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Tsukagoshi J, Yokoyama Y, Fujisaki T, Takagi H, Shirasu T, Kuno T. Systematic review and meta-analysis of the treatment strategies for coronary artery bypass graft patients with concomitant carotid artery atherosclerotic disease. J Vasc Surg 2023; 78:1083-1094.e8. [PMID: 37257673 DOI: 10.1016/j.jvs.2023.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/23/2023] [Accepted: 04/28/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Stroke is one of the devastating complications after coronary artery bypass graft (CABG). Underlying carotid artery atherosclerotic disease is reported to be an independent risk factor. The optimal treatment strategy for these patients remains under debate. METHODS We aimed to perform a network meta-analysis to evaluate the safety and efficacy of additional carotid interventions for patients with concomitant carotid artery atherosclerotic disease who require CABG by comparing perioperative adverse event rates. All articles through February 2022 were searched using MEDLINE and EMBASE to identify studies that investigated outcomes of CABG only as well as additional staged vs combined carotid interventions by both carotid endarterectomy (CEA) and carotid artery stenting (CAS). RESULTS Two randomized controlled trials and 23 observational studies were included, yielding a total of 32,473 patients who underwent combined CEA and CABG (n = 20,204), CEA and staged CABG (n = 6882), CABG and staged CEA (n = 340), CAS and CABG regardless of timing and sequences (n = 1224), and CABG only (n = 3823). No strategy showed a significant advantage over CABG only in all perioperative outcomes. CEA and staged CABG was associated with the lowest perioperative stroke/transient ischemic attack (TIA) rate, significantly lower compared with CAS and CABG (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.36-0.76) as well as CABG and staged CEA (OR, 0.41; 95% CI, 0.23-0.74), but was also associated with the highest perioperative mortality (OR, 2.50; 95% CI, 1.67-3.85, vs CAS and CABG) and myocardial infarction rate (OR, 3.70 [95% CI, 1.16-12.5] and OR, 2.50 [95% CI, 1.35-4.55] vs CAS and CABG, vs combined CEA and CABG, respectively). CONCLUSIONS CEA and staged CABG are associated with low perioperative stroke/transient ischemic attack rates with a tradeoff of higher mortality and myocardial infarction rate. No strategy showed a significant advantage over the CABG-only strategy in all perioperative outcomes, outlining the importance of a tailored approach and determining proper indications for carotid intervention in these patients.
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Affiliation(s)
- Junji Tsukagoshi
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Yujiro Yokoyama
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA
| | - Tomohiro Fujisaki
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and West, New York, NY; Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Takuro Shirasu
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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Hasan B, Farah M, Nayfeh T, Amin M, Malandris K, Abd-Rabu R, Shah S, Rajjoub R, Seisa MO, Saadi S, Hassett L, Prokop LJ, AbuRahma A, Murad MH. A Systematic Review Supporting the Society for Vascular Surgery Guidelines on the Management of Carotid Artery Disease. J Vasc Surg 2021; 75:99S-108S.e42. [PMID: 34153350 DOI: 10.1016/j.jvs.2021.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/01/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND To support the development of guidelines on the management of carotid disease, a writing committee from the Society for Vascular Surgery has commissioned this systematic review. METHODS We searched multiple data bases for studies addressing 5 questions: medical management vs. carotid revascularization (CEA) in asymptomatic patients, CEA vs. CAS in symptomatic low surgical risk patients, the optimal timing of revascularization after acute stroke, screening high risk patients for carotid disease, and the optimal sequence of interventions in patients with combined coronary and carotid disease. Studies were selected and appraised by pairs of independent reviewers. Meta-analyses were performed when feasible. RESULTS Medical management compared to carotid interventions in asymptomatic patients was associated with better early outcome during the first 30 days. However, CEA was associated with significantly lower long-term rate of stroke/death at 5 years. In symptomatic low risk surgical patients, CEA was associated with lower risk of stroke, but a significant increase in MI compared to CAS during the first 30 days. When the long-term outcome of transfemoral CAS vs. CEA in symptomatic patients were examined using pre-planned pooled analysis of individual patient data from four randomized trials, the risk of death or stroke within 120 days of the index procedure was 5.5% for CEA and 8.7% for CAS, which lends support that over the long-term, CEA has superior outcome than transfemoral CAS. When managing acute stroke, the comparison of CEA during the first 48 hours to that between day 2 and day14 did not reveal a statistically significant difference on outcomes during the first 30 days. Registry data show good results with CEA performed in the first week, but not within the first 48 hours. A single risk factor, aside from PAD, was associated with low carotid screening yield. Multiple risk factors greatly increase the yield of screening. Evidence on the timing of interventions in patients with combined carotid and coronary disease was sparse and imprecise. Patients without carotid symptoms, who had the carotid intervention first, compared to a combined carotid intervention and CABG, had better outcomes. CONCLUSIONS This updated evidence summary will support the SVS clinical practice guidelines for commonly raised clinical scenarios. CEA was superior to medical therapy in long-term prevention of stroke/death over medical therapy. CEA was also superior to transfemoral CAS in minimizing long-term stroke/death for symptomatic low risk surgical patients. CEA should optimally be performed between 2-14 days from the onset of acute stroke. Having multiple risk factors increases the value of carotid screening.
