1
|
Yu S, Chaney MA. Combined Coronary and Carotid Artery Disease: What to Operate on First? Or Both at the Same Time? J Cardiothorac Vasc Anesth 2024; 38:1417-1422. [PMID: 37839940 DOI: 10.1053/j.jvca.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/16/2023] [Indexed: 10/17/2023]
Affiliation(s)
- Sherman Yu
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
| |
Collapse
|
2
|
Mohammadian R, Tarighatnia A, Sharifipour E, Nourizadeh E, Parvizi R, Applegate CT, Nader ND. Carotid artery stenting prior to coronary artery bypass grafting in patients with carotid stenosis: Clinical outcomes. Interv Neuroradiol 2023; 29:30-36. [PMID: 35331026 PMCID: PMC9893238 DOI: 10.1177/15910199221067665] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Management of patients undergoing coronary artery bypass grafting (CABG) with obstructive disease of the carotid arteries is still a matter of debate. We compared the results of staged carotid artery stenting (CAS) before CABG in patients with carotid lesions. MATERIALS AND METHOD Patients with significant carotid artery disease who were deemed to simultaneously suffer from an obstructive coronary artery disease requiring CABG from 2008 to 2018 were screened and enrolled in this study. We performed a staged CAS in cases with ≥60% stenosis and neurological symptoms or asymptomatic patients with ≥80% carotid artery stenosis. Patients with bilateral carotid lesions received sequential CAS within three weeks. Six weeks after the CAS procedure, all patients underwent CABG. RESULTS A total of 142 patients were included. Eighty-five of these had neurological symptoms, while the remaining 40% were asymptomatic. Thirty-one patients underwent sequential CAS for bilateral lesions. The cerebrovascular event (CVE) following CAS (3 patients) and CABG (3 patients) was 4.2%. There was only a single case of mortality in this cohort. Although it was not statistically significant, CVE after CABG was more frequent in patients with bilateral carotid disease. CONCLUSIONS Our results showed that staged CAS could be performed with minimal adverse outcomes in patients suffering from a simultaneous occlusive disease of carotids and coronary arteries before CABG. Bilateral CAS will further decrease cerebrovascular events and could be performed consequently or concomitantly.
Collapse
Affiliation(s)
- Reza Mohammadian
- Radiology Department, East Clinical University Hospital, Stradins
University, Riga, Latvia
| | - Ali Tarighatnia
- Department Interventional Radiology, Aalinasab Hospital, ISSO,
Tabriz, Iran
| | - Ehsan Sharifipour
- Neuroscience Research Center, Qom University of Medical Sciences, Qom
University of Medical Sciences, Qom, Iran
| | | | - Rezayat Parvizi
- Cardiovascular Research Center, Tabriz University of Medical
Sciences, Shahid Madani Heart Center, Tabriz, Iran
| | - Camille T. Applegate
- Jacobs School of Medicine and Biomedical
Sciences, 955 Main Street, Buffalo, NY 14203, USA
| | - Nader D. Nader
- Dept. of Anesthesiology & Surgery, Jacobs School of Medicine and Biomedical
Sciences, UB-Gateway Building, 77 Goodell Street, Suite 550, Buffalo, NY
14203
| |
Collapse
|
3
|
Ruka E, Lesur O, Gingras M, Buruian M, Voisine É, Marzouk M, Dagenais F, Voisine P. Relationship Between the Degree of Carotid Stenosis and the Risk of Stroke in Patients Undergoing Cardiac Surgery. Can J Cardiol 2021; 38:347-354. [PMID: 34808321 DOI: 10.1016/j.cjca.2021.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND The impact of carotid stenosis (CS) in patients undergoing cardiac surgery remains controversial. The aim of this study was to evaluate the association between carotid stenosis and stroke and/or transient ischemic attack (TIA) in patients undergoing cardiac surgery on cardiopulmonary bypass. METHODS This is a retrospective cohort study including patients undergoing cardiac surgery on cardiopulmonary bypass between January 2006 and March 2018 at the Quebec Heart and Lung Institute. Data of patients' preoperative demographic characteristics, operative and postoperative variables were taken from a computerized database and patients' charts. Univariate and multivariate analyses were performed. RESULTS A total of 20,241 patients were included in the study. Among those who had received preoperative carotid ultrasound, 516 (2.6% of the total population) had unilateral or bilateral CS ≥50%. Categorized levels of carotid stenosis severity were identified as independent risk factors for post-operative stroke and/or transient ischemic attack occurrence. There was an almost three-fold increased risk of post-operative neurologic events in 80-99% CS vs. less severe 50-79% CS [OR 2.91; IC95% (1.30-6.54)] suggesting that the degree of severity of CS is potentially a strong independent predictor of post-operative neurologic events. CONCLUSIONS CS is an independent risk factor of post-operative stroke and/or TIA. This study suggests for the first time that the risk of stroke increases with the degree of severity of CS, with the greatest risk being for CS between 80-99%. The strength of this relationship and potential causality effect should be further explored in a prospective study focusing on this most at risk population.
Collapse
Affiliation(s)
- Emmeline Ruka
- Quebec Heart and Lung Institute, Québec, Canada; Faculty of Medicine, University of Sherbrooke, Québec, Canada
| | - Olivier Lesur
- Faculty of Medicine, University of Sherbrooke, Québec, Canada
| | | | | | | | | | - François Dagenais
- Quebec Heart and Lung Institute, Québec, Canada; Faculty of Medicine, Laval University, Québec, Canada
| | - Pierre Voisine
- Quebec Heart and Lung Institute, Québec, Canada; Faculty of Medicine, Laval University, Québec, Canada.
