disease. The indications for screening were asymptomatic carotid bruit in 24 patients, history of stroke or transient ischemic attack (TIA) in 12 patients, and neither stroke, TIA, or bruit in 7 patients. The tests were requested either by the attending cardiologists or by the cardiac surgeon to whom they were referred. One patient had already been diagnosed as having carotid artery disease in the past. Thirteen patients underwent additional carotid investigations. Eleven patients were demonstrated to have internal carotid artery stenosis > or = 60% and 3 patients underwent combined cardiac and carotid surgery. Review of the literature revealed the following groups to be at increased risk of future stroke unrelated to surgery, and of postoperative stroke: those with a history of stroke or TIA, those with carotid bruits, and, of importance, all patients with significant carotid stenosis. Recent data suggest that symptomatic patients and the elderly are at greatest risk.

CONCLUSIONS

Only 8% of patients undergoing urgent cardiac surgery in a 1-year period were screened for carotid artery disease. We suggest that screening should definitely be performed in all patients with a history of stroke or TIA, all patients with a bruit, and all patients aged > 65 years. The literature suggests, however, that significant reductions in stroke rate could be achieved by screening the whole cardiac surgical population, although there is a paucity of data that are specifically pertinent to this patient subgroup. Further data are therefore required for the construction of a scientifically valid and medicolegally sound policy.

Concomitant peripheral artery disease and asymptomatic coronary artery disease: a management strategy

The present study examines the use of routine coronary angiography (CAG) before elective peripheral artery disease (PAD) surgery and the early outcome and technical features of simultaneous coronary revascularization and PAD surgery in PAD patients with asymptomatic coronary artery disease (CAD). We performed preoperative CAG in 82 patients who were undergoing elective peripheral arterial bypass surgery and who had no diagnosis or symptoms of ischemic heart disease. The 82 patients were grouped according to the criteria of <70% stenosis, >70% stenosis, and no coronary stenosis. In patients with >70% coronary artery stenosis, we performed simultaneous peripheral artery bypass surgery and coronary artery bypass grafting (CABG), while the other patients underwent peripheral artery bypass only. Preoperative coronary angiography revealed CAD in 69.5% (n = 57) of patients. Patients with CAD were more likely to be older, hypertensive, and diabetic than patients without CAD (all p < 0.05). Preoperative electrocardiography showed that only 3/57 (5.3%) patients with CAD had ischemic heart disease. Of the 61 patients who underwent peripheral artery bypass, 27 (47.4%) underwent simultaneous CABG. Of the patients with CAD, 78.9% (45/57) required peripheral artery bypass, whereas 64.0% (16/25) of patients without CAD required peripheral artery bypass (p = 0.11). Comparing simultaneous CABG and peripheral artery bypass in PAD patients with CAD and isolated peripheral artery bypass in PAD patients regardless of CAD, the only significant difference was in operating time (362.00 +/- 79.18 vs. 246.55 +/- 79.15 min, p = 0.00). When compared with PAD patients with CAD who underwent isolated peripheral artery bypass, the results were similar. Two patients who had CAD and underwent isolated peripheral artery bypass died (p = 0.16). Patients with peripheral arterial obstructive disease should be examined for CAD using CAG, regardless of whether they have symptomatic ischemic heart disease, and simultaneous CABG and peripheral artery bypass is safe and feasible.

Staged anesthesia for combined carotid and coronary artery revascularization: a different approach

OBJECTIVE

Combined coronary artery bypass graft (CABG) surgery and carotid endarterectomy (CEA) are performed in an attempt to reduce the risk of postoperative stroke after CABG surgery in patients with significant or symptomatic carotid artery stenosis. The choice between regional and general anesthesia for CEA is still under debate. Regional anesthesia offers an excellent monitoring technique of the neurologic status of the awake patient during carotid clamping. In an attempt to improve monitoring of the neurologic status and avoid the use of temporary shunting in patients undergoing the combined procedure, a different approach is described combining regional anesthesia for CEA followed immediately by general anesthesia for CABG surgery.

DESIGN

Prospective nonrandomized case series.

SETTING

University hospital.

PARTICIPANTS

Twenty patients scheduled for combined CEA and CABG surgery underwent a "staged" anesthetic approach from January to December 2004.

INTERVENTIONS

Pulmonary, femoral artery, and urinary catheters were inserted under local anesthesia. A deep cervical plexus block was then performed and supplemented by a superficial cervical plexus block. The patient was draped for standard combined CEA and CABG surgery. CEA was then performed using standard techniques. Without altering the surgical field, general anesthesia was given and endotracheal intubation performed following the successful CEA. Coronary revascularization was then completed.

MEASUREMENTS AND MAIN RESULTS

CEA and CABG surgery were completed successfully in all patients. There was no need for conversion from local to general anesthesia. Endotracheal intubation was easily performed in all patients. There was no hospital mortality in this series. No neurologic events were observed during the CEA. A reversible ischemic stroke, ipsilateral to the CEA, occurred postoperatively on awakening from CABG surgery in 1 patient.

CONCLUSIONS

This staged anesthetic approach for combined CABG and CEA surgery is an alternative in this complex subset of patients.

Late Results of Combined Carotid and Coronary Surgery Using Actual Versus Actuarial Methodology

BACKGROUND

Controversy exists over the short-term results and long-term efficacy of concomitant coronary artery bypass grafting and carotid endarterectomy. Additionally, in this population actual versus actuarial assessment of nonfatal late events has not been previously reported.

METHODS

Hospital records of 500 consecutive patients having concomitant carotid endarterectomy and coronary artery bypass grafting between 1979 and 2001 were reviewed, allowing at least 1 year of follow-up on all patients. Long-term nonfatal complications were assessed by actual and actuarial methods.