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Affiliation(s)
- Bashar Hasan
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Magdoleen Farah
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Tarek Nayfeh
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Mustapha Amin
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Kostantinos Malandris
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Rami Abd-Rabu
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Sahrish Shah
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Rami Rajjoub
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Mohamed O Seisa
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | - Samer Saadi
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA
| | | | | | - Ali AbuRahma
- Department of Surgery, West Virginia University 3110 MacCorkle Ave., SE, Charleston, WV 25304
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Mayo Clinic, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA.
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Meta-Analysis of Perioperative Stroke and Mortality in CABG Patients With Carotid Stenosis. Neurologist 2020; 25:113-116. [DOI: 10.1097/nrl.0000000000000277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Volpi S, Ali JM. Is carotid screening redundant for patients undergoing coronary artery bypass grafting? J Card Surg 2020; 35:2297-2306. [PMID: 32678974 DOI: 10.1111/jocs.14771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/23/2020] [Accepted: 06/04/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Stroke is a devastating complication following coronary artery bypass grafting, which thankfully occurs with low incidence. The role of preoperative carotid ultrasound remains unclear. Whilst it is a cheap and reliable way of diagnosing carotid stenosis (CS), it is unclear if and how this knowledge should impact on subsequent patient management. METHODS A systematic review of the literature was performed using the PRISMA guideline. A literature search was conducted on the MEDLINE database from 1950 to May 2020 using the OVID interface. Fifteen papers out of a total of 5931 were identified for inclusion. RESULTS The evidence overall suggests that patients with severe CS are likely to have an increased incidence of postoperative stroke-however, the prevalence of severe CS is low, and even in this cohort of patients, the incidence is not particularly high. CONCLUSION In screened patients identified to have severe CS, there appears to be a generally low appetite for undertaking carotid intervention internationally either before or concurrently with the coronary artery bypass grafting. Putting this all together, the widespread screening of asymptomatic patients would appear to not be justified.
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Affiliation(s)
- Sara Volpi
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Jason M Ali
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge Biomedical Campus, Cambridge, United Kingdom
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Kara H. Preoperative Carotid Duplex Scanning in Patients Undergoing Coronary Artery Bypass Grafting. Braz J Cardiovasc Surg 2019; 34:581-587. [PMID: 31719009 PMCID: PMC6852445 DOI: 10.21470/1678-9741-2019-0131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Hakan Kara
- Giresun Ada Hospital Department of Cardiovascular Surgery Giresun Turkey Department of Cardiovascular Surgery, Giresun Ada Hospital, Giresun, Turkey
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Merghit R, Ait Athmane M, Lakehal A. [Atheromatous extra-coronary injury in patients with coronary disease: Result of a cross-sectional centre study carried out in the east of Algeria]. Ann Cardiol Angeiol (Paris) 2019; 68:201-206. [PMID: 30857643 DOI: 10.1016/j.ancard.2019.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 01/20/2019] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Patients with coronary heart disease often suffer from damage in another vessel which has, in some cases, no clinical signs. These combined conditions are important to be diagnosed in order to treat the patients thoroughly. AIM To estimate the frequency of other peripheral atheromatous injuries especially carotid artery disease, Abdominal aortic aneurysm (AAA) and Peripheral artery disease (PAD) in patients with coronary disease which were enrolled in the cardiology department of the university hospital of Constantine, Algeria. PATIENTS AND METHODS This descriptive cross-sectional monocentre study was carried out in the cardiovascular exploration unit in the university hospital of Constantine, Algeria. Enrolled patients had at least one significative coronary injury≥50 in one of the major coronary arteries. All of the patients have had an ultrasound examination (supra-aortic trunks doppler, aorta and inferior limbs doppler). Data were processed and analysed using SPSS 22 software. RESULTS The frequency of the association PAD with CAD was 34.7% which accounts for the highest frequency. Haemodynamic carotid injury (≥50%) and AAA were respectively associated with CAD in 12% and 4.6% of the cases. The triple associations CAD with AAA and Haemodynamic carotid injury was observed in 2.67% of the cases while CAD with PAD and carotid artery stenosis (≥50%) in 6.67% of the cases. The frequency of the association CAD with PAD and AAA was estimated at 3.66%. CONCLUSION Coronary artery disease goes often hand in hand with other heart conditions, which should be systematically considered in patients with CAD. Clinical examination along with recommended non-invasive imaging techniques can help improve the medical assessment of patients with CAD. Only with these means, thorough personalised and cost-beneficial medical care can be obtained.