| |
Collapse
|
4
|
Xiang B, Luo X, Yang Y, Qiu J, Zhang J, Li L, Yu P, Wang W, Zheng Z. Midterm results of coronary artery bypass graft surgery after synchronous or staged carotid revascularization. J Vasc Surg 2019; 70:1942-1949. [DOI: 10.1016/j.jvs.2019.02.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/27/2019] [Indexed: 10/26/2022]
|
5
|
Tzoumas A, Giannopoulos S, Texakalidis P, Charisis N, Machinis T, Koullias GJ. Synchronous versus Staged Carotid Endarterectomy and Coronary Artery Bypass Graft for Patients with Concomitant Severe Coronary and Carotid Artery Stenosis: A Systematic Review and Meta-analysis. Ann Vasc Surg 2019; 63:427-438.e1. [PMID: 31629126 DOI: 10.1016/j.avsg.2019.09.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/13/2019] [Accepted: 09/17/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Due to the systemic nature of atherosclerosis, arteries at different sites are commonly simultaneously affected. As a result, severe coronary artery disease (CAD) requiring coronary artery bypass grafting (CABG) frequently coexists with significant carotid stenosis that warrants revascularization. To compare simultaneous carotid endarterectomy (CEA) and CABG versus staged CEA and CABG for patients with concomitant CAD and carotid artery stenosis in terms of perioperative outcomes. METHODS This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. A meta-analysis was conducted with the use of a random effects model. The I2 statistic was used to assess for heterogeneity. RESULTS Eleven studies comprising 44,895 patients were included in this meta-analysis (21,710 in the synchronous group and 23,185 patients in the staged group). The synchronous CEA and CABG group had a statistically significant lower risk for myocardial infarction (MI) (odds ratio [OR] 0.15, 95% CI 0.04-0.61, I2 = 0%) and higher risk for stroke (OR 1.51, 95% CI 1.34-1.71, I2 = 0%) and death (OR 1.33, 95% CI 1.01-1.75, I2 = 47.8%). Transient ischemic attacks (TIAs) (OR 1.27, 95% CI 1.00-1.61, I2 = 0.0%), postoperative bleeding (OR 0.82, 95% CI 0.22-3.05, I2 = 0.0%), and pulmonary complications (OR 1.52, 95% CI 0.24-9.60, I2 = 67.5%) were similar between the 2 groups. CONCLUSIONS Patients in the simultaneous CEA and CABG group had a significantly higher risk of 30-day mortality and stroke and lower risk for MI as compared to staged CEA and CABG group. The rates of TIA, postoperative bleeding, and pulmonary complications were similar between the 2 groups. Future randomized trials or prospective cohorts are needed to validate our results.
Collapse
Affiliation(s)
- Andreas Tzoumas
- Department of Internal Medicine, Medical School Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Pavlos Texakalidis
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA
| | - Nektarios Charisis
- Division of Surgical Oncology, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Theofilos Machinis
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA
| | - George J Koullias
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| |
Collapse
|
6
|
Drakopoulou M, Oikonomou G, Soulaidopoulos S, Toutouzas K, Tousoulis D. Management of patients with concomitant coronary and carotid artery disease. Expert Rev Cardiovasc Ther 2019; 17:575-583. [DOI: 10.1080/14779072.2019.1642106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Maria Drakopoulou
- First Department of Cardiology, Medical School of Athens University, Hippokration Hospital, Athens, Greece
| | - Georgios Oikonomou
- First Department of Cardiology, Medical School of Athens University, Hippokration Hospital, Athens, Greece
| | - Stergios Soulaidopoulos
- First Department of Cardiology, Medical School of Athens University, Hippokration Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Medical School of Athens University, Hippokration Hospital, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, Medical School of Athens University, Hippokration Hospital, Athens, Greece
| |
Collapse
|
7
|
Poi MJ, Echeverria A, Lin PH. Contemporary Management of Patients with Concomitant Coronary and Carotid Artery Disease. World J Surg 2018; 42:272-282. [PMID: 28785837 DOI: 10.1007/s00268-017-4103-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The ideal management of concomitant carotid and coronary artery occlusive disease remains elusive. Although researchers have advocated the potential benefits of varying treatment strategies based on either concomitant or staged surgical treatment, there is no consensus in treatment guidelines among national or international clinical societies. Clinical studies show that coronary artery bypass grafting (CABG) with either staged or synchronous carotid endarterectomy (CEA) is associated with a high procedural stroke or death rate. Recent clinical studies have found carotid artery stenting (CAS) prior to CABG can lead to superior treatment outcomes in asymptomatic patients who are deemed high risk of CEA. With emerging data suggesting favorable outcome of CAS compared to CEA in patients with critical coronary artery disease, physicians must consider these diverging therapeutic options when treating patients with concurrent carotid and coronary disease. This review examines the available clinical data on therapeutic strategies in patients with concomitant carotid and coronary artery disease. A treatment paradigm for considering CAS or CEA as well as CABG and percutaneous coronary intervention is discussed.
Collapse
Affiliation(s)
- Mun J Poi
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77054, USA
| | - Angela Echeverria
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77054, USA
| | - Peter H Lin
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77054, USA. .,University Vascular Associates, Los Angeles, CA, USA.
| |
Collapse
|
8
|
Extrakranielle Karotisstenose beim herzchirurgischen Patienten. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00398-018-0250-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
9
|
Castaldo JE, Yacoub HA, Li Y, Kincaid H, Jenny D. Open Heart Surgery Does Not Increase the Incidence of Ipsilateral Ischemic Stroke in Patients with Asymptomatic Severe Carotid Stenosis. J Stroke Cerebrovasc Dis 2017. [PMID: 28623117 DOI: 10.1016/j.jstrokecerebrovasdis.2017.04.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE We evaluated the incidence of perioperative stroke following the institution's 2007 practice change of discontinuing combined carotid endarterectomy and open heart surgery (OHS) for patients with severe carotid stenosis. METHODS In this retrospective cohort study, we compared 113 patients undergoing coronary artery bypass grafting, aortic valve replacement, or both from 2007 to 2011 with data collected from 2001 to 2006 from a similar group of patients. Our aim was to assess whether the practice change led to a greater incidence of stroke. RESULTS A total of 7350 consecutive patients undergoing OHS during the specified time period were screened. Of these, 3030 had OHS between 2007 and 2011 but none were combined with carotid artery surgery (new cohort). The remaining 4320 had OHS before 2007 and 44 had combined procedures (old cohort). Of patients undergoing OHS during the 10-year period of observation, 230 had severe (>80%) carotid stenosis. In the old cohort (before 2007), carotid stenosis was associated with perioperative stroke in 2.5% of cases. None of the 113 patients having cardiac procedures after 2007 received combined carotid artery surgery; only 1 of these patients harboring severe carotid stenosis had an ischemic stroke (.9%) during the perioperative period. The difference in stroke incidence between the 2 cohorts was statistically significant (P = .002). CONCLUSION The incidence of stroke in patients with severe carotid artery stenosis undergoing OHS was lower after combined surgery was discontinued. Combined carotid and OHS itself seems to be an important risk factor for stroke.