RESULTS

Patient demographics revealed a mean age of 69 years; 74% (370 patients) were male; 75% (377 patients) presented with unstable coronary syndromes; 10% (50 patients) had an intraaortic balloon pump; and 66% (329 patients) were neurologically asymptomatic. Hospital mortality was 3.6% (18 patients). Significant multivariable predictors of hospital death were preoperative transient ischemic attack or myocardial infarction, and nonelective operation. Perioperative strokes were 4.6% (23 patients), of which 2.4% (12 patients) were ipsilateral and 2.2% (11 patients) were contralateral. Significant multivariable predictors of stroke were peripheral vascular disease and use of the right internal mammary artery. Ten-year actuarial survival was 43%. Ten-year actual versus Kaplan-Meier actuarial freedoms with 95% confidence limits from late events were myocardial infarction 87% (78% and 92%) versus 81% (75% and 87%); percutaneous coronary intervention 92% (85% and 96%) versus 89% (84% and 94%); reoperative coronary grafting 96% (89% and 99%) versus 94% (90% and 98%); total stroke 85% (77% and 91%) versus 82% (76% and 87%); ipsilateral stroke 90% (83% and 94%) versus 87% (82% and 92%); carotid endarterectomy 82% (73% and 88%) versus 75% (69% and 82%).

CONCLUSIONS

Concomitant carotid and coronary artery surgery is safe and effective, particularly in preventing ipsilateral stroke, and neutralizes the impact of unilateral carotid stenosis on early and late stroke. Actual, not actuarial, methods more accurately represent the true risk of nonfatal late events.

Concurrent coronary and carotid artery surgery: factors influencing perioperative outcome and long-term results†

AIMS

To assess risk factors for early and late outcome after concurrent carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG).

METHODS AND RESULTS

Records of all 311 consecutive patients having concurrent CEA and CABG from 1989 to 2002 were reviewed, and follow-up obtained (100% complete). In the group (mean age 67 years; 74% males), 62% had triple-vessel disease, 57% unstable angina, 31% left main coronary stenosis, 19% congestive heart failure, and 35% either a history of vascular procedures or existing vasculopathies. Preoperative assessment revealed transient ischaemic attack in 16%, stroke in 7%, and bilateral carotid disease in 20%. There were 7% emergent and 19% urgent operations, and ascending aorta was described as atheromatous or calcified in 21%. Hospital death occurred in 19 patients, myocardial infarction in seven, and permanent stroke in 12. Significant multivariable predictors of hospital death were aortic calcifications, coexisting vasculopathy, and emergent procedure. Significant predictors of postoperative stroke were calcified or dilated aorta, and of prolonged hospital stay were advanced age, unstable angina, and coexisting vascular disease. For hospital survivors, 10-year actuarial late event-free rates were: death, 50%; myocardial infarction, 84%; stroke, 93%; percutaneous angioplasty, 95%; redo CABG, 98%; and all morbidity and mortality, 48%. Significant multivariable predictors of late deaths were coexisting vasculopathy, age, renal insufficiency, previous cardiac surgery, tobacco abuse, calcified or atheromatous aorta, and duration of intensive care unit stay.

CONCLUSION

Concurrent CEA and CABG can be performed with acceptable operative mortality and morbidity, and good long-term freedom from coronary and neurologic events. Atheromatous aortic disease is a harbinger of poor operative and long-term outcome.

Simultaneous Carotid and Coronary Arteries Disease: Staged or Combined Surgical Approach?

BACKGROUND

Patients suffering from a concomitant coronary and carotid artery occlusive disease represent a high-risk population whose management remains controversial.

METHODS

Between April 1979 and June 2002, 202 patients (163 men and 39 women, mean age 65 +/- 7 years) were admitted at the Department of Cardiovascular Surgery of the University of Bologna for coronary artery bypass graft and carotid endarterectomy (CEA). In Group 1 (140 patients) coronary artery bypass graft and carotid endarterectomy were performed simultaneously while in Group 2 (62 patients) they were performed as two-staged procedures.

RESULTS

The rate of postoperative stroke was 6.4% in Group 1 (9/140) and 4.8% in Group 2 (3/62). Significant univariate predictors of myocardial infarction were smoking history and previous myocardial infarction; for stroke they were older, greater than 70 years, and a smoking history; for death the significant predictors were the operative approach, the low ejection fraction, smoking history, renal failure, and peripheral vascular occlusive disease. The hospital mortality was 6.4% in Group 1 versus 12.9% in Group 2.

CONCLUSIONS

Despite the highly selected populations, the contemporary surgical results indicate that the management of these patients needs careful pre-, intra-, and postoperative assessment and timing aimed at reducing the ischemic injuries, both cerebral and cardiac, therefore we believe that the surgical technique should be individualized for each patient.

The risk of stroke following CABG: one possible strategy to reduce it?

OBJECTIVE

Stroke remains a devastating complication of coronary artery bypass grafting (CABG): we evaluated whether a more aggressive diagnostic and therapeutic approach can reduce its incidence.

METHODS

Between January 1998 and January 2002, 1388 consecutive patients underwent isolated on pump CABG with blood cardioplegia. Among the first 627 patients (Group A), Echo-Doppler study (DS) was performed only in selected patients (58) with history of cerebrovascular disease (CVD) and/or carotid bruit; in 761 patients (Group B), DS was performed routinely. Carotid endarterectomy (CEA) was performed in 45 patients in Group A associated to CABG during cardiopulmonary bypass (CPB) and in 90 patients in Group B under local anaesthesia before CABG. Brain CT scan was performed in all cases with postoperative neurological symptoms.

RESULTS

The two groups were homogeneous for age, sex, associated diseases, history of CVD, number of graft and CPB time. There were no differences in terms of hospital mortality between Group A (22/627: 3.5%) and Group B (21/761: 2.75%); p=0.5. Postoperative stroke was observed in 24/627 (3.82%) patients of Group A and in 2/761 (0.26%) of Group B (p<0.001). Hospital mortality for stroke was higher in Group A (12/627: 1.91%) than in Group B (0/761; p<0.001) as well as the incidence of non-fatal stroke (Group A 12/627: 1.91% versus Group B 2/761: 0.26% p=0.006).

CONCLUSIONS

Preoperative DS, performed in all cases of CABG, followed by CEA under local anaesthesia in patients with critical carotid stenosis reduces the incidence of postoperative stroke.