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Affiliation(s)
- R Merghit
- Service de cardiologie, hôpital universitaire, Ali mendjli, 25OOO Constantine, Algérie.
| | - M Ait Athmane
- Service de cardiologie, centre hospitalo universitaire d'Annaba, 23000 Annaba, Algérie
| | - A Lakehal
- Service d'épidémiologie, centre hospitalo universitaire de Constantine, 25150 Constantine, Algérie
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Salehi Ravesh M, Rusch R, Friedrich C, Teickner C, Berndt R, Haneya A, Cremer J, Pühler T. Impact of patients´ age on short and long-term outcome after carotid endarterectomy and simultaneous coronary artery bypass grafting. J Cardiothorac Surg 2019; 14:109. [PMID: 31202278 PMCID: PMC6570883 DOI: 10.1186/s13019-019-0928-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 06/03/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to investigate whether age has an effect on short and long-term outcome in patients who undergo simultaneous coronary artery bypass grafting (CABG) and carotid endarterectomy. METHODS From 2005 to 2017, 186 consecutive elective patients underwent CABG and synchronous endarterectomy at our institution. Patients were retrospectively classified according to age into 2 groups: patients above 70 years (elderly group: n = 97, 76.1 ± 3.9 years) and patients below 70 years (younger group: n = 89, 63.2 ± 4.8 years). RESULTS The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, 4.4% vs. 2.5%; p < 0.001) and Society of Thoracic Surgeons (STS) score (0.7% vs. 1.6%; p < 0.001) were significantly higher in the elderly group. Otherwise, there was no difference between the two groups concerning important preoperative risk factors or the intraoperative data. Postoperatively, the incidence of temporary dialysis was significantly higher in the elderly group (14.4% vs. 3.4%; p = 0.009). The rate of tracheotomy (16.5% vs. 2.2%; p = 0.001), of re-intubation (7.9% vs. 18.6%; p = 0.033) and drainage loss (600 ml vs. 800 ml; p = 0.035) was significantly higher in this elderly group. Neurological complications and 30-day mortality were comparable. Long-term survival was satisfactory for both groups. Nevertheless, 5-year survival rates (63% vs. 85%) were significantly lower in the elderly group (p = 0.003). Logistic regression analysis identified chronic obstructive pulmonary disease (COPD) and arrhythmia as significant risk factors for 30-day-mortality, but not age. CONCLUSIONS CABG in combination with synchronous endarterectomy can also be performed with satisfactory results in elderly patients.
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Affiliation(s)
- Mona Salehi Ravesh
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller-Street 3, Building 41, 24105, Kiel, Germany.
| | - Rene Rusch
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller street 3, Building 18, Kiel, Germany
| | - Christine Friedrich
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller street 3, Building 18, Kiel, Germany
| | - Christoph Teickner
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller street 3, Building 18, Kiel, Germany
| | - Rouven Berndt
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller street 3, Building 18, Kiel, Germany
| | - Assad Haneya
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller street 3, Building 18, Kiel, Germany
| | - Jochen Cremer
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller street 3, Building 18, Kiel, Germany
| | - Thomas Pühler
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller street 3, Building 18, Kiel, Germany
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Sahadevan M, Chee KH, Tai MLS. Prevalence of extracranial carotid atherosclerosis in the patients with coronary artery disease in a tertiary hospital in Malaysia. Medicine (Baltimore) 2019; 98:e15082. [PMID: 30985661 PMCID: PMC6485885 DOI: 10.1097/md.0000000000015082] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
There is limited information regarding the prevalence of extracranial carotid atherosclerosis in the patients with coronary artery disease (CAD) undergoing coronary artery bypass graft (CABG) surgery in South East Asia. The primary objective was to assess the prevalence of extracranial carotid stenosis, raised carotid intima media thickness (CIMT), and plaques in the patients with CAD undergoing elective CABG. The secondary objective was to evaluate the risk factors for extracranial carotid atherosclerosis.A total of 119 consecutive patients with CAD undergoing elective CABG in a tertiary hospital in Malaysia were recruited. Data on the demographic characteristics and risk factors were collected. The ultrasound carotid Doppler findings comprising of raised CIMT, plaques, and stenosis in the extracranial carotid vessels were recorded.The mean age of the patients was 64.26 ± 10.12 (range 42-89). Most of the patients were men (73.1%). The patients consisted of 44 (37%) Malays, 26 (21.8%) Chinese, and 49 (41.2%) Indians.A total of 67 (56.3%) patients had raised CIMT, 89 (74.8%) patients had plaques, and 10 (8.4%) patients had stenosis in the internal and common carotid arteries. The mean age of patients with plaques was higher compared to those without plaques (66.00 ± 9.63 vs 59.10 ± 9.92, P = .001). The body mass index (BMI) of patients with stenosis was higher compared to those without stenosis (28.35 ± 4.92 vs 25.75 ± 3.16, P = .02).The patients with plaques were more likely to be older, whereas the patients with carotid stenosis were more likely to have higher BMI.