Collapse
Affiliation(s)
- John E Castaldo
- Lehigh Valley Health Network, LVPG Neurology, Center for Advanced Health Care, Allentown, Pennsylvania
| | - Hussam A Yacoub
- Lehigh Valley Health Network, LVPG Neurology, Center for Advanced Health Care, Allentown, Pennsylvania.
| | - Yuebing Li
- Cleveland Clinic, Neuromuscular Center, Cleveland, Ohio
| | - Hope Kincaid
- Lehigh Valley Health Network, Network Office of Research and Innovation, Allentown, Pennsylvania
| | - Donna Jenny
- Lehigh Valley Health Network, LVPG Neurology, Center for Advanced Health Care, Allentown, Pennsylvania
| |
Collapse
|
10
|
Abstract
Perioperative care of the patients with neurological diseases can be challenging. Most important consideration is the management and understanding of pathophysiology of these disorders and evaluation of new neurological changes that occur perioperatively. Perioperative generally refers to 3 phases of surgery: preoperative, intraoperative, and postoperative. We have tried to address few commonly encountered neurological conditions in clinical practice, such as delirium, stroke, epilepsy, myasthenia gravis, and Parkinson disease. In this article, we emphasize on early diagnosis and management strategies of neurological disorders in the perioperative period to minimize morbidity and mortality of patients.
Collapse
Affiliation(s)
- Manjeet Singh Dhallu
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmed Baiomi
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhavi Biyyam
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sridhar Chilimuri
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
11
|
Naylor AR. A Critical Review of the Role of Carotid Disease and the Outcomes of Staged and Synchronous Carotid Surgery. Semin Cardiothorac Vasc Anesth 2016; 8:37-42. [PMID: 15372126 DOI: 10.1177/108925320400800108] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Few subjects are as enduring as the management of patients with combined carotid and cardiac disease. This paper reviews the available evidence supporting and refuting the role of carotid artery disease in the pathophysiology of stroke after coronary artery bypass grafting surgery and analyzes the results of systematic reviews of staged and synchronous carotid reconstruction. The available data suggest that only about 40% of strokes (at most) could be directly attributable to ipsilateral carotid artery disease. The rate of death and stroke following staged or synchronous carotid surgery in all published series was 6% and 9%, respectively. Unfortunately, natural history data are inadequate to determine whether a policy of prophylactic carotid endarterectomy reduces the risk of stroke after cardiac surgery.
Collapse
Affiliation(s)
- A R Naylor
- Department of Surgery, Leicester Royal Infirmary, Leicester, England.
| |
Collapse
|
12
|
Abstract
Background:Since the validation of carotid endarterectomy (CEA) as an effective means of stroke prevention, there has been renewed interest in its best indications and methods, as well as in how it compares to carotid angioplasty and stenting (CAS). This review examines these topics, as well as the investigation of carotid stenosis and the role of auditing and reporting CEAresults.Investigation:Brain imaging with CTor MRI should be obtained in patients considered for CEA, in order to document infarction and rule out mass lesions. Carotid investigation begins with ultrasound and, if results agree with subsequent, good-quality MRAor CTangiography, treatment can be planned and catheter angiography avoided. An equally acceptable approach is to proceed directly from ultrasound to catheter angiography, which is still the gold-standard in carotid artery assessment.Indications:Appropriate patients for CEA are those symptomatic with transient ischemic attacks or nondisabling stroke due to 70-99% carotid stenosis; the maximum allowable stroke and death rate being 6%. Uncertain candidates for CEA are those with 50 - 69% symptomatic stenosis, and those with asymptomatic stenosis ≥ 60% but, if selected carefully on the basis of additional risk factors (related to both the carotid plaque and certain patient characteristics), some will benefit from surgery. Asymptomatic patients will only benefit if surgery can be provided with exceptionally low major complication rates (3% or less). Inappropriate patients are those with less than 50% symptomatic or 60% asymptomatic stenosis, and those with unstable medical or neurological conditions.Techniques:Carotid endarterectomy can be performed with either regional or general anaesthesia and, for the latter, there are a number of monitoring techniques available to assess cerebral perfusion during carotid cross-clamping. While monitoring cannot be considered mandatory and no single monitoring technique has emerged as being clearly superior, EEG is most commonly used. “Eversion” endarterectomy is a variation in surgical technique, and there is some evidence that more widely practiced patch closure may reduce the acute risk of operative stroke and the longer-term risk of recurrent stenosis.Carotid angioplasty and stenting:Experience with this endovascular and less invasive procedure grows, and its technology continues to evolve. Some experienced therapists have reported excellent results in case series and a number of randomized trials are now underway comparing CAS to CEA. However, at this time it is premature to incorporate CAS into routine practice replacing CEA.Auditing:It has been shown that auditing of CEA indications and results with regular feed-back to the operating surgeons can significantly improve the performance of this operation. Carotid endarterectomy auditing is recommended on both local and regional levels.
Collapse
Affiliation(s)
- J Max Findlay
- Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | | | | | | |
Collapse
|
13
|
Probasco J, Sahin B, Tran T, Chung TH, Rosenthal LS, Mari Z, Levy M. The preoperative neurological evaluation. Neurohospitalist 2014; 3:209-20. [PMID: 24198903 DOI: 10.1177/1941874413476042] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Neurological diseases are prevalent in the general population, and the neurohospitalist has an important role to play in the preoperative planning for patients with and at risk for developing neurological disease. The neurohospitalist can provide patients and their families as well as anesthesiologists, surgeons, hospitalists, and other providers guidance in particular to the patient's neurological disease and those he or she is at risk for. Here we present considerations and guidance for the neurohospitalist providing preoperative consultation for the neurological patient with or at risk of disturbances of consciousness, cerebrovascular and carotid disease, epilepsy, neuromuscular disease, and Parkinson disease.
Collapse
Affiliation(s)
- John Probasco
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | | | | | | |
Collapse
|
14
|
Management of carotid disease in patients undergoing coronary artery bypass surgery: is it time to change our approach? Curr Opin Cardiol 2012; 26:480-7. [PMID: 21822137 DOI: 10.1097/hco.0b013e32834a7035] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The management of concurrent severe carotid and coronary disease is a subject of ongoing debate in the absence of randomized clinical trials. Amidst the growing controversy, the clinician has to carefully tailor the best strategy for a given patient based on neurologic and cardiac symptoms. This review aims to compile current evidence in this area to help plan strategies for the optimal management of coexisting severe carotid and coronary disease. RECENT FINDINGS Carotid revascularization with carotid endarterectomy (CEA) or stenting (CAS) is frequently performed in conjunction with coronary artery bypass surgery (CABG) in the United States for asymptomatic carotid disease. The risk of perioperative stroke with unilateral asymptomatic 70-99% carotid stenosis is likely small based on several observational data. Moreover, the risk associated with both staged and combined CEA-CABG procedures in the asymptomatic population may outweigh any benefit. Carotid artery stenting is an alternative option in patients with severe coronary disease who are considered 'high risk' for CEA. Neurologically symptomatic patients require carotid revascularization prior to or in conjunction with CABG surgery. Ultimately, the choice of carotid revascularization or conservative management will depend on clinical characteristics, anatomy, and local expertise. SUMMARY Severe carotid disease in the CABG population is often unilateral and asymptomatic. Based on the available data, conservative carotid therapy in the low-risk asymptomatic individuals is likely the best treatment option. Carotid revascularization may be justified in symptomatic or high-risk patients such as those with contralateral carotid occlusion or bilateral severe stenosis.