Concomitant Carotid Endarterectomy and Coronary Bypass Surgery: Outcome of On-Pump and Off-Pump Techniques

BACKGROUND

There continues to be a dilemma regarding the best means of surgical management of significant carotid artery disease in patients requiring coronary artery bypass surgery. A combined approach of coronary artery bypass and carotid endarterectomy has shown good results in patients with concomitant carotid and coronary artery disease. We reviewed our results of coronary artery surgery using conventional cardiopulmonary bypass or off-pump techniques and carotid endarterectomy done as a combined procedure.

METHODS

Between January 1996 and June 2002, 358 patients underwent concomitant coronary artery bypass and carotid endarterectomy. There were 140 males (84.3%) and 26 females (15.7%) in group I. Group II consisted of 158 males (82.3%) and 34 females (17.7%). One hundred sixty-six patients (group I) were done off pump whereas in 192 patients (group II), the procedure was done using conventional cardiopulmonary bypass. Carotid endarterectomy was performed before coronary artery bypass surgery in both groups.

RESULTS

The average number of grafts were 3.4 +/- 0.8 with average operative time of 4.2 +/- 0.4 hours in group I, and 3.3 +/- 0.8 graft with operative time of 5.3 +/- 1.2 hours in group II (p = 0.239 and p < 0.001, respectively). There were 2 deaths (1.2%) in group I and 3 deaths (1.6%) in group II (p = 0.870). No patient from group I and 1 patient (0.5%) from group II had postoperative stroke (p = 0.941). Mean hospital stay was 9.0 +/- 1.2 days in group I and 11.2 +/- 1.7 days in group II (p < 0.001). At mean follow-up of 2.8 +/- 0.9 years in group I, 2 patients (1.2%) had late death due to cardiac failure and contralateral carotid endarterectomy was done in 2 patients (1.2%). Group II had mean follow-up of 2.4 +/- 0.6 years, during which 4 patients (2.1%) had late death and contralateral carotid endarterectomy was done in 3 patients (1.6%). Late stroke was seen in 1 patient (0.6%) from group I and 2 patients (1.0%) from group II.

CONCLUSIONS

Concomitant carotid endarterectomy and coronary artery bypass is a safe and effective procedure in patients with significant coronary and carotid artery disease. Equally good results can be reproduced using cardiopulmonary bypass or off-pump techniques for coronary artery surgery, with low morbidity, mortality, and good long-term results.

Brain injury after adult cardiac surgery

Despite remarkable progress in surgical, cardiopulmonary bypass and anaesthetic techniques during the last three decades, brain damage remains an important complication of adult cardiac surgery. Effective brain protection strategies are already implemented today, but ongoing research is needed to meet the challenges faced in operating on increasingly old and disabled patients. The incidence of brain injury may be reduced by modifying the surgical procedure according to carotid duplex scanning and epiaortic echocardiography, by using techniques to reduce microembolization during cardiopulmonary bypass and by optimizing patient temperature during and after surgery. Increased knowledge will aid in choosing the best procedure or combination of procedures in each case to ensure that risks do not outweigh benefits.

Treatment of combined coronary and carotid artery disease

PURPOSE OF REVIEW

The purpose of this review is to evaluate the current indications and results of treatment of combined coronary and carotid disease. Synchronous carotid stenosis in patients with coronary artery disease poses a management challenge in patients with advanced atherosclerosis.

RECENT FINDINGS

Recent case series continue to demonstrate concomitant coronary and carotid disease with significant carotid stenosis greater than 70% in approximately 8% of patients evaluated for coronary artery bypass grafting. Surgical management options include staged operations addressing the carotid stenosis first, reverse staged operations addressing the coronary disease first, and combined synchronous operations addressing both territories during the same anesthetic. Recent reports demonstrate safety and acceptable risks with each operative approach. Lower trends in stroke rates were noted following staged procedures when compared with combined procedures. However, several metaanalyses showed no significant difference in rates of combined morbidity and mortality for all three strategies. Total morbidity and mortality risks for combined disease tended to be higher than for isolated coronary artery bypass grafting or carotid endarterectomy procedures performed for disease in a single vascular territory.

SUMMARY

Despite a large volume of data present in the literature, the treatment indications and surgical options remain controversial. We currently advocate treatment of symptomatic territory first in favor of staged procedures and reserve combined procedures for patients with critical stenosis or symptoms in both territories.

A systematic review of outcome following synchronous carotid endarterectomy and coronary artery bypass: Influence of surgical and patient variables

OBJECTIVES

Outcomes after synchronous carotid endarterectomy (CEA) plus coronary artery bypass (CABG) relative to surgical and patient based variables.

DESIGN

Systematic review of 94 published series (7863 synchronous procedures).

RESULTS

11.5% of patients died or suffered a stroke/myocardial infarction in the peri-operative period (95% CI 10.1-12.9). The risk of death/stroke appeared to significantly diminish in studies published between 1993-2002, compared with 1972-1992 (7.2% (95% CI 6.5-9.1) versus 10.7% (95% CI 8.9-12.5), p = 0.03). However, increasing operative experience was not associated with significantly lower risks of death/stroke; (1-49 cases (9.6% (95% CI 7.5-11.8); 50-99 cases (9.1% (95% CI 6.4-11.8); 100+ cases (8.4% (95% CI 6.9-10.1) (p = 0.64)). Patients with severe bilateral carotid disease were significantly more likely to suffer death and/or stroke compared to patients with unilateral disease (odds ratio 2.5, 95% CI 1.4-5.0, p = 0.001). Similarly, patients with a prior history of stroke/transient ischaemic attack (TIA) were significantly more likely to suffer a further stroke than asymptomatic patients (odds ratio 1.8, 95% CI 1.1-2.8, p = 0.008). There was no difference in the risk of death/stroke relative to the timing of CEA (pre- versus on-cardiopulmonary bypass), but recent small studies indicate that improved outcomes might be achieved by performing CABG 'off-bypass'.

CONCLUSIONS

Synchronous CEA + CABG is associated with a not insignificant cardiovascular risk. No comparable information is available for similar patients undergoing CABG without prophylactic CEA.