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Affiliation(s)
| | | | - Mei-Ling Sharon Tai
- Division of Neurology, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
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Lescan M, Steger V, Andic M, Veseli K, Haeberle H, Krüger T, Schlensak C. Cardiac surgery in the presence of chronic internal carotid artery occlusion. Heart Vessels 2019; 34:1471-1478. [PMID: 30904987 DOI: 10.1007/s00380-019-01381-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 03/15/2019] [Indexed: 02/02/2023]
Abstract
The aim was to evaluate the incidence of stroke in the setting of cardiac surgery with or without hemodynamically relevant asymptomatic carotid stenosis contralateral to the occlusion. We designed a historical cohorts study, focused on patients with unilateral totally occluded internal carotid arteries who were referred for any cardiac surgery at our center. Isolated unilateral occlusions were assigned to group 1 (n = 60), and those with a contralateral stenosis grade ≥ 60% were included in group 2 (n = 51). A total of 111 patients operated in our center from 1997 to 2016 were included. Patients in group 2 had an asymptomatic contralateral internal carotid artery stenosis with a mean stenosis grade of 71 ± 20%. Simultaneous carotid endarterectomy (CEA) was performed in 22 patients from group 2. The overall mortality was 8/111 (7.2%). Carotid-associated mortality was not observed, whereas an overall stroke incidence of 8/111 (7.2%) was detected. The group-related outcome showed comparable results for mortality (group 1: 4/60 (6.7%) vs. group 2: 4/51 (7.8%); p = 1.0). Regarding stroke incidence, group 2 had a higher incidence of overall strokes (2/60 (3.3%) vs. 6/51 (11.8%); p = 0.14) with more contralateral (0/60 (0%) vs. 2/51 (3.9%); p = 0.209) and ipsilateral strokes (2/60 (3.3%) vs. 4/51 (7.8%); p = 0.411). Stroke rate peaked in patients with simultaneous carotid and cardiac surgery (n = 22; 18.2%; p = 0.048). Performing simultaneous CEA during cardiac surgery in the presence of a contralateral occlusion may promote stroke. Asymptomatic contralateral carotid stenosis is a risk factor for stroke in patients with carotid occlusion prior to cardiac surgery.
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Affiliation(s)
- Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Hoppe-Seyler Strasse 3, D-72076, Tübingen, Germany.
| | - Volker Steger
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Hoppe-Seyler Strasse 3, D-72076, Tübingen, Germany
| | - Mateja Andic
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Hoppe-Seyler Strasse 3, D-72076, Tübingen, Germany
| | - Kujtim Veseli
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Hoppe-Seyler Strasse 3, D-72076, Tübingen, Germany
| | - Helene Haeberle
- Department of Anesthesiology, University Medical Center Tübingen, Tübingen, Germany
| | - Tobias Krüger
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Hoppe-Seyler Strasse 3, D-72076, Tübingen, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Hoppe-Seyler Strasse 3, D-72076, Tübingen, Germany
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Tsunekawa T, Sawada M, Kato T, Motoji Y, Kinoshita T, Hirakawa A, Okawa Y, Tomita S. The Prevalence and Distribution of Occlusive Lesions of the Cerebral Arteries in Patients Undergoing Coronary Artery Bypass Graft Surgery. Semin Thorac Cardiovasc Surg 2018. [PMID: 29518536 DOI: 10.1053/j.semtcvs.2018.02.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Intracranial cerebral atherosclerosis is a significant predictor of stroke after coronary artery bypass grafting (CABG). However, there is limited information on intracranial occlusive lesions in patients undergoing CABG. The purpose of the study was to elucidate the precise prevalence and distribution of occlusive lesions of the extracranial and intracranial arteries in patients undergoing CABG. Between 2009 and 2016, 205 patients underwent preoperative magnetic resonance angiography and elective CABG. The prevalence and the distribution of occlusive lesions were retrospectively examined by preoperative magnetic resonance angiography. Association between postoperative central nervous system (CNS) complications and the occlusive lesions was analyzed. Fifty-six patients (27.3%) and 60 patients (29.3%) had occlusive lesions of the extracranial and intracranial arteries, respectively. Twenty-eight patients (13.7%) had both extracranial and intracranial occlusive lesions. Thirty-one (15.1%) and 45 (22.0%) patients had severe stenosis or occlusion of the extracranial and intracranial arteries, respectively. The intracranial internal carotid artery was the most commonly affected intracranial artery (60 vessels; 62.5%), followed by the middle cerebral arteries (20 vessels; 20.8%). Sixteen patients (7.8%) suffered from postoperative CNS complications, including 2 permanent strokes. The etiology of the stroke was attributable to a predefined intracranial lesion in 1 patient. In multivariate analysis, the presence of intracranial occlusive lesions was found to have an independent association with the development of CNS complications (odds ratio 4.05; 95% confidence interval 1.13-14.6). The prevalence of intracranial occlusive lesions was higher than that of extracranial lesions in patients undergoing CABG. There was a solid trend toward the anterior distribution of the intracranial occlusive lesions.