Collapse
|
15
|
Cao L, Li Q, Bi Q, Yu QJ. Risk factors for recurrent stroke after coronary artery bypass grafting. J Cardiothorac Surg 2011; 6:157. [PMID: 22112676 PMCID: PMC3253694 DOI: 10.1186/1749-8090-6-157] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 11/23/2011] [Indexed: 11/28/2022] Open
Abstract
Objectives Preventing stroke after coronary artery bypass grafting (CABG) remains a therapeutic goal, due in part to the lack of identifiable risk factors. The aim of this study, accordingly, was to identify risk factors in CABG patients with a previous history of stroke. Methods Patients with a history of stroke who underwent CABG at Beijing An Zhen hospital from January 2007 to July 2010 were selected (n = 430), and divided into two groups according to the occurrence of postoperative stroke. Pre-operative and post-operative data were retrospectively collected and analyzed by univariate and multivariate logistic regression analyses. Results Thirty-two patients (7.4%) suffered post-operative stroke. Univariate analysis identified several statistically significant risk factors in the post-operative stroke group, including pre-surgical left ventricular ejection fractions (LVEF) ≤50%, on-pump surgery, post-operative atrial fibrillation (AF), and hypotension. Multivariable analysis identified 4 independent risk factors for recurrent stroke: unstable angina (odds ratio (OR) = 2.95, 95% CI: 1.05-8.28), LVEF ≤50% (OR = 2.77, 95% CI: 1.23-6.27), AF (OR = 4.69, 95% CI: 1.89-11.63), and hypotension (OR = 2.55, 95% CI: 1.07-6.04). Conclusion Unstable angina, LVEF ≤50%, post-operative AF, and post-operative hypotension are independent risk factors of recurrent stroke in CABG patients with a previous history of stroke.
Collapse
Affiliation(s)
- Li Cao
- Department of Anesthesiology, Cardiovascular Institute and Fuwai Hospital, Chinese Academic Medical Science and Peking Union Medical College, Beijing, China
| | | | | | | |
Collapse
|
16
|
Synchronous carotid artery stenting and open heart surgery. J Vasc Surg 2011; 53:1237-41. [DOI: 10.1016/j.jvs.2010.11.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 11/01/2010] [Accepted: 11/06/2010] [Indexed: 11/20/2022]
|
17
|
Naylor AR, Bown MJ. Stroke after Cardiac Surgery and its Association with Asymptomatic Carotid Disease: An Updated Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2011; 41:607-24. [PMID: 21396854 DOI: 10.1016/j.ejvs.2011.02.016] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 02/13/2011] [Indexed: 11/19/2022]
Affiliation(s)
- A R Naylor
- The Department of Vascular Surgery at Leicester Royal Infirmary, Leicester LE2 7LX, UK.
| | | |
Collapse
|
18
|
Is carotid artery disease responsible for perioperative strokes after coronary artery bypass surgery? J Vasc Surg 2011; 52:1716-21. [PMID: 21146753 DOI: 10.1016/j.jvs.2010.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 09/01/2010] [Accepted: 09/01/2010] [Indexed: 11/20/2022]
Abstract
The coronary and extracranial carotid vascular beds are often simultaneously affected by significant atherosclerotic disease, and stroke is one of the potential major complications of coronary artery surgery. As a result, there is no shortage of reports in the vascular surgery literature describing simultaneous coronary and carotid artery revascularizations. Generally, these reports have found this combination of operations safe, but have stopped short of proving that it is necessary. Intuitively, simultaneous carotid endarterectomy and coronary artery bypass surgery could be justified if most perioperative strokes were the result of a significant carotid stenosis, either directly or indirectly. At first glance this appears to be a fairly straightforward issue; however, much of the evidence on both sides of the argument is circumstantial. One significant problem in analyzing outcome by choice of treatment in patients presenting with both coronary and carotid disease is the multiple potential causes of stroke in coronary bypass patients, which include hemorrhage and atheroemboli from aortic atheromas during clamping. But this controversial subject is now open to discussion, and our debaters have been given the challenge to clarify the evidence to justify their claims.
Collapse
|
19
|
Park YJ, Kim DI, Roh YN, Kim WS, Lee YT, Kim GM, Kim DK, Kim YW. Comparative Results of Combined Coronary Artery Bypass Grafting and Carotid Endarterectomy versus Staged Operation. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2011. [DOI: 10.4174/jkss.2011.80.1.61] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Yang Jin Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Ik Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Nam Roh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wook Sung Kim
- Department of Thoracic and Cardiovscular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Tak Lee
- Department of Thoracic and Cardiovscular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Duk-Kyung Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Wook Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
20
|
Surgical Management of Asymptomatic Carotid Stenosis. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10076-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
21
|
Part Two: Against the Motion Carotid Disease is Responsible for the Increased Risk of Stroke after Coronary Bypass Surgery. Eur J Vasc Endovasc Surg 2010; 40:693-5. [DOI: 10.1016/j.ejvs.2010.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
22
|
Curry P, Berg G, Butler J. Carotid artery disease and stroke during coronary artery bypass surgery. Br J Hosp Med (Lond) 2010; 71:631-4. [PMID: 21063256 DOI: 10.12968/hmed.2010.71.11.79662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Stroke is a devastating complication during coronary artery bypass grafting. Screening may identify patients at highest risk. Surgical timing, sequence strategies and carotid stenting remain unresolved. Selective use of techniques could prevent adverse neurological sequelae while achieving complete myocardial revascularization.