A systematic review of outcomes following staged and synchronous carotid endarterectomy and coronary artery bypass

OBJECTIVES

to determine the overall cardiovascular risk for patients with combined cardiac and carotid artery disease undergoing synchronous coronary artery bypass (CABG) and carotid endarterectomy (CEA), staged CEA then CABG and reverse staged CABG then CEA.

DESIGN

systematic review of 97 published studies following 8972 staged or synchronous operations.

RESULTS

mortality was highest in patients undergoing synchronous CEA+CABG (4.6%, 95% CI 4.1-5.2). Reverse staged procedures (CABG-CEA) were associated with the highest risk of ipsilateral stroke (5.8%, 95% CI 0.0-14.3) and any stroke (6.3%, 95% CI 1.0-11.7). Peri-operative myocardial infarction (MI) was lowest following the reverse staged procedure (0.9%, 95% CI 0.5-1.4) and highest in patients undergoing staged CEA-CABG (6.5%, 95% CI 3.2-9.7). The risk of death+/-any stroke was highest in patients undergoing synchronous CEA+CABG (8.7%, 95% CI 7.7-9.8) and lowest following staged CEA-CABG (6.1%, 95% CI 2.9-9.3). The risk of death/stroke or MI was 11.5% (95% CI 10.1-12.9) following synchronous procedures versus 10.2% (95% CI 7.4-13.1) after staged CEA then CABG.

CONCLUSIONS

10-12% of patients undergoing staged or synchronous procedures suffered death or major cardiovascular morbidity (stroke, MI) within 30 days of surgery. Overall, there was no significant difference in outcomes for staged and synchronous procedures and no comparable data for patients with combined cardiac and carotid disease not undergoing staged or synchronous surgery.

Multistate population-based outcomes of combined carotid endarterectomy and coronary artery bypass

OBJECTIVES

The management of combined carotid and coronary disease is controversial, and the outcomes of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) have not been determined on a community-wide basis. This study was undertaken to evaluate the community-wide outcomes of combined CEA and CABG and to evaluate the risk for adverse events.

METHODS

A complete medical record review of 10,561 CEA procedures randomly selected from Medicare patients undergoing CEA in 10 states was performed. In this sample, 226 procedures were performed in combination with CABG in the same operative event.

RESULTS

Recent ipsilateral stroke or transient ischemic attack was the indication for the CEA in only 12% of patients undergoing CEA/CABG, and 56% were asymptomatic with respect to the carotid lesion. The combined stroke and death rate was 17.7% (25 nonfatal strokes, two fatal strokes, and 13 nonstroke deaths). Eighty percent of the nonfatal strokes were disabling. Proximal aortic arch atherosclerosis and symptomatic carotid stenosis were associated with stroke (P <.05). Female gender, emergent operation, redo CABG, blood pressure on pump, total pump time, presence of left main disease, and number of diseased coronaries were associated with mortality (P <.05). The strokes appeared to be associated with the operative event, but diagnosis was delayed and postevent carotid patency was not documented. Most strokes were not limited to the hemisphere ipsilateral to the CEA.

CONCLUSION

The community-wide outcomes of combined CEA/CABG in the Medicare population are inferior to those reported in many single-institution reviews. Diagnosis of postoperative stroke is often delayed, and most strokes are not limited to the hemisphere ipsilateral to the CEA operative site.

Carotid stenosis: medical and surgical aspects

Medical treatment for carotid disease is similar to the treatment of atherosclerosis, with some recent data suggesting that there is a benefit to an aspirin-dipyridamole combination. CEA has revolutionized the treatment of symptomatic and asymptomatic carotid stenosis. This approach remains the gold standard for the surgical treatment of carotid artery stenosis, against which emerging modalities such as percutaneous carotid stenting should be compared. Higher-risk, asymptomatic patients can safely undergo CEA in high-volume centers for stenosis greater than 80% as defined by ultrasound.

Stent placement for the treatment of occlusive atherosclerotic carotid artery disease in patients with concomitant coronary artery disease

OBJECT

The authors report their experience with carotid artery stent placement (CASP) in patients with concomitant carotid artery (CA) and coronary artery (CorA) diseases.

METHODS

In a review of 320 consecutive patients who underwent CASP, the authors identified 49 with severe CorA disease in addition to significant CA stenosis, who had undergone CASP before planned CorA bypass grafting (CorABG). The average age of these 49 patients was 68 years. In 39 patients (80%) the New York Heart Association functional classification grade was IV and in 10 the grade was III. In 26 patients 50% or greater stenosis of the left main CorA was found. Seventeen patients (35%) suffered from either significant hemodynamic contralateral CA stenosis (> 60% stenosis; eight patients) or contralateral CA occlusion (nine patients). Sixteen patients (33%) had symptomatic CA disease. No cerebrovascular events occurred during CorABG. Four patients (8%) died of cardiac arrest and one patient (2%) suffered a major stroke within 30 days after the CorABG procedure. No patient experienced clinically significant recurrent CA stenosis during the study period (average clinical follow-up period 27 months).

CONCLUSIONS

Carotid artery stent placement should be considered as an alternative for the management of concomitant CA and CorA diseases. These preliminary results support the feasibility and durability of CASP in the population studied.

Operative and 5-year outcomes of combined carotid and coronary revascularization: review of a large contemporary experience

BACKGROUND

Surgical treatment of concomitant coronary and carotid disease is controversial. Studies comparing staged versus combined coronary artery bypass grafting and carotid endarterectomy (CABG/CEA) report varying and often conflicting operative results. Also, few studies have investigated the long-term outcomes of combined surgery.

METHODS

We reviewed the operative outcome and 5-year survival results of 189 consecutive patients (69+/-9 years old, 66 [35%] female patients) who underwent combined CABG/CEA between 1994 and 1999. Survival follow-up was conducted in February 2001 and the incidence of late stroke, carotid surgery, and myocardial infarction was investigated in all surviving patients by mail survey. A phone interview was done by a surgeon of patients with late strokes or repeated CEA.

