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

Staged Versus Concomitant Carotid Endarterectomy and Aortic Valve Replacement: A Case Report and Literature Review

Stroke is a common complication of cardiac surgery, and carotid artery stenosis is an established risk factor for stroke. Therefore, patients with carotid artery stenosis who are undergoing cardiac surgery require proper management of the former either simultaneously or before cardiac surgery. We present a challenging case of a 67-year-old male patient who presented with generalized weakness, severe aortic stenosis, and significant bilateral carotid artery stenosis. The coexistence of these findings sparked a debate about whether to perform a carotid endarterectomy first or an aortic valve replacement. Moreover, a past history of percutaneous coronary intervention and coronary artery bypass grafts made the decision more challenging. Multiple approaches have been employed for the management of coexisting carotid artery stenosis with cardiac surgery; however, no definitive guidelines exist, especially for surgeries other than coronary artery bypass grafts or where the carotid stenosis is bilateral and severe.

Outcomes of simultaneous carotid endarterectomy and coronary artery bypass grafting: A single centre experience

OBJECTIVE

Stroke following a coronary artery bypass surgery is a well-known complication often predisposed by carotid artery disease. Perioperative risk of stroke after on-pump cardiac surgery can overall affect 2% of patients. Patients with 80-99% unilateral carotid artery stenosis carry a 4% risk of stroke. Significant carotid artery stenosis is present in 3-10% of patients who are candidates for coronary artery bypass grafting (CABG). Those patients might be considered for either simultaneous or staged carotid endarterectomy and CABG to reduce the risk of stroke and death. The purpose of this study was to evaluate preoperative and intraoperative risk factors for myocardial infarction (MI), stroke and death and assess complications occurring during the early postoperative period after simultaneous CABG/CAE procedure.

METHODS

A single centre retrospective analysis of 134 patients from 2015 to 2019 who underwent simultaneous CABG/CEA was performed. At the same period, a total of 2827 CABG were performed, of which 4.7% were simultaneous interventions. We excluded staged CEA/CABG procedures, off-pump CABG and urgent CABG patients. All patients included in the study met the criteria for elective CABG for triple-vessel or left main trunk symptomatic coronary artery disease (CAD) with asymptomatic >70% carotid stenosis or symptomatic ipsilateral >50% carotid stenosis regardless of the degree of contralateral carotid artery stenosis. Patient demographics, comorbidities and operative details were reviewed. The primary endpoint was to assess the intraoperative and 30-day risk of stroke and death after simultaneous CEA/CABG procedure.

RESULTS

Simultaneous CEA/CABG is effective procedure that can be performed in high-risk symptomatic patients with acceptable results. Predictors of postoperative stroke were smoking (P = 0.011), history of MI (P = 0.046), history of CABG (P = 0.013), and history of stroke/TIA (P = 0.005). Significant risk factors for adverse major postoperative complications after simultaneous CEA/CABG procedure were cardiac arrhythmia (AF or AFL) (P = 0.045), previous MI (P < 0.001), and smoking (P = 0.001).

CONCLUSIONS

Synchronous CEA/CABG procedure can be performed with acceptable results in patients having a high risk of stroke, septuagenarians and older.

Combined Treatment With Carotid Endoarterectomy and Coronary Artery Bypass Grafting: A Single-Institutional Experience in 222 Patients

INTRODUCTION

Carotid atherosclerotic disease is a known independent risk factor of post operative stroke after coronary artery bypass grafting (CABG). The best management of concomitant coronary artery disease and carotid artery disease remains debated. Current strategies include simultaneous carotid endoarterectomy (CEA) and CABG, staged CEA followed by CABG, staged CABG followed by CEA, staged transfemoral carotid artery stenting (TF-CAS) followed by CABG, simultaneous TF-CAS and CABG and transcarotid artery stenting.

METHODS

We report our experience based on a cohort of 222 patients undergoing combined CEA and CABG surgery who come to our observation from 2004 to 2020. All patients with >70% carotid stenosis and severe multivessel or common truncal coronary artery disease underwent combined CEA and CABG surgery at our instituion. 30% of patients had previously remote neurological symptoms or a cerebral CT-scan with ischemic lesions. Patients with carotid stenosis >70%, either asymptomatic or symptomatic, underwent CT-scan without contrast media to assess ischemic brain injury, and in some cases, if necessary, CT-angiography of the neck and intracranial vessels.