Collapse
Affiliation(s)
- Philip Curry
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank, Glasgow
| | | | | |
Collapse
|
23
|
Simultaneous Hybrid Revascularization by Carotid Stenting and Coronary Artery Bypass Grafting. JACC Cardiovasc Interv 2009; 2:393-401. [DOI: 10.1016/j.jcin.2009.02.010] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Revised: 01/21/2009] [Accepted: 02/07/2009] [Indexed: 11/17/2022]
|
24
|
Ranaweera PS, Bigelow BC, Leary MC, de la Torre R, Sellke F, Garcia LA. Endovascular carotid artery stenting and early coronary artery bypass grafting for asymptomatic carotid artery stenosis: Long-term outcomes and neurologic events. Catheter Cardiovasc Interv 2009; 73:139-42. [DOI: 10.1002/ccd.21824] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
25
|
Manabe S, Shimokawa T, Fukui T, Fumimoto KU, Ozawa N, Seki H, Ikenaga S, Takanashi S. Influence of carotid artery stenosis on stroke in patients undergoing off-pump coronary artery bypass grafting. Eur J Cardiothorac Surg 2008; 34:1005-8. [PMID: 18783959 DOI: 10.1016/j.ejcts.2008.08.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 07/13/2008] [Accepted: 08/04/2008] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE It is well known that the presence of carotid artery stenosis increases the risk of perioperative stroke in patients undergoing cardiac surgery with cardiopulmonary bypass. Although off-pump coronary artery bypass grafting (CABG) can avoid the adverse effects of cardiopulmonary bypass, the influence of carotid artery stenosis on the incidence of stroke in patients undergoing off-pump CABG has not been well clarified. METHODS We conducted a retrospective study of 461 patients who underwent elective off-pump CABG after screening for carotid artery stenosis at our institute between September 2004 and May 2007. The incidence and etiologies of stroke were identified. Preoperative screening revealed significant carotid artery stenosis in 49 patients. Clinical results were compared between patients with and without carotid artery stenosis. RESULTS Postoperative stroke occurred in two (0.43%) of the 462 study patients, and in-hospital mortality occurred in three (0.65%). Stroke was due to decreased perfusion resulting from hypovolemic shock in one and thrombosis in the other. There was neither stroke nor in-hospital mortality in patients with carotid artery stenosis, although there were two strokes (0.49%) and three in-hospital mortalities (0.73%) in patients without carotid artery stenosis. CONCLUSIONS The influence of carotid artery stenosis on the incidence of perioperative stroke may be little in off-pump CABG, especially in patients with moderate carotid artery stenosis.
Collapse
Affiliation(s)
- Susumu Manabe
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Fuchu, Tokyo 183-0003, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Bell PRF. Is carotid angioplasty followed by cardiac surgery a safe and effective treatment for carotid artery stenosis? NATURE CLINICAL PRACTICE. CARDIOVASCULAR MEDICINE 2008; 5:246-247. [PMID: 18349824 DOI: 10.1038/ncpcardio1162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Accepted: 01/28/2008] [Indexed: 05/26/2023]
Affiliation(s)
- Peter R F Bell
- Department of Surgery, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX, UK.
| |
Collapse
|
27
|
Guzman LA, Costa MA, Angiolillo DJ, Zenni M, Wludyka P, Silliman S, Bass TA. A Systematic Review of Outcomes in Patients With Staged Carotid Artery Stenting and Coronary Artery Bypass Graft Surgery. Stroke 2008; 39:361-5. [PMID: 18174484 DOI: 10.1161/strokeaha.107.495010] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Luis A. Guzman
- From the Division of Cardiology (L.A.G., M.A.C., D.J.A., M.Z., T.A.B.), the Division of Neurology (S.S.), and the Office of Research Affairs (P.W.), University of Florida College of Medicine–Jacksonville, Jacksonville, Fla
| | - Marco A. Costa
- From the Division of Cardiology (L.A.G., M.A.C., D.J.A., M.Z., T.A.B.), the Division of Neurology (S.S.), and the Office of Research Affairs (P.W.), University of Florida College of Medicine–Jacksonville, Jacksonville, Fla
| | - Dominick J. Angiolillo
- From the Division of Cardiology (L.A.G., M.A.C., D.J.A., M.Z., T.A.B.), the Division of Neurology (S.S.), and the Office of Research Affairs (P.W.), University of Florida College of Medicine–Jacksonville, Jacksonville, Fla
| | - Martin Zenni
- From the Division of Cardiology (L.A.G., M.A.C., D.J.A., M.Z., T.A.B.), the Division of Neurology (S.S.), and the Office of Research Affairs (P.W.), University of Florida College of Medicine–Jacksonville, Jacksonville, Fla
| | - Peter Wludyka
- From the Division of Cardiology (L.A.G., M.A.C., D.J.A., M.Z., T.A.B.), the Division of Neurology (S.S.), and the Office of Research Affairs (P.W.), University of Florida College of Medicine–Jacksonville, Jacksonville, Fla
| | - Scott Silliman
- From the Division of Cardiology (L.A.G., M.A.C., D.J.A., M.Z., T.A.B.), the Division of Neurology (S.S.), and the Office of Research Affairs (P.W.), University of Florida College of Medicine–Jacksonville, Jacksonville, Fla
| | - Theodore A. Bass
- From the Division of Cardiology (L.A.G., M.A.C., D.J.A., M.Z., T.A.B.), the Division of Neurology (S.S.), and the Office of Research Affairs (P.W.), University of Florida College of Medicine–Jacksonville, Jacksonville, Fla
| |
Collapse
|
28
|
Versaci F, Del Giudice C, Scafuri A, Zeitani J, Gandini R, Nardi P, Salvati A, Pampana E, Sebastiano F, Romagnoli A, Simonetti G, Chiariello L. Sequential Hybrid Carotid and Coronary Artery Revascularization: Immediate and Mid-Term Results. Ann Thorac Surg 2007; 84:1508-13; discussion 1513-4. [DOI: 10.1016/j.athoracsur.2007.05.048] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 05/18/2007] [Accepted: 05/21/2007] [Indexed: 11/16/2022]
|
29
|
Van der Heyden J, Suttorp MJ, Bal ET, Ernst JM, Ackerstaff RG, Schaap J, Kelder JC, Schepens M, Plokker HW. Staged Carotid Angioplasty and Stenting Followed by Cardiac Surgery in Patients With Severe Asymptomatic Carotid Artery Stenosis. Circulation 2007; 116:2036-42. [PMID: 17938290 DOI: 10.1161/circulationaha.106.658625] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The strategy for treating patients with severe asymptomatic carotid artery stenosis and cardiac disease remains unresolved. Staged or combined carotid endarterectomy in these patients offers the potential benefit of decreased neurological morbidity during and after cardiac surgery; however, in high-risk patients with severe coronary artery disease, chronic obstructive pulmonary disease, or renal impairment, the incidence of death and stroke is significantly higher.
Methods and Results—
We report the results of a prospective, single-center study designed to evaluate the feasibility and safety of carotid artery angioplasty and stenting (CAS) before cardiac surgery in neurologically asymptomatic patients. The periprocedural and long-term outcomes of 356 consecutive patients who underwent CAS before cardiac surgery were analyzed. The procedural success rate of CAS was 97.7%. The death and stroke rate from time of CAS to 30 days after cardiac surgery was 4.8% (n=17). The myocardial infarction rate from time of CAS to 30 days after cardiac surgery was 2.0% (n=7), and the combined death, stroke, and myocardial infarction rate was 6.7% (n=24). Distal embolic protection devices were used in 40% of the cases.