RESULTS

Operative death occurred in 5 of 189 patients (2.65%) 4 of which were in-hospital deaths. A total of 5 (2 permanent, 3 transient [2.65%]) perioperative strokes were documented in these patients, and 1 of the perioperative strokes patients died in the hospital. In all, 156 of 189 patients (82.5%) were alive at the time of the study and completed surveys were collected from 153 of 156 patients (98%). Of these 153 patients, 4 reported a late stroke (2.6%), 5 suffered a myocardial infarction (3.3%), and 16 (10.5%) underwent subsequent CEA (7 ipsilateral to original CEA). Angioplasty (3 of 153, 2.0%) and redo surgery (1 of 153, 0.66%) occurred infrequently. Median survival follow-up was 51 months (range 12 to 84), and the corresponding 5-year Kaplan-Meier survival was 79.4%. This survival was similar to that of age-matched isolated CABG patients (n = 532) with documented history of cerebrovascular disease but no surgical carotid lesions.

CONCLUSIONS

Our results suggest that combined CABG/ CEA is safe and may in fact reduce the risk of adverse outcomes in the intermediate term compared with age and risk-matched patients. We speculate the latter may be attributable to a cerebrovascular protective effect of CABG/CEA pending verification by randomized trials. An economic benefit of CABG/CEA may also be inferred from avoiding separate coronary and carotid operations and reduction in the high costs of perioperative stroke.

Concomitant carotid endarterectomy and coronary bypass surgery: should cardiopulmonary bypass be used for the carotid procedure?

BACKGROUND AND OBJECTIVES

With the increasing age of patients undergoing coronary artery bypass grafting (CABG), a greater number have associated clinically significant carotid disease. This study determined the morbidity and mortality for combined carotid endarterectomy (CEA)/CABG using cardiopulmonary bypass (CPB) for both procedures versus a combined approach using CPB only during CABG.

PATIENTS AND METHODS

Between 1993 and 2000, 65 patients (Group I) underwent combined CEA and CABG using CPB for both surgical procedures and 88 patients (Group II) underwent combined CEA and CABG using CPB only during CABG. The demographic, clinical, and carotid and coronary angiographic data were similar between groups. In Group I, 22 (33.8%) patients and 32 (36%) patients in Group II presented with contralateral carotid artery stenosis.

RESULTS

CPB time was significantly longer in Group I, 127+/-21 minutes versus 98+/-11 minutes in Group II patients (p = 0.001). The incidence of surgical revision for bleeding and deep sternal wound infection was higher in Group I patients, 2 (3%) versus 1 (1.1%) and 5 (7.7%) versus 2 (2.2%), respectively, but not significant. Hospital mortality in Group I was 6% (4 patients) versus 5.7% (5 patients) in Group II (p = ns). Neurologic complications occurred in 4 (6%) and 5 (5.7%) patients in Group I and II, respectively (p = ns). Postoperative renal dysfunction was more common in Group I patients (22 [33.8%]) then in Group II patients 16 (19%) (p = 0.04). Of these patients, (16 [19%]) 8 (12.3%) in Group I and 6 (6.8%) in Group II required postoperative ultrafiltration (p = ns). Infectious complications were more frequent in Group I patients, 5 (7.7%) versus 2 (2.3%), but not statistically significant (p = ns). Overall actuarial survival at 1, 3, and 5 years, including all deaths, was 92%, 88%, and 82% in Group I versus 93%, 86%, and 81% in Group II (p = ns). Overall freedom from stroke at 5 years was 87.5% in Group I and 86.4% in Group II.

CONCLUSIONS

We conclude that combined CEA/CABG using CPB only during the myocardial revascularization procedure remains the technique of choice in patients with coronary and carotid artery disease, offering better outcome in terms of perioperative morbidity than a combined CEA/CABG using CPB for both procedures.

Coronary artery bypass and carotid endarterectomy: combined approach

Controversy exists concerning the best management of patients with coronary artery and carotid artery disease. Between June 1994 and July 2000, 88 patients with coronary artery and carotid artery disease underwent combined coronary artery surgery and carotid endarterectomy. Demographics and perioperative variables of these patients were compared with those of 266 patients undergoing isolated coronary artery surgery. Patients in the combined coronary artery bypass grafting and carotid endarterectomy group were elderly patients (p=0.0001) with a higher prevalence of female gender (p=0.0001), left ventricular dysfunction (p=0.006), left main coronary artery disease (p=0.033), triple-vessel coronary artery disease (p=0.002), unstable angina pectoris (p=0.004), and history of prior neurologic events (p=0.0001). Three (3.4%) patients in the combined group and 5 (1.9%) patients in the isolated coronary artery surgery group (p=0.317) developed perioperative myocardial infarction. Two (2.3%) patients in the combined group developed a permanent postoperative neurologic event. Hospital mortality was 5.7% (5 patients) in the combined coronary artery bypass grafting and carotid endarterectomy group and 1.5% (4 patients) in the isolated coronary artery surgery group (p=0.046). Patients with concomitant carotid and coronary artery disease have an advanced arteriosclerosis. Although combined coronary artery bypass grafting and carotid endarterectomy is associated with a higher risk of death and perioperative myocardial infarction than simple coronary artery surgery, this procedure is a preferable approach for these high-risk patients and results in lower neurologic morbidity.

Bilateral carotid stenting combined with three-vessel percutaneous coronary intervention in single setting

We describe a patient who underwent bilateral internal carotid artery stenting and three-vessel percutaneous coronary intervention during the same procedure. Stenting of carotid arteries was performed employing our innovative technique combining coronary and peripheral devices. No complications occurred. The patient was discharged home 1 day after the intervention and remains asymptomatic, leading a fully active life. To our knowledge, unstaged bilateral carotid stenting combined with three-vessel coronary intervention has not been reported previously.

Combined Surgery for cardiac and carotid disease: management and results of a rational approach

OBJECTIVES

The aim of the present study was to apply a rational plan for simultaneous cardiac and carotid surgery in high-risk patients.