RESULTS

The overall perioperative mortality rate was 4.1% (9/222 patients). Two patients (.9%) had periprocedural ipsilateral transient ischemic attack (TIA) which completely resolved by the second postoperative day. Two patients (.9%) had an ipsilateral stroke, while 7 patients (3.2%) had a stroke of the controlateral brain hemisphere. Two patients (.9%) patients were affected by periprocedural coma caused by cerebral hypoperfusion due to perioperative heart failure. There were no statistically significant differences between patients in Extracorporeal Circulation (ECC) and Off-pump patients in the onset of perioperative stroke.

CONCLUSION

Our experience reported that combined surgical treatment of CEA and CABG, possibly Off-Pump, is a feasible treatment procedure, able to minimize the risk of post-operative stroke and cognitive deficits.

Preoperative Carotid Duplex Scanning in Patients Undergoing Coronary Artery Bypass Grafting

OBJECTIVE

The aim of this study was to determine the prevalence and risk factors of carotid artery stenosis (CAS) using carotid duplex ultrasound in patients undergoing coronary artery bypass grafting (CABG).

METHODS

This retrospective study was conducted between January 2017 and January 2018 and included 166 consecutive patients [130 males (78.31%), 36 females (21.69%); mean age: 64.25±9.78 years] who underwent elective and isolated CABG. Patients who had significant CAS (≥50% stenosis) were compared with patients who had non-significant CAS (<50% stenosis). Logistic regression analysis was applied across the selected parameters to identify risk factors for significant CAS.

RESULTS

Of all patients, 36 (21.68%) had CAS ≥50% and 8 (4.81%) had unilateral carotid stenosis ≥70%. Carotid endarterectomy/CABG was performed simultaneously in five (3.01%) patients. None of these patients had cardiac and neurological problems during the postoperative period. The overall incidence of cerebrovascular accident (CVA) after CABG was 1.20% (n=2). Age (P=0.011) and history of CVA (P=0.035) were significantly higher in the CAS ≥50 group than in the CAS <50 group. Significant CAS was identified as a risk factor for postoperative CVA (P=0.013).

CONCLUSION

Age and history of CVA were identified as risk factors for significant CAS. Furthermore, significant CAS was identified as a risk factor for postoperative CVA. For this reason, carotid screening is recommended for patients undergoing CABG even in the absence of associated risk factors.

Risk and Outcome after Simultaneous Carotid Surgery and Cardiac Surgery: Single Centre Experience

OBJECTIVE

Carotid artery stenosis in patients undergoing open-heart surgery may increase risk and deteriorate outcome. The aim of the study was the analysis of risks and outcome after simultaneous carotid and cardiac surgery.

METHODS

We retrospectively reviewed the medical records of 100 consecutive patients who underwent simultaneous carotid surgery and open-heart surgery during a 5-year period (from 2006 to 2010). Seventy patients were male and 30 female; the mean age was 70.9±7.9 years (median: 71.8 years). Seventy-three patients underwent coronary bypass grafting (CABG), 18 patients combined CABG and valve procedures, 7 patients CABG combined with other procedures, and 3 patients isolated valve surgery. More than half of patients had had bilateral carotid artery pathology (n=51) including contralateral carotid artery occlusion in 12 cases.

RESULTS

Carotid artery patch plasty was performed in 71 patients and eversion technique in 29. In 75 cases an intraluminal shunt was used. Thirty-day mortality rate was 7% due to cardiac complications (n=5), metabolic disturbance (n=1), and diffuse cerebral embolism (n=1). There were no carotid surgery-related deaths. Postoperatively, transient cerebral ischemia occurred in one patient and stroke with mild permanent neurological deficit (Rankin level 2) in another patient.

CONCLUSION

Simultaneous carotid artery surgery and open-heart surgery have low risk. The underlying cardiac disease influences outcome.

Treatment strategy for combined carotid artery stenosis and coronary artery disease: staged or simultaneous surgical procedure?

