Asymptomatic carotid disease in patients undergoing major cardiovascular operations: can prophylactic endarterectomy be justified?

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.

Cardiac surgery in the presence of chronic internal carotid artery occlusion

The aim was to evaluate the incidence of stroke in the setting of cardiac surgery with or without hemodynamically relevant asymptomatic carotid stenosis contralateral to the occlusion. We designed a historical cohorts study, focused on patients with unilateral totally occluded internal carotid arteries who were referred for any cardiac surgery at our center. Isolated unilateral occlusions were assigned to group 1 (n = 60), and those with a contralateral stenosis grade ≥ 60% were included in group 2 (n = 51). A total of 111 patients operated in our center from 1997 to 2016 were included. Patients in group 2 had an asymptomatic contralateral internal carotid artery stenosis with a mean stenosis grade of 71 ± 20%. Simultaneous carotid endarterectomy (CEA) was performed in 22 patients from group 2. The overall mortality was 8/111 (7.2%). Carotid-associated mortality was not observed, whereas an overall stroke incidence of 8/111 (7.2%) was detected. The group-related outcome showed comparable results for mortality (group 1: 4/60 (6.7%) vs. group 2: 4/51 (7.8%); p = 1.0). Regarding stroke incidence, group 2 had a higher incidence of overall strokes (2/60 (3.3%) vs. 6/51 (11.8%); p = 0.14) with more contralateral (0/60 (0%) vs. 2/51 (3.9%); p = 0.209) and ipsilateral strokes (2/60 (3.3%) vs. 4/51 (7.8%); p = 0.411). Stroke rate peaked in patients with simultaneous carotid and cardiac surgery (n = 22; 18.2%; p = 0.048). Performing simultaneous CEA during cardiac surgery in the presence of a contralateral occlusion may promote stroke. Asymptomatic contralateral carotid stenosis is a risk factor for stroke in patients with carotid occlusion prior to cardiac surgery.

Risk Estimates of Stroke After Coronary Artery Bypass Graft and Carotid Endarterectomy

Neurologic complications of cardiovascular surgeries are well documented in the literature. Neurologic deficits may be mild and reversible or may be associated with permanent neurologic deficit. The incidence and severity of such complications vary according to the type of surgical procedure and usually correlate with patients' preoperative general medical condition, duration of surgeries, and intraoperative complications.

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.

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.

The impact of an occluded internal carotid artery on the mortality and morbidity of patients undergoing coronary artery bypass grafting

PURPOSE

To evaluate whether the presence of stenosis or an occluded internal carotid artery (ICA) influences perioperative stroke and mortality rates in patients subjected to coronary artery bypass grafting (CABG).

MATERIAL AND METHODS

Between January 1995 and July 1998, 3,344 patients (59% males; 41% females) had CABG performed at our institution. Preoperative carotid duplex scans performed by registered vascular technologists at an ICAVL accredited laboratory were available for review in all patients. Of these, 3,101 (92.7%) had < 60% ICA stenosis (group A), 182 (5.4%) had 60% to 99% ICA stenosis (group B), and the remaining 61 (1.8%) had a occluded ICA (group C). In the latter group, 53 patients (87%) had < 60% contralateral ICA stenosis, while 8 (13.1%) had significant (60% to 99%) contralateral stenoses. Concomitant carotid endarterectomies (CEAs) were performed in 70 patients in group B (40%) and in 2 patients in group C (3.2%). Age, indications for surgery, prevalence of diabetes, hypertension, and smoking were similar in all groups. The mean pump time for groups A, B and C were 132, 138, and 125 minutes, respectively. The aortic cross-clamp time for group A, B, C were 78, 75, and 75 minutes, respectively. Statistical analyses were performed using the chi-square, Fisher's exact test, and unpaired t test.

RESULTS

Perioperative stroke rates (30 days) were 1.6%, 3.8%, and 6.5% for groups A, B, and C, respectively. Group A results varied significantly from groups B (P < 0.03) and C (P < 0.003). No statistically significant difference was noted between groups B and C (P = 0.6). The presence of a contralateral ICA stenosis in group C patients was predictive of a perioperative stroke (25% versus 3.8%; P < 0.0001). Concomitant CEAs for contralateral severe ICA stenosis in group C were associated with higher stroke rate (100%) when compared with those in group B patients (4.2%; P < 0.02). Perioperative (30 days) mortality rates for groups A, B, and C were 3.6%, 6.6%, and 8.6%, respectively. The mortality rate for group A was lower than for groups B (P < 0.05) and C (P < 0.05).