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Affiliation(s)
| | - Motoshi Sawada
- Department of Neurosurgery, Matsunami General Hospital, Gifu, Japan
| | - Takayoshi Kato
- Department of Cardiovascular Surgery, Gifu Heart Center, Gifu, Japan
| | - Yusuke Motoji
- Department of Cardiovascular Surgery, Gifu Heart Center, Gifu, Japan
| | | | - Akihiro Hirakawa
- Department of Biostatistics and Bioinformatics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuhide Okawa
- Department of Cardiovascular Surgery, Gifu Heart Center, Gifu, Japan
| | - Shinji Tomita
- Department of Cardiovascular Surgery, Gifu Heart Center, Gifu, Japan
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Taneja S, Chauhan S, Kapoor PM, Jagia P, Bisoi AK. Prevalence of carotid artery stenosis in neurologically asymptomatic patients undergoing coronary artery bypass grafting for coronary artery disease: Role of anesthesiologist in preoperative assessment and intraoperative management. Ann Card Anaesth 2016; 19:76-83. [PMID: 26750678 PMCID: PMC4900376 DOI: 10.4103/0971-9784.173024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective(s): This study aimed to determine the prevalence of carotid artery stenosis (CAS) due to atherosclerosis in neurologically asymptomatic patients undergoing coronary artery bypass grafting (CABG) for coronary artery disease (CAD). It contemplated a greater role for the cardiac anesthesiologist in the perioperative management of such patients with either previously undiagnosed carotid artery disease or towards re-assessment of severity of CAS. Design: Prospective, observational clinical study. Setting: Operation room of a cardiac surgery centre of a tertiary teaching hospital. Participants: A hundred adult patients with New York Heart Association (NYHA) classification I to III presenting electively for CABG. Interventions: All patients included in this study were subjected to ultrasonic examination by means of acarotid doppler scan to access for presence of CAS just prior to induction of general anesthesia. Measurements and Main Results: Based on parameters measured using carotid doppler, the presence of CAS was defined using standard criteria. The prevalence of CAS was found to be as high as 38% amongst the patients included in our study. The risk factors for CAS were identified to be advanced age, history of smoking, diabetes mellitus, dyslipidaemia and presence of a carotid bruit. Conclusion: This study points towards the relatively wide prevalence of carotid artery disease in neurologically asymptomatic patients undergoing CABG for CAD in the elective setting. It highlights the need to routinely incorporate carotid ultrasonography in the armamentarium of the cardiac anesthesiologist as standard of care for all patients presenting for CABG.
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Affiliation(s)
- Sameer Taneja
- Department of Cardiac Anesthesiology, All India Institute of Medial Sciences, New Delhi, India
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Avci A, Fidan S, Tabakçı MM, Toprak C, Alizade E, Acar E, Bayam E, Tellice M, Naser A, Kargın R. Association between the Gensini Score and Carotid Artery Stenosis. Korean Circ J 2016; 46:639-645. [PMID: 27721854 PMCID: PMC5054175 DOI: 10.4070/kcj.2016.46.5.639] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/28/2015] [Accepted: 01/12/2016] [Indexed: 12/25/2022] Open
Abstract
Background and Objectives The aim of this study was to evaluate the association between the extent of coronary artery disease assessed by the Gensini score and/or the SYNTAX score and the significant carotid stenosis in patients undergoing coronary artery bypass grafting (CABG). Subjects and Methods A total of 225 patients who had carotid doppler ultrasonography prior to CABG were included retrospectively. Significant coronary artery disease was assumed as a lumen diameter stenosis of ≥50% in any of the major epicardial coronary arteries. The severity of carotid stenosis was determined by B-mode and duplex ultrasonography. Clinically significant carotid stenosis was defined as peak systolic velocity greater than 125 cm/s. Results The mean value of SYNTAX score and Gensini score was highest in patients allocated to significant carotid stenosis (22.98±7.32, p<0.001 and 77.40±32.35, p<0.001, respectively). The other risk factors for significant carotid stenosis were found to be male gender (p=0.029), carotid bruit (p<0.001), diabetes (p=0.021), left main disease (p=0.002), 3-vessel disease (p=0.008), chronic total coronary occlusion (p=0.001), and coronary artery calcification (p=0.001) in univariate analysis. However, only the Gensini score (odds ratio[OR]=1.030, p=0.004), carotid bruit (OR=0.068, p<0.001), and male gender (OR=0.190, p=0.003) were the independent predictors. The Gensini score cut off value predicting significant carotid stenosis was 50.5 with 77% sensitivity (p<0.001). Conclusion The Gensini score may be used to identify patients at high risk for significant carotid stenosis prior to CABG.
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Affiliation(s)
- Anil Avci
- Deparment of Cardiology, 1-Kartal Koşuyolu Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Serdar Fidan
- Deparment of Cardiology, 1-Kartal Koşuyolu Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Mehmet Mustafa Tabakçı
- Deparment of Cardiology, 1-Kartal Koşuyolu Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Cuneyt Toprak
- Deparment of Cardiology, 1-Kartal Koşuyolu Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Elnur Alizade
- Deparment of Cardiology, 1-Kartal Koşuyolu Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Emrah Acar
- Deparment of Cardiology, 1-Kartal Koşuyolu Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Emrah Bayam
- Deparment of Cardiology, 1-Kartal Koşuyolu Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Muhammet Tellice
- Deparment of Cardiology, 1-Kartal Koşuyolu Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Abdurrahman Naser
- Deparment of Cardiology, 1-Kartal Koşuyolu Cardiovascular Research and Training Hospital, Istanbul, Turkey
| | - Ramazan Kargın
- Deparment of Cardiology, 1-Kartal Koşuyolu Cardiovascular Research and Training Hospital, Istanbul, Turkey
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Hines GL, Scott WC, Schubach SL, Tyd D, Wehbe U. Hemodynamically Significant Carotid Disease and Prophylactic Carotid Endarterectomy in CABG Patients—Impact on Perioperative Neurologic Events. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449703100206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Perioperative neurologic deficits occur in 2-5% of patients undergoing isolated coronary artery bypass grafting (CABG). The effect of preexisting high-grade carotid artery stenosis, as determined by (1) the presence of a cervical bruit, (2) ocular plethysmog raphy (OPG), and (3) duplex scan, and the value of prophylactic carotid endarterectomy in preventing stroke, are uncertain. The hospital courses of 427 patients who underwent pre-CABG carotid duplex scan and coronary artery bypass (CAB) as the only cardiac procedure between April 1992 and June 1994 were reviewed (1) to evaluate the rela tionship between carotid stenosis and perioperative neurologic events and (2) to determine whether endarterectomy for high-grade lesions (80-99%) decreases the risk of perioperative cerebrovascular accident (CVA). There were 11 strokes (2.58%) in 427 patients, 4 CVAs occurred in 389 patients without significant carotid disease; 12 patients had total occlusion of one carotid artery and 4 of them developed a CVA (33.3%); 26 patients had a high-grade stenosis (80-99%) of one carotid artery. Twelve of these patients underwent either a pre-CABG carotid endarterectomy (CE) (5 patients) or simul taneous CE + CABG (7 patients). There were no neurologic events in this group. The 14 other patients with 80-99% stenosis did not undergo a CE. There were 3 CVAs and 1 transient ischemic attack (TIA) in this group. Seven of 11 CVAs (64%) occurred in 34 patients with either total or high-grade carotid disease (P < .0001 by Fisher Exact Test and Wilcoxin Rank Sum). Conclusions: (1) high-grade or total occlusion of a carotid artery is associated with significantly increased risk or perioperative neurologic events. (2) Carotid endarterec tomy appears to be protective. (3) A significant number (4 of 11) of neurologic events are due to causes other than carotid stenosis.