MATERIALS AND METHODS

A consecutive series of 89 patients with coexisting severe cardiac and carotid disease were operated on during a 5-year period with routinary carotid shunting, moderate hypothermia and balanced anaesthesia. The combined surgical procedures were coronary artery by-pass grafts (CABG) + carotid endarterectomy (CEA) in 81 patients, CABG + CEA + aortic valve replacement (AVR) in four patients, and four cases of CEA + AVR. RESSULTS: Two deaths (2%), three acute myocardial infarctions (3%) and one (1%) major stroke occurred in five patients during the perioperative (30 days) period for a combined rate of death and/or disabling stroke of 3%. There were five reversible neurological deficits. Carotid and aortic mean clamping times were 9 and 60 min respectively. Patients were discharged after a mean length of stay in Intensive Care Unit (ICU) of 131 h and 7 days of hospitalisation post-ICU.

CONCLUSIONS

Based on our results, combined interventions of CEA and CABG can be performed with an acceptable morbidity and mortality when severe carotid stenosis is associated with advanced, symptomatic cardiac disease. The management of these patients needs careful and appropriate pre-intra and post-operative assessment and timing aimed to reduce the ischaemic injuries, both cardiac and cerebral, especially during CBP time.

Stroke after coronary artery bypass grafting in patients with cerebrovascular disease

BACKGROUND

Stroke has been associated with a significantly increased mortality from coronary artery bypass grafting (CABG). To determine the predictors of stroke in patients undergoing CABG, we collected data on 472 consecutive patients.

METHODS

From March 1991 to March 1999, all patients undergoing CABG at our institution underwent routine duplex scanning of the extracranial carotid and vertebral arteries. Seven patients with symptomatic carotid stenosis were treated by carotid endarterectomy (CEA) before CABG.

RESULTS

There was a 10-fold increase in mortality (12.5%) associated with postoperative stroke. Many variables were analyzed by a multivariate technique and the severity of extracranial carotid artery stenosis was determined to be the only independent predictor of postoperative stroke (p < 0.01). None of the patients with carotid artery occlusion and none of the patients who underwent CEA before CABG experienced a stroke.

CONCLUSIONS

To reduce the stroke rate, the indications for prophylactic CEA may be extended for asymptomatic patients with carotid artery stenosis greater than 75%.

The safety of combined cardiac and vascular operations: how much is too much?

OBJECTIVE

The purpose of this study was to identify factors correlating with a poor outcome following combined cardiac and vascular procedures.

METHODS

We reviewed 45 consecutive patients undergoing combined cardiac and vascular operations. These included cardiac/CEA (n=27), cardiac/AAA (n=13), cardiac/AAA/one other vascular reconstruction (n=4), and cardiac/renal artery bypass (n=1). Group I included all patients with no morbidity or mortality (n=41) and Group II included patients who died or suffered significant morbidity (stroke, renal failure) (n=4).

RESULTS

Overall mortality was 4.4% (2/45). These two patients underwent cardiac surgery combined with two additional vascular procedures (cardiac/AAA/other). In patients undergoing cardiac/CEA or cardiac/AAA, there were no deaths and one stroke (contralateral to CEA). Group II had significantly decreased ejection fraction (39%+/-6% vs 52%+/-1%) and an increased number of procedures (2.75 vs 2.04).

CONCLUSIONS

Combined cardiac surgery and vascular reconstruction can be performed safely. However, multiple vascular reconstructions or the presence of decreased ejection fraction increased operative risk.

Continuing controversy in the management of concomitant coronary and carotid disease: an overview

OBJECTIVES

To perform an analytical overview of the risk factors, pathogenesis of stroke and the strategies for the management of concomitant coronary artery disease and carotid artery stenosis (CAS). Four strategies were analysed; CABG in the presence of CAS, combined (CE+CABG), reverse (CABG+CE<3 months) and prior staged (CE+CABG<3 months).

METHODS

A literature search formed the basis of a reference database. Outcome was assessed by the 30-day permanent stroke and mortality rate for the different approaches. Accrued rates of permanent stroke and mortality rate were expressed in terms of mean stroke and mortality rate (MSR, MMR). Data was analysed comparatively and expressed in terms of P value, odds ratio and confidence limits.

RESULTS

33 different risk factors for stroke at CABG were identified. Significant factors included: ascending aortic atheroma, emergency procedures, impaired left ventricular function, cardioplegia and peripheral vascular disease. Risk of stroke at CABG increased with higher grade CAS (50 vs. 80%, P=0.009). Pathogenesis of stroke at CABG is multifactorial; the role of flow limiting CAS is controversial and other mechanisms are implicated. Analysis of the four strategies revealed that in the Prior Stage (n=573) the MSR was 1.5% and MMR 5.9%, in the Unprotected CABG+CAS series the MSR was 3.8% (n=840) and MMR (n=596) 4.4%, in the Reverse stage series (n=83) the MSR was 2.4%, and MMR 4.8%. For Combined procedures (n=3,295) the MSR was 3.9% and MMR 4.5%. Comparative analysis indicated a significant reduction in stroke for Prior vs. Combined (1.5 vs. 3.9%, P=0.007, odds 0.39, CI 0.2-0.77) with a higher mortality (5.9 vs. 4.5%, P=0.1, odds 1.41, Cl 0.96-2.06, NS). The stroke rate in the Prior stage also remained significantly lower compared to the Unprotected CABG group both mixed (P=0.015) and asymptomatic CAS (P=0.047). When total risks (MSR+MMR), were analysed, similar results were found between the groups; Prior 7.4%, Reverse stage 7.2%, Combined 8.4%, Unprotected CABG+ >50% CAS 11.5%.

CONCLUSIONS

Stroke at CABG is due to multiple risk factors, one of which is high-grade carotid stenosis. Pathophysiology of stroke, although multifactorial, supports embolism rather than flow limitation as the primary mechanism. Lack of randomised trials has made it impossible to draw firm conclusions regarding the best management strategy. There was no significant difference in the overall stroke and mortality risk between the various strategies, however, subgroup analysis suggests that, when carefully selected, patients do better by staging the operations. In our opinion patients without severe cardiac disease should be considered for Prior staging and the rest for Combined procedure. The role of reverse staging needs further evaluation.