Conclusions—
This large cohort of asymptomatic patients who underwent staged CAS and cardiac surgery experienced a low periprocedural complication rate. The high rate of freedom from death and stroke during the 5 years of follow-up supports the long-term durability of this approach. Our findings suggest that this new strategy may become a valuable alternative in the treatment of patients with combined carotid and cardiac disease.
Collapse
Affiliation(s)
- Jan Van der Heyden
- From the Department of Interventional Cardiology (J.V.d.H., M.J.S., E.T.B., J.M.E., J.S., J.C.K., H.W.P.), Department of Cardiothoracic and Cardiovascular Surgery (M.S.), and Department of Clinical Neurophysiology (R.G.A.), St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Maarten J. Suttorp
- From the Department of Interventional Cardiology (J.V.d.H., M.J.S., E.T.B., J.M.E., J.S., J.C.K., H.W.P.), Department of Cardiothoracic and Cardiovascular Surgery (M.S.), and Department of Clinical Neurophysiology (R.G.A.), St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Egbert T. Bal
- From the Department of Interventional Cardiology (J.V.d.H., M.J.S., E.T.B., J.M.E., J.S., J.C.K., H.W.P.), Department of Cardiothoracic and Cardiovascular Surgery (M.S.), and Department of Clinical Neurophysiology (R.G.A.), St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jef M. Ernst
- From the Department of Interventional Cardiology (J.V.d.H., M.J.S., E.T.B., J.M.E., J.S., J.C.K., H.W.P.), Department of Cardiothoracic and Cardiovascular Surgery (M.S.), and Department of Clinical Neurophysiology (R.G.A.), St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Rob G. Ackerstaff
- From the Department of Interventional Cardiology (J.V.d.H., M.J.S., E.T.B., J.M.E., J.S., J.C.K., H.W.P.), Department of Cardiothoracic and Cardiovascular Surgery (M.S.), and Department of Clinical Neurophysiology (R.G.A.), St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jeroen Schaap
- From the Department of Interventional Cardiology (J.V.d.H., M.J.S., E.T.B., J.M.E., J.S., J.C.K., H.W.P.), Department of Cardiothoracic and Cardiovascular Surgery (M.S.), and Department of Clinical Neurophysiology (R.G.A.), St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Johannes C. Kelder
- From the Department of Interventional Cardiology (J.V.d.H., M.J.S., E.T.B., J.M.E., J.S., J.C.K., H.W.P.), Department of Cardiothoracic and Cardiovascular Surgery (M.S.), and Department of Clinical Neurophysiology (R.G.A.), St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Mark Schepens
- From the Department of Interventional Cardiology (J.V.d.H., M.J.S., E.T.B., J.M.E., J.S., J.C.K., H.W.P.), Department of Cardiothoracic and Cardiovascular Surgery (M.S.), and Department of Clinical Neurophysiology (R.G.A.), St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Herbert W. Plokker
- From the Department of Interventional Cardiology (J.V.d.H., M.J.S., E.T.B., J.M.E., J.S., J.C.K., H.W.P.), Department of Cardiothoracic and Cardiovascular Surgery (M.S.), and Department of Clinical Neurophysiology (R.G.A.), St. Antonius Hospital, Nieuwegein, the Netherlands
| |
Collapse
|
30
|
Schoof J, Lubahn W, Baeumer M, Kross R, Wallesch CW, Kozian A, Huth C, Goertler M. Impaired cerebral autoregulation distal to carotid stenosis/occlusion is associated with increased risk of stroke at cardiac surgery with cardiopulmonary bypass. J Thorac Cardiovasc Surg 2007; 134:690-6. [PMID: 17723819 DOI: 10.1016/j.jtcvs.2007.03.018] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2007] [Revised: 03/20/2007] [Accepted: 03/29/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Severe carotid stenosis and occlusion are associated with an increased risk of stroke during and after cardiac surgery with cardiopulmonary bypass. Relevance of an impaired cerebral autoregulation caused by stenosis/occlusion is unknown. METHODS We prospectively assessed the incidence of stroke in relation to severity of carotid disease and corresponding autoregulatory reserve in 2797 patients who had coronary artery bypass graft and/or valve surgery with cardiopulmonary bypass. Patients underwent preoperative carotid sonography and, in case of severe extracranial disease, transcranial Doppler sonography with carbon dioxide stimulation to assess cerebrovascular reserve capacity. RESULTS Sixty-seven (2.4%) patients had an ischemic stroke, which was fatal in 5. Anterior hemispheric stroke occurred in 42 (1.9%) patients with no/low-grade stenosis, 6 (1.8%) with medium-grade stenosis, 1 (0.6%) with high-grade stenosis/occlusion and normal autoregulation, and 3 (27.3%) with high-grade stenosis/occlusion and exhausted autoregulatory reserve. Increased risk was observed in patients with high-grade stenosis/occlusion and exhausted autoregulatory reserve also after adjustment for potential confounders (adjusted odds ratio [OR] 28.3, 95% confidence interval [CI] 5.8-139.1). Stroke risk was not increased in patients with stenosis/occlusion and normal autoregulation (1.5%, adjusted OR 0.6, 95% CI 0.2-1.6). CONCLUSIONS Cerebrovascular reserve capacity evaluated by preoperative transcranial Doppler carbon dioxide testing is a major determinant of stroke risk in patients with carotid artery stenosis/occlusion undergoing cardiac surgery with cardiopulmonary bypass. Its assessment facilitates identification of patients with an excess perioperative stroke risk.