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Affiliation(s)
- George L. Hines
- Division of Vascular Surgery, Winthrop-University Hospital, Mineola, New York
| | - William C. Scott
- Division of Vascular Surgery, Winthrop-University Hospital, Mineola, New York
| | - Scott L. Schubach
- Division of Vascular Surgery, Winthrop-University Hospital, Mineola, New York
| | - Donna Tyd
- Division of Vascular Surgery, Winthrop-University Hospital, Mineola, New York
| | - Ulla Wehbe
- Division of Vascular Surgery, Winthrop-University Hospital, Mineola, New York
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Rao PV, Hosabettu PK, Dhaded S, Mathew A, Punnen J, Kanchi M. Distal Carotid Perfusion in Combined Carotid Endarterectomy and OP-CABG. Asian Cardiovasc Thorac Ann 2016; 15:164-6. [PMID: 17387204 DOI: 10.1177/021849230701500219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
An alternative method of maintaining carotid perfusion during combined carotid endarterectomy and off-pump coronary artery bypass grafting involves insertion of a cannula in the ascending aorta after a median sternotomy. This cannula is connected to a perfusion cannula, the distal end of which is inserted into the carotid artery beyond the carotid arteriotomy. This technique of aortico-carotid shunting and carotid perfusion was utilized in nine patients who underwent successful combined carotid endarterectomy and off-pump coronary artery bypass grafting.
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Affiliation(s)
- Parachuri V Rao
- Department of Cardiac Surgery, Narayana Hrudayalaya Institute of Medical Sciences, Bangalore, India
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15
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Ashrafi M, Ball S, Ali A, Zeynali I, Perricone V. Carotid endarterectomy for critical stenosis prior to cardiac surgery: Should it be done? A retrospective cohort study. Int J Surg 2016; 26:53-7. [PMID: 26790974 DOI: 10.1016/j.ijsu.2015.12.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/01/2015] [Accepted: 12/18/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Stroke remains a major cause of morbidity and mortality after cardiac surgery affecting 2% of patients. Extra-cranial carotid artery disease has been implicated in the aetiology of post cardiac surgery stroke. The aim of the study was to evaluate and compare the morbidity and mortality in patients undergoing cardiac surgery with or without staged carotid endarterectomy (CEA) in a tertiary referral centre. METHODS A 5 year retrospective study was performed. The primary endpoints were defined as peri-operative stroke and myocardial infarction (MI) with secondary outcome defined as death within 30 days of surgery. RESULTS In total 5924 cardiac procedures and 29 staged CEA's were performed. The rate of stroke and MI was significantly higher in patients undergoing staged CEA pre-cardiac surgery compared to patients undergoing cardiac surgery with confirmed or presumed normal carotid arteries (10.34% vs 1.43%; P = .008 and 13.79% vs 0.38%; P < .0001, respectively). There was no significant difference in the stroke and MI rate in those patients undergoing cardiac surgery with confirmed or presumed normal carotid arteries compared to those with significant carotid disease undergoing cardiac surgery with no prior carotid intervention (1.43% vs 3.16%; P > .05 and 0.38% vs 1.05%; P > .05, respectively). CONCLUSIONS Carotid disease is associated with an increased risk of stroke post cardiac surgery. Staged carotid intervention cannot be justified based on these results. Increased risk of stroke post cardiac surgery in patients with significant carotid disease needs to be accepted, as the risk of stroke and MI during carotid intervention pre cardiac surgery is significantly higher.