CONCLUSION

The presence of an ICA occlusion increases the morbidity and mortality in patients undergoing CABG. To the best of our knowledge, this is the first reported large series of patients that investigates the role of carotid occlusions.

Asymptomatic carotid stenosis in patients undergoing major cardiac surgery: can percutaneous carotid angioplasty be an alternative?

OBJECTIVE

As the mortality associated with coronary artery bypass grafts has fallen, morbidity has become an increasing problem. The improvement of transluminal carotid angioplasty is enlarged to patients with asymptomatic severe carotid stenosis (> 85%) requiring coronary surgery.

METHODS

Between January 1993 and January 1995, 10 patients underwent percutaneous carotid angioplasty prior to cardiac surgery (17.4 days). Mean age was 71 +/- 4.3 years. Four patients showed a contralateral occlusion of the internal carotid artery. Transluminal carotid angioplasty was carried out with a triple coaxial catheter system. Six angioplasties required a Strecker stent.

RESULTS

Mean follow-up was 11.4 months. No mortality was observed. Only one patient showed a transient hemianopsia. All patients underwent angiography at four months. Two patients required a new procedure of carotid angioplasty completed with a Strecker stent in one case and by dilatation of a stent in another patient.

CONCLUSION

The results of transluminal carotid angioplasty, in this short series, are encouraging in this group of high-risk morbidity and mortality (elderly patients, bilateral carotid lesions, multiple coronary arterial grafts).

Adverse neurologic events: risks of intracardiac versus extracardiac surgery

Intracardiac operations such as valve replacements have typically carried a higher risk (4.2% to 13%) of overt central nervous system outcome, compared with coronary artery bypass grafting (CABG) procedures (0.6% to 5.2%). This is likely owing to the increased risk of macroembolization of air or particulate matter from the surgical field during intracardiac surgery. The periods of highest risk for emboli are during aortic cannulation and especially during release of aortic clamps and weaning from bypass. The number of embolic events measured with transcranial Doppler is significantly higher in patients undergoing valve surgery compared with coronary surgery, particularly during cardiac ejection and immediately after bypass. However, there is current evidence that neurologic risk is increasing in patients undergoing CABG owing to the tendency to operate on older patients with more severe aortic atherosclerosis and cerebrovascular disease. Patients having an intracardiac procedure combined with a CABG procedure may be at particularly high risk for adverse neurologic outcome. For all cardiac surgical patients, there is some cause for optimism in that risk may be minimized by improved assessment (e.g., intraoperative transesophageal or epiaortic echocardiographic scanning of the ascending aorta to identify patients at risk) and monitoring (e.g., detection of embolic phenomena, using transesophageal echocardiography or transcranial Doppler technology). Furthermore, in the future, development and testing of more ideal cerebroprotective drugs may allow amelioration of neurologic injury, either by pretreating all patients at risk, or possibly even by delaying treatment until after the suspected occurrence of an insult.

Guidelines for carotid endarterectomy. A multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association

BACKGROUND AND PURPOSE

Indications for carotid endarterectomy have engendered considerable debate among experts and have resulted in publication of retrospective reviews, natural history studies, audits of community practice, position papers, expert opinion statements, and finally prospective randomized trials. The American Heart Association assembled a group of experts in a multidisciplinary consensus conference to develop this statement.

METHODS

A conference was held July 16-18, 1993, in Park City, Utah, that included recognized experts in neurology, neurosurgery, vascular surgery, and healthcare planning. A program of critical topics was developed, and each expert presented a talk and provided the chairman with a summary statement. From these summary statements a document was developed and edited onsite to achieve consensus before final revision.

RESULTS

The first section of this document reviews the natural history, methods of patient evaluation, options for medical management, results of surgical management, data from position statements, and results to date of prospective randomized trials for symptomatic and asymptomatic patients with carotid artery disease. The second section divides 96 potential indications for carotid endarterectomy, based on surgical risk, into four categories: (1) Proven: This is the strongest indication for carotid endarterectomy; data are supported by results of prospective contemporary randomized trials. (2) Acceptable but not proven: a good indication for operation; supported by promising but not scientifically certain data. (3) Uncertain: Data are insufficient to define the risk/benefit ratio. (4) Proven inappropriate: Current data are adequate to show that the risk of surgery outweighs any benefit.