Patients with combined carotid and coronary arterial diseases pose a high risk of cerebrovascular events, and the treatment of choice with either a simultaneous or a staged surgical procedure remains controversial. The literature of combined carotid and coronary arterial diseases of a recent decade in English was retrieved. Totally 41,901 patients undergoing simultaneous or staged carotid and coronary procedures from 53 reports were included. As a result, carotid endarterectomy plus coronary artery bypass remained the most commonly used procedure for the intervention of combined carotid artery stenosis and coronary artery disease, and was associated with higher incidences of perioperative transient ischemic attack, stroke and hospital mortality, but with less perioperative myocardial infarction comparing with the staged procedures. Patients with a simultaneous carotid endarterectomy and coronary artery bypass were generally related more to an advanced atherosclerotic coronary artery disease, so that a pure comparison between the two strategies was not always possible. To compare the efficacy of different surgical methods for combined carotid and coronary arterial diseases is of pronounced importance. The new hybrid approach consisting of the simultaneous carotid artery stenting and subsequent on-pump coronary artery bypass can be a safe approach, with the aim to reduce the surgical trauma as compared to surgical procedures, and to reduce the risk of myocardial infarction in the interval period required for the staged operations. Thus, for patients with combined carotid artery stenosis and coronary artery disease, the simultaneous surgical procedure, rather than the staged procedure, is recommended.

Association between carotid and coronary artery disease in patients with aortic valve stenosis: an angiographic study

BACKGROUND

Patients with aortic stenosis have a high prevalence of coronary artery disease, but there is little information about the association of coronary artery disease and carotid artery disease.

METHODS

The study includes 317 consecutive patients with aortic stenosis, who underwent carotid and coronary angiography during the same catheterization before aortic valve replacement.

RESULTS

At univariate analysis, the prevalence of coronary artery disease was associated with (1) presence of carotid artery disease (P < .001); (2) angina pectoris as presentation symptom (P < .001); (3) age more than 65 years (P < .05); and (4) hypertension (P < .05). At multivariate analysis, only carotid artery disease, angina, and age emerged as independent predictors of coronary artery disease. The combination of 2 variables (carotid artery disease, angina) allowed the identification of 4 groups, with decreasing prevalence of coronary artery disease: (1) angina+/carotid artery disease+: 85%; (2) angina-/ carotid artery disease+: 50%; (3) angina+/carotid artery disease-: 41%; (4) angina-/carotid artery disease-: 21% (P < .001).

CONCLUSION

In patients with symptomatic aortic stenosis, the presence of significant carotid artery disease is a strong marker of significant coronary artery disease.

Selective Screening for Asymptomatic Carotid Artery Disease Prior to Isolated Heart Valve Surgery

Objective

To assess the yield of screening for asymptomatic carotid artery disease prior to isolated heart valve surgery (IHVS).

Methods

Retrospective analysis of the preoperative carotid duplex scans performed in neurologically asymptomatic patients who underwent IHVS between 2003 and 2006 was performed. Internal carotid artery (ICA) stenosis of 70% was considered significant. Patients with concomitant coronary artery disease were excluded.

Results

A total of 177 patients underwent IHVS (one valve in 165 and 2 valves in 12 patients). No or minor ICA disease detected in 172 patients. Four patients (2.25%) had significant unilateral ICA stenosis and 1 patient (0.56%) had unilateral ICA occlusion. Three patients (1.69%) suffered postoperative stroke, while 2 patients (1.1%) suffered transient ischemic attacks. All neurologically affected patients had normal preoperative carotid duplex. The in-hospital mortality was 4.5%.

Conclusion

Prevalence of significant ICA disease is low in patients undergoing IHVS. This population does not benefit from preoperative carotid screening.

Predictive value of asymptomatic cervical bruit for carotid artery disease in coronary artery surgery revisited

OBJECTIVE

To investigate the predictive value of asymptomatic cervical bruit for detecting internal carotid artery disease in consecutive patients undergoing coronary artery bypass grafting (CABG).

DESIGN

A prospective cohort study.

SETTING

Tertiary referral university hospitals.

PATIENTS

153 consecutive patients (mean age 57 years) undergoing CABG, without previous history of cerebrovascular events.

INTERVENTIONS

Patients underwent detailed pre-operative work-up, including coronary angiography and carotid artery duplex scanning. Internal carotid artery diameter stenosis was graded as A: normal; B: < 15%; C: 15%-50%; D: 50-80%; D+: > 80-99% and E=complete occlusion.