Collapse
Affiliation(s)
- Julia Schoof
- Department of Neurology, University of Magdeburg, Magdeburg, Germany
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Türköz A, Türköz R, Gülcan O, Sener M, Kiziltan T, Calişkan E, Bozdoğan N, Arslan G. Wake-Up Test After Carotid Endarterectomy for Combined Carotid–Coronary Artery Surgery: A Case Series. J Cardiothorac Vasc Anesth 2007; 21:540-6. [PMID: 17678781 DOI: 10.1053/j.jvca.2006.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Indexed: 11/11/2022]
Abstract
OBJECTIVE In combined carotid-coronary artery surgery, it is important to determine patients' neurologic status after carotid endarterectomy (CEA). An initial stroke could be exacerbated by cardiopulmonary bypass required for coronary artery bypass graft (CABG) surgery. Various monitoring methods (eg, electroencephalogram) have been used to reduce neurologic deficits during CEA under general anesthesia. However, none of the methods of determining neurologic status of patients are ideal during the time between the end of CEA and the beginning of CABG surgery. In this study, patient's neurologic status was assessed after CEA with a wake-up test to identify stroke before CABG surgery. DESIGN A prospective nonrandomized case series. SETTING Single institution, university hospital. PARTICIPANTS Forty-four patients with carotid artery stenosis and coronary artery disease underwent combined carotid-coronary artery surgery. INTERVENTIONS After CEA, propofol and remifentanil anesthesia was discontinued, the wake-up test was performed, and then anesthesia was reinstituted for CABG surgery. MEASUREMENTS AND RESULTS A total of 48 wake-up tests were performed in 43 patients. Two wake-up tests were performed in each of the 5 patients who underwent bilateral CEA. Postoperative stroke were seen in 2 patients. In the first patient, despite a normal wake-up test, the stroke occurred in the cerebral hemisphere contralateral to the CEA, and the patient recovered within 12 days. In the second patient, there was a positive wake-up test after CEA, and he recovered within 3 days. One patient died postoperatively because of ventricular failure. CONCLUSIONS Although this is a case series, the authors believe that performing a neurologic examination using a wake-up test may make a contribution and increases the safety of combined surgical procedures in patients with coronary and carotid artery disease.
Collapse
Affiliation(s)
- Ayda Türköz
- Department of Anesthesiology, Başkent University Adana Teaching and Medical Research Center, Adana, Turkey.
| | | | | | | | | | | | | | | |
Collapse
|
32
|
Virmani R, Ladich ER, Burke AP, Kolodgie FD. Histopathology of carotid atherosclerotic disease. Neurosurgery 2007; 59:S219-27; discussion S3-13. [PMID: 17053606 DOI: 10.1227/01.neu.0000239895.00373.e4] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Stroke is the third leading cause of death in the United States, constituting approximately 700,000 cases each year, of which about 500,000 are first attacks and 200,000 are recurrent attacks. Ischemic stroke accounts for the majority of all strokes (88%), followed by intracerebral hemorrhage (9%) and subarachnoid hemorrhage (3%). Patients with substantial carotid narrowing are at increased risk for major stroke; however, recent studies suggest that factors other than the degree of carotid stenosis are involved in ischemic stroke pathogenesis. Atherosclerotic plaque of the stenotic carotid artery is the underlying cause of the majority of ischemic strokes and specific plaque characteristics have been associated with ischemic brain injury. Several studies have demonstrated that the mechanisms of plaque instability in the carotid circulation are similar to those in the coronary circulation. The purpose of this review is to characterize atherosclerotic carotid disease in light of our knowledge of coronary atherosclerosis and relate carotid plaque morphology to cerebral ischemic syndromes. Histological examination of the carotid plaque specimen should provide insights into the underlying plaque morphology that is responsible for the disease and should help determine the potential treatments that are likely to be beneficial in the prevention of a subsequent event.
Collapse
Affiliation(s)
- Renu Virmani
- International Registry of Pathology, Inc., Gaithersburg, Maryland, USA
| | | | | | | |
Collapse
|
33
|
Affiliation(s)
- Magdy Selim
- Department of Neurology, Division of Cerebrovascular Diseases, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
| |
Collapse
|
34
|
Chiariello L, Tomai F, Zeitani J, Versaci F. Simultaneous Hybrid Revascularization by Carotid Stenting and Coronary Artery Bypass Grafting. Ann Thorac Surg 2006; 81:1883-5. [PMID: 16631695 DOI: 10.1016/j.athoracsur.2005.04.086] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2005] [Revised: 04/25/2005] [Accepted: 04/26/2005] [Indexed: 11/28/2022]
Abstract
Surgical treatment of simultaneous coronary and carotid disease is still controversial, because of the high risk of morbidity and mortality after combined or staged carotid artery endoarterectomy and the coronary artery bypass grafting approach. We report the first 10 patients with concomitant coronary and carotid disease successfully treated with an alternative strategy consisting of simultaneous hybrid revascularization by carotid artery stenting and coronary artery bypass grafting.
Collapse
Affiliation(s)
- Luigi Chiariello
- Divisione di Cardiochirurgia, Università Tor Vergata, Rome, Italy.
| | | | | | | |
Collapse
|
35
|
Mendiz O, Oscar M, Fava C, Carlos F, Valdivieso L, León V, Dulbecco E, Eduardo D, Raffaelli H, Héctor R, Lev G, Gustavo L, Favaloro R, Roberto F. Synchronous carotid stenting and cardiac surgery: An initial single-center experience. Catheter Cardiovasc Interv 2006; 68:424-8. [PMID: 16892442 DOI: 10.1002/ccd.20883] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Concurrent severe carotid and cardiac disease is a challenging situation where staged surgery is probably the most common strategy, although it is still controversial. We report in-hospital and midterm outcome of 30 patients who received carotid stenting and synchronous cardiac surgery. All received carotid stenting under aspirin and regular unfractioned heparin (UFH) and were immediately transferred to the operating room for coronary and/or cardiac valve surgery. All patients received aspirin and clopidogrel once bleeding was ruled out, after surgery. In-hospital complications were: three surgical related deaths, one TIA, and no patient suffered stroke or myocardial infarction. Hospital stay was 14 +/- 11.8 days. Survivors were followed for 18.4 +/- 14 months. There were two non-related deaths, but no stroke nor cardiac or carotid reinterventions. In conclusion, this small series showed that synchronous carotid stenting and cardiac surgery was feasible with an acceptable complication rate in a high-surgical-risk population which could not undergo staged procedures.
Collapse
Affiliation(s)
- Oscar Mendiz
- Department of Interventional Cardiology, Fundación Favaloro, Buenos Aires, Argentina.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Paciaroni M, Caso V, Acciarresi M, Baumgartner RW, Agnelli G. Management of asymptomatic carotid stenosis in patients undergoing general and vascular surgical procedures. J Neurol Neurosurg Psychiatry 2005; 76:1332-6. [PMID: 16170071 PMCID: PMC1739358 DOI: 10.1136/jnnp.2005.066936] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Current available data do not seem to support the strategy for carotid endarterectomy prior to surgical intervention in patients with asymptomatic carotid stenosis. However, in patients with coronary artery disease, synchronous carotid endarterectomy and coronary artery bypass grafting should be considered where there is a proven surgical risk of <3% with unilateral asymptomatic stenosis >60% or bilateral carotid stenosis >75% on the same side as the most severe stenosis. Clarification of the optimal strategy requires an adequately powered, multicentre, randomised clinical trial.