Long-term results of simultaneous carotid endarterectomy and myocardial revascularization with cardiopulmonary bypass used for both procedures

OBJECTIVE

Controversy continues about the treatment of patients with a concomitant occlusive disease of the coronary and carotid arteries. Our operative strategy in these patients is to do simultaneous carotid endarterectomy and myocardial revascularization in conjunction with cardiopulmonary bypass with mild hypothermia. We report our experience with this kind of one-stage procedure and its retrospective long-term results.

METHODS

From February 1985 to September 1998, 340 patients underwent simultaneous carotid endarterectomy and myocardial revascularization. The average age of the patients was 65.3 years; 45.6% were neurologically symptomatic, and 44.4% had bilateral carotid stenosis. The indication for carotid endarterectomy was lumen diameter reduction of more than 75%, angiographic signs of thrombogenic endovascular morphology, or both. Carotid endarterectomy was performed in conjunction with cardiopulmonary bypass with mild hypothermia, hemodilution, systemic heparinization, and controlled hemodynamics under pulsatile perfusion for additional cerebral protection.

RESULTS

There were 16 perioperative neurologic complications (4.7%), 11 permanent deficits (3.2%), and 9 cardiac complications (2.6%). Early mortality was 2.6% (SE 0.8%): 2 patients had a stroke and 2 had a myocardial infarction. The 5-year survival was 78.9% (SE 2.6%), and freedom from ipsilateral stroke and cardiac event were 93.2% (SE 1.5%) and 87.5% (SE 2.1%), respectively. The predictor for early death was age over 70 years, and predictors for late death were age over 70 years, previous myocardial infarction, previous stroke, and bilateral carotid stenosis of greater than 90%.

CONCLUSION

On the basis of our long-term results, we believe that simultaneous carotid endarterectomy and myocardial revascularization in conjunction with cardiopulmonary bypass is a method safe enough to prefer its routine use with acceptable low operative risk and satisfactory long-term morbidity.

Early results of percutaneous intervention for severe coexisting carotid and coronary artery disease

Fifty-one patients with severe coexisting carotid and symptomatic coronary artery occlusive disease successfully underwent staged or simultaneous coronary angioplasty and carotid stenting. One pericardial effusion and 2 minor strokes with full recovery occurred in the hospital, but no major neurologic events, myocardial infarction, or death were observed and no repeat revascularization was required within the 30-day follow-up.

Risk neutralization in cardiac operations: detection and treatment of associated carotid disease

BACKGROUND

A screening and treatment protocol was implemented to extend the benefit of prophylactic carotid endarterectomy to patients who had open heart operations.

METHODS

Patients aged 65 or older or who at any age had left main coronary disease, transient ischemic attack, or stroke were eligible for preoperative carotid duplex screening. Carotid endarterectomies and open heart operations were planned as a staged (n = 59) or combined procedure (n = 55) for angiographically confirmed carotid stenosis of at least 80%.

RESULTS

Duplex scans were obtained in 1,719 of 7,035 open heart surgical patients over 8 years. The overall stroke rate was 1.5% (108 of 7,035). Seven of these were strokes of carotid origin (0.1%). There were 129 patients with at least 80% stenosis. One hundred fourteen had carotid endarterectomy preceding open heart operation, and none had carotid artery stroke. Twelve patients with at least 80% carotid stenosis by duplex scan had open heart operations without prophylactic carotid endarterectomies. There were four carotid strokes in these 12 patients (p = 0.0001; odds ratio, 20.2). Stroke risk remained significantly elevated (16.8%, p = 0.005) in the 50% to 79% group. The changes associated with the reduced risk afforded by this screening and treatment strategy amounted to $346 for each patient in the study.

CONCLUSIONS

The risk of carotid stroke at the time of cardiac operation can be defined by duplex screening. Prophylactic carotid endarterectomy neutralizes the risk in those with at least 80% stenosis. Consideration for lowering the threshold for assessment and treatment of carotid stenoses appears warranted. The economic investment is recouped by the savings in system resources that would have been depleted through care for carotid stroke and its sequelae.

Neurological complications of cardiac surgery: the need for new paradigms in prevention and treatment

Neurological injury is a devastating complication of cardiac surgery that results in a longer duration of hospitalization, increased costs, and increased likelihood of death. Such injury can affect any level of the central nervous system, and its manifestations are broad, ranging from neurocognitive dysfunction to frank stroke. Many variables have been found to be indicative or risk for perioperative neurological injury, but the predictive models are more useful for stroke risk than for neurocognitive dysfunction. Strategies aimed at reducing neurological injury during cardiac surgery have focused, for the most part, on the technical aspects of cardiopulmonary bypass. The concomitant performance of carotid endarterectomy and cardiac surgery continues to be controversial, although the management of patients with symptomatic carotid stenosis is better defined. Cerebral embolism, including atheroembolism from the ascending aorta, has an important role in the pathogenesis of neurological injury of all types. Epiaortic ultrasound imaging of the aorta is a sensitive technique for the identification of atherosclerosis of the ascending aorta at the time of surgery, which can allow it to be avoided and therefore reduce the risk for atheroembolism. Results of laboratory investigations have provided insight into the mechanisms of ischemic neuronal injury and a basis for the development of neuroprotective drugs. Neuroprotection may best be accomplished during cardiac surgery because, in contrast to nonsurgical situations, potential agents can be administered before the neurological insult occurs. Reducing the incidence of perioperative stroke will require a multidisciplinary approach that includes novel diagnostic and therapeutic strategies.

Management of coexisting coronary artery and asymptomatic carotid artery disease: report of a series of patients treated with coronary bypass alone

BACKGROUND

A retrospective chart review of 94 patients with asymptomatic high-grade carotid stenosis undergoing coronary bypass (and valve replacement in some cases) was performed to determine whether significant carotid lesions can be safely ignored in patients undergoing cardiac surgical procedures. These operations were performed during a 2-year period.