CONCLUSIONS

Indications for carotid endarterectomy in symptomatic good-risk patients with a surgeon whose surgical morbidity and mortality rate is less than 6% are as follows. (1) Proven: one or more TIAs in the past 6 months and carotid stenosis > or = 70% or mild stroke within 6 months and a carotid stenosis > or = 70%; (2) acceptable but not proven: TIAs within the past 6 months and a stenosis 50% to 69%, progressive stroke and a stenosis > or = 70%, mild or moderate stroke in the past 6 months and a stenosis 50% to 69%, or carotid endarterectomy ipsilateral to TIAs and a stenosis > or = 70% combined with required coronary artery bypass grafting; (3) uncertain: TIAs with a stenosis < 50%, mild stroke and stenosis < 50%, TIAs with a stenosis < 70% combined with coronary artery bypass grafting, or symptomatic, acute carotid thrombosis; (4) proven inappropriate: moderate stroke with stenosis < 50%, not on aspirin; single TIA, < 50% stenosis, not on aspirin; high-risk patient with multiple TIAs, not on aspirin, stenosis < 50%; high-risk patient, mild or moderate stroke, stenosis < 50%, not on aspirin; global ischemic symptoms with stenosis < 50%; acute dissection, asymptomatic on heparin. Indications for carotid endarterectomy in asymptomatic good-risk patients performed by a surgeon whose surgical morbidity and mortality rate is less than 3% are as follows. (1) Proven: none. As this statement went to press, the National Institute of Neurological Disorders and Stroke issued a clinical advisory stating that the Institute has halted the Asymptomatic Carotid Atherosclerosis Study (ACAS) because of a clear benefit in favor of surgery for patients with carotid stenosis > or = 60% as measured by diameter reduction. When the ACAS report is published, this indication will be recategorized as proven. (2) acceptable but not proven: stenosis > 75% by linear diameter; (3) uncertain: stenosis > 75% in a high-risk patient/surgeon (surgical morbidity and mortality rate > 3%), combined carotid/coronary operations, or ulcerative lesions without hemodynamically significant stenosis; (4) proven inappropriate: operations with a combined stroke morbidity and mortality > 5%.

Guidelines for carotid endarterectomy. A multidisciplinary consensus statement from the ad hoc Committee, American Heart Association

BACKGROUND AND PURPOSE

Indications for carotid endarterectomy have engendered considerable debate among experts and have resulted in publication of retrospective reviews, natural history studies, audits of community practice, position papers, expert opinion statements, and finally prospective randomized trials. The American Heart Association assembled a group of experts in a multidisciplinary consensus conference to develop this statement.

METHODS

A conference was held July 16-18, 1993, in Park City, Utah, that included recognized experts in neurology, neurosurgery, vascular surgery, and healthcare planning. A program of critical topics was developed, and each expert presented a talk and provided the chairman with a summary statement. From these summary statements a document was developed and edited onsite to achieve consensus before final revision.

RESULTS

The first section of this document reviews the natural history, methods of patient evaluation, options for medical management, results of surgical management, data from position statements, and results to date of prospective randomized trials for symptomatic and asymptomatic patients with carotid artery disease. The second section divides 96 potential indications for carotid endarterectomy, based on surgical risk, into four categories: (1) Proven: This is the strongest indication for carotid endarterectomy; data are supported by results of prospective contemporary randomized trials. (2) Acceptable but not proven: a good indication for operation; supported by promising but not scientifically certain data. (3) Uncertain: Data are insufficient to define the risk/benefit ratio. (4) Proven inappropriate: Current data are adequate to show that the risk of surgery outweighs any benefit.