Collapse
Affiliation(s)
- M Paciaroni
- Stroke Unit, University of Perugia, Ospedale Silvestrini, Sant'Andrea delle Fratte, Perugia 06126, Italy.
| | | | | | | | | |
Collapse
|
37
|
Ghosh J, Murray D, Khwaja N, Murphy MO, Walker MG. The Influence of Asymptomatic Significant Carotid Disease on Mortality and Morbidity in Patients Undergoing Coronary Artery Bypass Surgery. Eur J Vasc Endovasc Surg 2005; 29:88-90. [PMID: 15570278 DOI: 10.1016/j.ejvs.2004.07.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Controversy exists regarding the optimal management of patients with coexisting coronary and extracranial carotid artery disease. This study investigates the incidence of death, cerebrovascular events and myocardial infarction (MI) in patients with asymptomatic significant carotid artery disease undergoing coronary artery bypass graft (CABG) surgery. DESIGN Prospective cohort. METHODS Fifty patients with asymptomatic carotid stenoses > or =70% associated with cervical bruits undergoing CABG without prophylactic carotid endarterectomy (CEA) were followed up over a median period of 68 months following surgery cerebrovascular events, MI and mortality were recorded. All patients received optimal secondary prevention for cardiovascular disease unless contraindicated. RESULTS No cerebrovascular events occurred within 30 days of surgery. One patient suffered an ipsilateral transient ischaemic attack (TIA) 14 months after CABG. Two patients died within 30 days; one from an MI, the other from pancreatitis. Three deaths occurred after 30 days; one from MI, one from primary lung cancer and one following rupture of an abdominal aortic aneurysm. No non-fatal MIs occurred. CONCLUSIONS In this patient group the overall risk of death, cerebrovascular events and MI was 4% during the first 30 days postoperatively and 8% thereafter. This compares favourably with published series for staged or combined CEA-CABG procedures. For asymptomatic significant carotid disease, prophylactic CEA prior to CABG does not appear to confer any advantage over CABG alone.
Collapse
Affiliation(s)
- J Ghosh
- Department of Vascular Surgery, Manchester Royal Infirmary, Manchester M13 9WL, UK
| | | | | | | | | |
Collapse
|
38
|
Espinola-Klein C, Rupprecht HJ, Meyer J. [Carotid stenosis concomitant to coronary artery disease]. Chirurg 2004; 75:667-71. [PMID: 15221090 DOI: 10.1007/s00104-004-0903-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Carotid stenosis is frequent in patients with coronary artery disease (CAD). In the literature, 9-28% of patients with CAD have additional carotid artery stenosis, predictors of which are advanced age, smoking, diabetes mellitus, arterial hypertension, coronary multivessel disease, and peripheral arterial disease. Moreover, patients with unstable coronary syndromes and those with elevated inflammatory markers such as C-reactive protein or fibrinogen more often have concomitant CAD and carotid artery stenosis. The long-term prognosis of these patients is worse than with CAD only. Therefore, patients with CAD should be screened for additional carotid artery stenosis, especially if coronary artery bypass grafting is planned. Continuous wave Doppler sonography and color-coded duplex sonography are suitable methods to screen for carotid artery stenosis.
Collapse
Affiliation(s)
- Ch Espinola-Klein
- II. Medizinische Klinik und Poliklinik, Johannes-Gutenberg-Universität Mainz.
| | | | | |
Collapse
|
39
|
Findlay JM, Marchak BE. Carotid Endarterectomy. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50073-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
40
|
Abstract
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.
Collapse
Affiliation(s)
- Joseph Huh
- Division of Cardiothoracic Surgery, Houston Veterans Affairs Medical Center, Ben Taub General Hospital, Baylor College of Medicine, Houston, Texas 77401, USA.
| | | | | |
Collapse
|
41
|
Naylor R, Cuffe RL, Rothwell PM, Loftus IM, Bell PR. A systematic review of outcome following synchronous carotid endarterectomy and coronary artery bypass: Influence of surgical and patient variables. Eur J Vasc Endovasc Surg 2003; 26:230-41. [PMID: 14509884 DOI: 10.1053/ejvs.2002.1975] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
Collapse
Affiliation(s)
- R Naylor
- Department of Vascular Surgery at Leicester Royal Infirmary, Clinical Neurology, The Radcliffe Infirmary, P.O. Box 65, Leicester Royal Infirmary, Leicester, U.K
| | | | | | | | | |
Collapse
|
42
|
Rijbroek A, Wisselink W, Rauwerda JA. The impact of training in unselected patients on mortality and morbidity in carotid endarterectomy in a vascular training center and the recommendations of the European Board of Surgery Qualification in Vascular Surgery. Eur J Vasc Endovasc Surg 2003; 26:256-61. [PMID: 14509887 DOI: 10.1053/ejvs.2002.1944] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To investigate the impact of training of vascular fellows on the results of carotid endarterectomy (CEA) in unselected patients and to evaluate the recommendations of the European Board of Surgery Qualification in Vascular Surgery (EBSQ-VASC) concerning CEA. METHODS Complication rates and selection criteria of all CEAs, performed between 1995 and 2000 (n = 200) were retrospectively analysed and correlated to operating surgeon; supervised, nonsupervised vascular trainees, and consultant vascular surgeons. The number of CEAs were compared with the required minimal procedures according to the EBSQ-VASC. RESULTS Selection criteria for CEA did not differ significantly between operating surgeon groups, except that combined procedures were more performed by nonsupervised trainees and asymptomatic stenosis by consultant surgeons. The overall persistent disabling stroke rate and stroke-related mortality was 3%, with 4.3% in the supervised group, 0% in the unsupervised, and 2.8% in the consultant surgeon group, respectively. The amount of CEAs corresponded to the demands of the EBSQ-VASC. CONCLUSIONS In our institution, no significant differences in neurological morbidity and mortality following CEA could be demonstrated in relation to surgeon training level. The number of CEAs performed by residents fulfill the criteria of the EBSQ-VASC. We conclude that CEA can be safely taught to vascular trainees in unselected patients in a vascular training centre.
Collapse
Affiliation(s)
- A Rijbroek
- Department of General and Vascular Surgery, Kennemer Gasthuis Haarlem, PO Box 417, 2000 AK Haarlem, The Netherlands
| | | | | |
Collapse
|
43
|
Naylor AR, Cuffe RL, Rothwell PM, Bell PRF. A systematic review of outcomes following staged and synchronous carotid endarterectomy and coronary artery bypass. Eur J Vasc Endovasc Surg 2003; 25:380-9. [PMID: 12713775 DOI: 10.1053/ejvs.2002.1895] [Citation(s) in RCA: 196] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
Collapse
Affiliation(s)
- A R Naylor
- Department of Vascular Surgery, Clinical Sciences Building, PO Box 65, Leicester Royal Infirmary, Leicester LE2 7LX, UK
| | | | | | | |
Collapse
|