PATIENTS AND METHODS

There were 55 men and 39 women, with an age range of 37-89 years. Seventy-one patients had unilateral high-grade carotid stenosis, 17 patients had bilateral high-grade lesions, and six patients had unilateral high-grade stenosis and contralateral occlusion. Associated medical problems were recorded and short-term follow-up was obtained.

RESULTS

There was one perioperative stroke and no deaths in this group of patients.

CONCLUSIONS

Although these data indicate that high-grade carotid stenoses may be safely ignored during cardiac surgical procedures, a multicentre prospective randomized trial is needed to determine the appropriate treatment of the patient with coexisting carotid and coronary artery disease.

Carotid disease in patients scheduled for coronary artery bypass: analysis of 678 patients

The purpose of this article is to investigate the frequency of carotid disease and to identify high-risk groups among patients scheduled for isolated coronary artery bypass grafting (CABG) procedures under nonemergent conditions. A total of 678 consecutive patients underwent preoperative carotid artery duplex scanning (CADS) before CABG procedures. Morphology of carotid artery was determined and five groups were formed. Age, sex, cervical bruit, diabetes mellitus (DM), hypertension, smoking, history of cerebrovascular event (CVE), peripheral vascular disease (PVD), and severity of coronary artery disease were investigated to describe the high-risk group for carotid artery disease. In 41% of patients carotid examination produced normal findings; 46.2% had less than 60% luminal stenoses, 7.1% had 60-79% stenoses, 4.6% had 80-99% stenoses, and 1.2% had total occlusion. Previous cerebral ischemic events (CVE) (p<0.05), hypertension (p < 0.01), smoking (p < 0.01), advanced age (p < 0.01), and female sex (p < 0.01) were identified as high-risk factors for carotid artery stenoses. There was a linear association between carotid disease and coronary disease (p < 0.05). Documentation of previous CVE, hypertension, smoking, advanced age, female sex, and severe coronary artery disease may be helpful in identifying patients at high risk for carotid artery stenoses.

Combined carotid endarterectomy and coronary artery bypass: immediate and long-term results

Data from 213 cases of simultaneous carotid endarterectomy and coronary artery bypass grafting (CEN/CABG) were analyzed (1980-1996). There were 154 males (72.3%), and 59 females (27.7%), (mean age: 65. 6 years, range: 42-83). One hundred and thirty-two patients (62.0%) had angina, 58 (37.2%) had myocardial infarction, and 23 (10.8%) had congestive heart failure. Symptomatic cerebrovascular disease was present in 89 patients (41.7%). One hundred and twenty-two patients (57.2%) had three-vessel coronary artery disease, 41 (19.2%) had left main disease, and 27 (12.6%) had a low ejection fraction (ejection fraction </=30%). Significant (>/=75% diameter reduction) stenosis was present in 168 (78.8%) of the operated carotid arteries. The contralateral internal carotid artery was severely stenosed or occluded in 35 patients (16.4%). The hospital mortality rate was 5. 6% (12 patients). The cause of death was cardiac in ten patients (4. 6%), and neurologic in two (1%). Eleven patients (5.1%) developed a stroke postoperatively; eight strokes were ipsilateral to the operated artery, and six were permanent. Myocardial infarction occurred in five patients (2.3%). Independent predictors of early mortality were age >62 years, hypertension, and postoperative stroke (p < 0.05). Male sex was the only independent predictor of neurologic morbidity (p < 0.05). Late follow-up data were obtained for 163 (81.0%) patients (mean: 54.8 months, range: 1-168). Four (9. 3%) out of the 43 late deaths were attributed to strokes. There were three (1.8%) late ipsilateral strokes, and five (3.1%) contralateral strokes. The 5- and 10-year survival probabilities were 75 +/- 4%, and 52 +/- 6.9%. The freedom from late ipsilateral neurologic morbidity at 5 and 10 years were 97 +/- 1.7% and 90 +/- 4.0%, respectively. Taken together, the results indicate that combined carotid endarterectomy and coronary artery bypass grafting can be performed safely in this high-risk group of patients. Excellent long-term freedom from stroke can be expected.

Combined carotid endarterectomy and coronary revascularization operation

The increasing risk of perioperative stroke after coronary artery bypass grafting can in part be attributed to the increased incidence of carotid stenosis with increasing patient age. The efficacy of carotid endarterectomy has been demonstrated for both symptomatic and asymptomatic patients. Combined operations yield acceptable mortality and stroke risks, provide good freedom from late events, and cost less than staged operations.

Rapid-staged strategy for concomitant critical carotid and left main coronary disease with left ventricular dysfunction: IABP use

BACKGROUND

Few reports address the high-risk patient population with concomitant critical carotid and left main coronary disease with left ventricular dysfunction. To decrease the risks involved with the simultaneous and traditional staged surgical approaches, we developed a rapid staging strategy using an intraaortic balloon pump.

METHODS

Between 1992 and 1996, 20 patients presented with a high-risk "triad" defined by greater than 70% stenosis of the left main coronary artery, ejection fraction less than 0.30, and greater than 90% stenosis of the internal carotid artery. An intraaortic balloon pump was placed immediately before carotid endarterectomy under angiographic guidance. Less than 24 hours later (mean, 18 hours) coronary artery bypass grafting was performed, and the intraaortic balloon pump was removed the day of coronary artery bypass grafting in all cases (total IABP duration, <36 hours).

RESULTS

Eighteen patients (18/20) were extubated on the day of coronary artery bypass grafting (mean, 12 hours). Sixteen patients (16/20) were transferred from the intensive care unit within 48 hours, with total hospital stay ranging from 6 to 12 days (mean, 8 days). There were no 30-day postoperative deaths, myocardial infarctions, or neurologic, vascular, bleeding, or other major complications. At a mean 29.4-month follow-up, there were two noncardiac deaths and no neurologic events. Six-month, 1-year, and 2-year follow-up ultrasounds showed all operative carotid arteries remained patent.

CONCLUSIONS

A rapid staged procedure with angiographically guided placement of the intraaortic balloon pump was safe and effective in this very high risk patient population. It may be an option to decrease the risks involved with simultaneous operations and increase the efficiency and safety of "traditional" staged carotid and coronary artery bypass grafting procedures.