CONCLUSIONS

Indications for carotid endarterectomy in symptomatic good-risk patients with a surgeon whose surgical morbidity and mortality rate is less than 6% are as follows. (1) Proven: one or more TIAs in the past 6 months and carotid stenosis > or = 70% or mild stroke within 6 months and a carotid stenosis > or = 70%; (2) acceptable but not proven: TIAs within the past 6 months and a stenosis 50% to 69%, progressive stroke and a stenosis > or = 70%, mild or moderate stroke in the past 6 months and a stenosis 50% to 69%, or carotid endarterectomy ipsilateral to TIAs and a stenosis > or = 70% combined with required coronary artery bypass grafting; (3) uncertain: TIAs with a stenosis < 50%, mild stroke and stenosis < 50%, TIAs with a stenosis < 70% combined with coronary artery bypass grafting, or symptomatic, acute carotid thrombosis; (4) proven inappropriate: moderate stroke with stenosis < 50%, not on aspirin; single TIA, < 50% stenosis, not on aspirin; high-risk patient with multiple TIAs, not on aspirin, stenosis < 50%; high-risk patient, mild or moderate stroke, stenosis < 50%, not on aspirin; global ischemic symptoms with stenosis < 50%; acute dissection, asymptomatic on heparin. Indications for carotid endarterectomy in asymptomatic good-risk patients performed by a surgeon whose surgical morbidity and mortality rate is less than 3% are as follows. (1) Proven: none. (As this statement went to press, the National Institute of Neurological Disorders and Stroke issued a clinical advisory stating that the Institute has halted the Asymptomatic Carotid Atherosclerosis Study (ACAS) because of a clear benefit in favor of surgery for patients with carotid stenosis > or = 60% as measured by diameter reduction. When the ACAS report is published, this indication will be recategorized as proven. (2) acceptable but not proven: stenosis > 75% by linear diameter; (3) uncertain; stenosis > 75% in a high-risk patient/surgeon (surgical morbidity and mortality rate > 3%), combined carotid/coronary operations, or ulcerative lesions without hemodynamically significant stenosis; (4) proven inappropriate: operations with a combined stroke morbidity and mortality > 5%.

Neuropsychiatric complications of cardiac surgery

Historically, intracardiac operations have carried a higher risk of neurologic complications than coronary artery bypass grafting (CABG) procedures, although the incidence of such complications has been increasing after CABG in recent years. In both intracardiac and extracardiac surgery, macroemboli from the surgical field cause most neurologic complications. The periods of highest risk for emboli are during aortic cannulation, onset of bypass, and weaning from bypass. Risk factors include atherosclerosis of the ascending aorta, advanced age, presence of concomitant cerebral vascular disease, previous neurologic abnormality, duration of surgery, diabetes, and history of failure of the native circulation. Although hypothermia is beneficial in elective circulatory arrest, its usefulness in reducing postoperative central nervous system deficits during routine cardiac operations may be limited. Studies suggest a role for barbiturate protection in intracardiac but not in extracardiac surgery. Studies have not shown better neurologic or neuropsychological outcome with the use of membrane oxygenation and arterial filtration. Recent studies suggest no correlation of neurologic injury with serum glucose levels during CABG, with either duration or severity of hypotension during hypothermic CABG, or with blood gas management during hypothermic CABG.

The intra-aortic balloon pump, a novel addition to staged repair of combined symptomatic cerebrovascular and coronary artery disease

Five patients with severe symptomatic carotid and coronary artery disease were treated with staged carotid endarterectomy and coronary artery bypass grafting (CABG) under the protection of an intra-aortic balloon pump (IABP) over a 56-month period. All patients presented with unstable angina and multiple ipsilateral transient ischemic attacks. Two of the four patients had four previous myocardial infarctions. Arteriography demonstrated three-vessel coronary artery disease and 80% to 95% stenosis of the ipsilateral internal carotid artery in all patients. An IABP was placed prior to uneventful carotid endarterectomy performed with vein patch angioplasty (three patients) or primary closure (two patients) under general anesthesia. All five patients had remarkably stable blood pressure and cardiac outputs while on the IABP. Twenty-four hours after carotid endarterectomy the patients underwent uneventful CABG of three or more vessels. No complications occurred with either surgical procedure. One patient required femoral embolectomy and repair of a small false femoral aneurysm following removal of the IABP. All patients were discharged home 7 to 13 days after CABG. This initial report suggests that IABP can be used safely in staged operations for carefully selected patients with unstable angina and severe symptomatic carotid artery disease.