RESULTS

72 patients (47.1%) (95% CI: 39%, 55%) had no evidence of internal carotid artery stenosis; 81 (52.9%) (95% CI: 44.9%, 60.9%) had varying grades of disease, unilateral or bilateral. Cervical bruit was detected in 12/153 patients (7.8%) (95% CI: 3.5%, 12.1%) of whom all but one (0.7%) had varying grades of internal carotid artery disease; of these, 4 patients had bilateral cervical bruit (2.6%) (95% CI: 0.06%, 5.2%). The sensitivity, specificity, positive and negative predictive values and overall accuracy of cervical bruit for detection of > or = 50% internal carotid artery stenosis were 23.5%, 95.8%, 25%, 95.5% and 91.8%, respectively. The relative risk of > or = 50% stenosis ipsilateral to cervical bruit in 306 sides was 5.58 (95% CI: 2.0, 15.0) and the odds ratio 7.1 (95% CI: 2.0, 25.0).

CONCLUSIONS

Asymptomatic cervical bruit proved a highly specific clinical sign for detection of internal carotid artery stenosis, whether haemodynamically significant (> or = 50%) or otherwise, in patients undergoing myocardial revascularisation. This was matched by a high negative predictive value and overall accuracy for flow limiting atheroma (> or = 50% stenosis). Yet, steering carotid investigations on the basis of cervical bruit alone would result in > or = 80% internal carotid artery stenosis remaining undetected in 3% of overall patients, in whom cervical bruit is absent.

Ultrasound assessment of internal carotid disease candidates to endovascular carotid stenting and cardiac surgery is inaccurate in patients with severe aortic valve stenosis

PURPOSE

The association of internal carotid artery disease (ICAD) with aortic valve stenosis (AVS) constitutes a very high-risk clinical occurrence in which combined surgery may increase the operative risks and carotid stenting before or after cardiac surgery may be a valuable option. Unfortunately, in patients with AVS, the evaluation of carotid arteries by Doppler ultrasound (DUS) may be inaccurate. The present retrospective study is aimed to evaluate the pitfalls of DUS and the role of carotid angiography before carotid stenting in evaluating ICAD in patients with AVS.

METHODS

We analyzed the clinical, hemodynamic, and angiographic findings of 200 patients with moderate to severe AVS (5.5% of 3600 patients underwent cardiac catheterization; mean age, 68.5+/-10.6 years) investigated in our institution over the past 2 years. Patients with moderate to severe AVS, candidates to open cardiac surgery, underwent carotid ultrasonography to assess ICAD and complete left and right catheterization with coronary artery angiography, and in case of doubtful carotid artery sonography, the patients underwent also carotid artery angiography at the time of complete cardiac catheterization before confirming the indication to carotid stenting or combined surgery.

RESULTS

Seventy patients with moderate to severe AVS and doubtful carotid ultrasonography underwent coincident carotid angiography. Reasons for suboptimal Doppler ultrasonographic examination are related to the anatomical or to the difficult evaluation of Doppler flow due to hemodynamic influences of AVS. On carotid angiography, 20 patients (28.5%, male/female, 8/12; mean age, 72.1+/-5.1 years) were diagnosed to have critical stenosis of one (16 patients) or both (4 patients) internal carotid arteries; in five patients, a significant ICAD was not diagnosed by DUS, whereas in seven patients, the stenosis was underestimated by DUS (mean luminal narrowing, 58+/-12.7% vs. 76.7+/-19.3%, P<.03), and in the other eight patients, DUS overestimated ICAD (77+/-12% vs. 62+/- 13.4%, P<.02). Out of this group, six patients underwent successful carotid stenting, six combined surgical treatments, and eight underwent simple cardiac surgery.

CONCLUSIONS

Doppler ultrasound may be inconclusive in evaluating ICAD in patients with moderate to severe AVS candidates to cardiac surgery and endovascular carotid stenting. Carotid angiography may be proposed at the time of cardiac catheterization in patients with inconclusive DUS examination.

Treatment of combined coronary and carotid artery disease

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

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

OBJECTIVES

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Carotid stent-supported angioplasty in a patient with symptomatic and critical aortic stenosis

We report a successful carotid angioplasty in a patient with symptomatic and critical aortic stenosis. The safety and feasibility of this technique in this scenario have not been well established and reported. With careful planning and technique, we believe the procedure should be safe and feasible.