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Affiliation(s)
- Mohammed Ashrafi
- Department of Vascular Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK.
| | - Stephen Ball
- Department of Vascular Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Abid Ali
- Department of Vascular Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Iraj Zeynali
- Department of Vascular Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Vittorio Perricone
- Department of Vascular Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
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Cheng Y, Gao J, Wang J, Wang S, Peng J. Risk Factors for Carotid Artery Stenosis in Chinese Patients Undergoing Coronary Artery Bypass Graft Interventions. Medicine (Baltimore) 2015; 94:e1119. [PMID: 26181548 PMCID: PMC4617077 DOI: 10.1097/md.0000000000001119] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Current guidelines established in the USA and Europe for coronary artery bypass graft (CABG) suggest that patients ≥65 and ≥70 years of age, or with certain atherosclerotic-risk factors, should be screened preoperatively for extracranial carotid artery stenosis (CAS) to assess their risk of perioperative stoke. We sought factors that should be taken into consideration when treating Chinese CABG patients using CABG guidelines based on an analysis of CAS in a large cohort of Chinese CABG patients. We analyzed data for 1558 Chinese CABG patients who were screened preoperatively for CAS using duplex ultrasonography at a single institution. We defined significant and severe CAS as ≥50% and ≥70% stenosis, respectively, in one or more common or internal carotid arteries. We investigated the prevalence of CAS, the incidence of perioperative stroke, and the risk factors for CAS in the CABG cohort. The prevalence of CAS in the CABG cohort was 21.2%. Multivariate stepwise logistic regression analysis showed that an age ≥50 years and a history of smoking (odds ratios = 8.36 and 1.83, respectively) were independent risk factors for CAS (P < 0.05 for both). The incidence of perioperative stroke among CABG patients with significant or severe CAS was significantly higher (2.4% and 2.9%, respectively) than in CABG patients with <50% stenosis (0.5%; P = 0.004 and 0.029, respectively). Chinese CABG patients with a history of smoking or ≥50 years of age should undergo preoperative screening for CAS to assess their risk of perioperative stroke.
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Affiliation(s)
- Yi Cheng
- From the Department of Diagnostic Ultrasound, Beijing An Zhen Hospital (YC, JW); and Department of Cardiology, Beijing Shi Ji Tan Hospital, Affiliated of Capital University of Medical Sciences, Beijing, China (JYG, SW, JJP). *Yi Cheng and Junyi Gao contributed equally to this article as the co-first author
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Kara I, Erkin A, Saclı H, Demirtas M, Percin B, Diler MS, Kırali K. The Effects of Near-Infrared Spectroscopy on the Neurocognitive Functions in the Patients Undergoing Coronary Artery Bypass Grafting with Asymptomatic Carotid Artery Disease: A Randomized Prospective Study. Ann Thorac Cardiovasc Surg 2015; 21:544-50. [PMID: 26133933 DOI: 10.5761/atcs.oa.15-00118] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The purpose of this study was to research the use of near-infrared spectroscopy (NIRS) on the neurocognitive functions in the patients undergoing coronary artery bypass grafting (CABG) with asymptomatic carotid artery disease. METHODS The study design was carried out with the participation of 79 patients in a prospective, randomized and double blind control method. The patients were separated into two groups as NIRS (n = 43) and no NIRS (n = 36). A neurocognitive test was applied preoperatively and postoperatively to all patients before discharge. Cognitive functions were evaluated by applying the Montreal Cognitive Assessment test (MoCA). RESULTS The decrease in the postoperative score of mean MoCA in no NIRS group was statistically significant when compared to preoperatively (p <0.001). Postoperative mean MoCA score was found to be significantly higher in NIRS group (NIRS: 26.8 ± 1.9 vs. no NIRS: 23.6 ± 2.5, p <0.001). It has been determined that there was a moderately positive significant correlation between the increase in the NIRS used patients (%) and increase in the MoCA score of the patients (r = 0.59, p <0.001). CONCLUSION Intraoperative NIRS usage in the patients undergoing CABG with carotid artery disease might be useful due to its postoperative positive effects on the cognitive functions.
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Affiliation(s)
- Ibrahim Kara
- Sakarya University, Faculty of Medicine, Department of Cardiovascular Surgery, Sakarya, Turkey
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18
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Lysenko AV, Belov YV, Stonogin AV. [Simultaneous brachiocephalic arteries reconstruction and coronary artery bypass grafting]. Khirurgiia (Mosk) 2015:10-18. [PMID: 26031945 DOI: 10.17116/hirurgia2015310-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
It is presented the results of simultaneous surgical treatment of 55 patients with brachiocephalic arteries lesion and ischemic heart disease. All patients underwent reconstructive operations on brachiocephalic arteries and CABG. The features of diagnosis and surgical stage are described. The indications for this method are defined. The authors studied russian and world experience; complications of simultaneous operations are presented. It is suggested ways for improvement of results of simultaneous reconstructions.