Combined cardiac operation and carotid endarterectomy during aortic cross-clamping

We present a surgical technique that we believe provides superior cerebral protection for simultaneous correction of carotid and cardiac pathology with low operative mortality and stroke rate. Our study population consists of 23 consecutive patients undergoing cardiac operation between August 1989 and April 1991 who also had associated critical (greater than 85%) carotid artery stenosis. Using 20 degrees C systemic hypothermia for cerebral protection, we performed simultaneous correction of both lesions during the aortic cross-clamp period, using continuous retrograde blood cardioplegia for myocardial protection. Mean patient age was 69.4 years; 83% were 65 years or older. Eighty-seven percent had angina, 35% had recent myocardial infarctions (within 30 days), and 52% had congestive heart failure. Asymptomatic bruit was found in 39%, and 61% had previous strokes, neurologic symptoms, or both. All had 85% or greater luminal narrowing on cerebral angiography, with 65% having severe or critical contralateral disease as well. Sixty-one percent had associated other vascular pathology, including peripheral vascular occlusive disease, renal artery stenosis, or abdominal aortic aneurysm. There were no postoperative strokes or neurologic events. One early vein graft occlusion resulted in postoperative myocardial infarction and subsequent death (4.3%).

Synchronous operation for ischemic cardiac and cerebrovascular disease: early results and long-term follow-up

The late follow-up of 230 patients who underwent synchronous operation for extensive, obstructive extracranial and coronary artery disease from 1974 to 1989 was analyzed. Mean age at operation was 62.5 years; 161 patients (70%) were in New York Heart Association class III or IV, 185 (80%) had triple-vessel disease, and 67 (29%) had left main stem lesions of 50% or more. Previous myocardial infarctions were present in 132 patients (57%). Only 78 had normal left ventricular function. Included were 16 patients undergoing coronary reoperations, 17 patients with additional cardiac procedures, and 3 with synchronous pulmonary procedures. Symptomatic extracranial vascular disease or stabilized neurological deficits were present in 108 patients. Bilateral hemodynamically significant carotid disease was present in 91 patients and arch vessel lesions in 37. The hospital mortality in 8 patients (3.5%) was due to cardiac (n = 4), neurological (n = 1), or multiorgan failure (n = 3). Operative morbidity was mainly neurological (n = 20, 8.7%): 7 reversible deficits and 7 major strokes occurred, 2 reversible and 5 major strokes were related to the operated side(s), and 4 postoperative myocardial infarctions occurred. Actuarial survival at 5 years was 74% (+/- 3.3), at 10 years 54% (+/- 4.9), and at 15 years, 35% (+/- 6.6). This was mainly determined by late cardiac death (41/66). Late morbidity was mainly attributable to cardiac causes rather than neurological causes. At 5 and 10 years, respectively, 72% and 44% of the patients were free of major cardiac and neurological events or death. Synchronous revascularization can be performed relatively safely. The long-term outcome is determined by the extent and severity of the cardiovascular disease.

Perioperative stroke. Part II: Cardiac surgery and cardiogenic embolic stroke

The major mechanism of stroke in cardiac surgery is embolization. The risk is higher in intracardiac than in extracardiac surgery. The incidence of stoke associated with CABG is about 5%. The cerebral protective properties of isoflurane and thiopentone, acid-base management, and monitoring of cerebral perfusion during cardiopulmonary bypass are discussed. Prophylactic carotid endarterectomy for patients with asymptomatic carotid disease before cardiac surgery is not necessary. Symptomatic carotid disease increases the risk of stroke, and the management of patients who have both symptomatic coronary and carotid artery diseases is discussed. Cardiogenic embolism is probably responsible for many perioperative strokes. Patients with atrial fibrillation, valvular disease, and prosthetic heart valves are at high risk of cardiogenic embolism. Strokes associated with cardioversion, pacemaker insertion, coronary arteriography and angioplasty are explored.

Combined carotid and coronary artery surgery: a review of the literature

This article reviews 41 different reports that describe various means of surgical management of coexistent carotid and coronary artery disease in almost 1,500 patients. Stroke is the major risk for patients undergoing myocardial revascularization in the presence of symptomatic carotid artery disease or an asymptomatic carotid bruit that reflects an ulcerative lesion or stenosis exceeding 75%. However, patients with asymptomatic carotid stenosis should not routinely undergo prophylactic carotid endarterectomy. Myocardial infarction is the major hazard in patients undergoing carotid endarterectomy who have coronary artery disease. This risk is magnified when the disease is silent. A high level of awareness and rigorous screening are essential in all patients suspected of having coexistent disease. Although a protocol for the management of these patients is important, individual assessment is essential.