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Affiliation(s)
- A V Lysenko
- Department of cardiac surgery of the Clinic of Aortic and Cardiovascular Surgery, Chair of Cardiovascular Surgery and Interventional Cardiology, Institute of postgraduate education of the I.M. Sechenov First Moscow State Medical University
| | - Yu V Belov
- Department of cardiac surgery of the Clinic of Aortic and Cardiovascular Surgery, Chair of Cardiovascular Surgery and Interventional Cardiology, Institute of postgraduate education of the I.M. Sechenov First Moscow State Medical University
| | - A V Stonogin
- Department of cardiac surgery of the Clinic of Aortic and Cardiovascular Surgery, Chair of Cardiovascular Surgery and Interventional Cardiology, Institute of postgraduate education of the I.M. Sechenov First Moscow State Medical University
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Aydin E, Ozen Y, Sarikaya S, Yukseltan I. Simultaneous coronary artery bypass grafting and carotid endarterectomy can be performed with low mortality rates. Cardiovasc J Afr 2014; 25:130-3. [PMID: 25000443 PMCID: PMC4120123 DOI: 10.5830/cvja-2014-018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 04/10/2014] [Indexed: 11/24/2022] Open
Abstract
Introduction There is controversy over the best approach for patients with concomitant carotid and coronary artery disease. In this study, we report on our experience with simultaneous carotid endarterectomy (CEA) and coronary artery bypass graft (CABG) surgery in our clinic in the light of data in the literature. Methods Between January 1996 and January 2009, a total of 110 patients (86 males, 24 females; mean age 65.11 ± 7.81 years; range 44–85 years), who were admitted to the cardiovascular surgery clinic at our hospital, were retrospectively analysed. All patients underwent simultaneous CEA and CABG. Demographic characteristics of the patients and a history of previous myocardial infarction (MI), hypertension, diabetes mellitus, hyperlipidaemia, peripheral arterial disease and smoking were recorded. Results One patient (0.9%) with major stroke died due to ventricular fibrillation. Peri-operative neurological complications were observed in seven patients (6%). Complications were persistent in two patients. Four patients (3%) had postoperative major stroke, whereas three patients (2%) had transient hemiparesis. No peri-operative myocardial infarction was observed. Conclusion Simultaneous CEA and CABG can be performed with low rates of mortality and morbidity.
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Affiliation(s)
- Ebuzer Aydin
- Kartal Kosuyolu Training and Research Hospital, Istanbul, Turkey.
| | - Yucel Ozen
- Kartal Kosuyolu Training and Research Hospital, Istanbul, Turkey
| | - Sabit Sarikaya
- Kartal Kosuyolu Training and Research Hospital, Istanbul, Turkey
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Abstract
OPINION STATEMENT Numerous risk factors for perioperative stroke have been identified and many are modifiable. Surgical patients with a history of cerebrovascular disease should be evaluated by a neurologist. Cardiac and cerebrovascular testing is critical in identifying patients at high risk for perioperative stroke. The identification and treatment of carotid disease in the context of upcoming surgery has been a source of controversy. Routine carotid revascularization performed with coronary artery bypass graft (CABG) surgery for incidentally discovered carotid stenosis is not recommended. Prior to aortic manipulation during CABG, epiaortic ultrasound should be performed to identify aortic atheromatous plaques. If possible, preoperative aspirin, beta blocker, statin, and angiotensin converting-enzyme (ACE) inhibitor therapy should be continued in the perioperative period. Patients who are prescribed anticoagulation at high risk of thromboembolism should receive bridging anticoagulation during the perioperative period. The identification and prevention of postoperative atrial fibrillation (AF) is central to stroke prevention. CABG patients should be initiated on beta blockade +/- amiodarone to prevent postoperative AF. Many practitioners have been traditionally nihilistic towards acute perioperative stroke treatment. Given the narrow therapeutic window of treatment options, candidacy is dependent on timely recognition. Intravenous and endovascular thrombolysis/therapies are viable options in selected patients under the guidance and expertise of a neurologist. This article will present the epidemiology of perioperative stroke, the pathophysiology, risk assessment and stratification for common surgeries. The article will additionally focus on treatment options including modifiable risk factor reduction and the perioperative management of medications.
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Heyer KS, Eskandari MK. Carotid stenting: risk factors for periprocedural stroke. Expert Rev Neurother 2014; 8:469-77. [DOI: 10.1586/14737175.8.3.469] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Open and Endovascular Management of Concomitant Severe Carotid and Coronary Artery Disease: Tabular Review of the Literature. Ann Vasc Surg 2012; 26:125-40. [DOI: 10.1016/j.avsg.2011.02.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 01/10/2011] [Accepted: 02/09/2011] [Indexed: 11/20/2022]
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23
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Illuminati G, Ricco JB, Caliò F, Pacilè MA, Miraldi F, Frati G, Macrina F, Toscano M. Short-term results of a randomized trial examining timing of carotid endarterectomy in patients with severe asymptomatic unilateral carotid stenosis undergoing coronary artery bypass grafting. J Vasc Surg 2011; 54:993-9; discussion 998-9. [PMID: 21703806 DOI: 10.1016/j.jvs.2011.03.284] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 03/28/2011] [Accepted: 03/28/2011] [Indexed: 11/25/2022]
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Reprinted Article “Carotid Artery Disease and Stroke During Coronary Artery Bypass: A Critical Review of the Literature”. Eur J Vasc Endovasc Surg 2011; 42 Suppl 1:S73-83. [DOI: 10.1016/j.ejvs.2011.06.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2002] [Indexed: 11/24/2022]
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25
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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]
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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: 98] [Impact Index Per Article: 7.5] [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.
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Dick AM, Brothers T, Robison JG, Elliott BM, Kratz JM, Toole JM, Crumbley AJ, Crawford FA. Combined Carotid Endarterectomy and Coronary Artery Bypass Grafting Versus Coronary Artery Bypass Grafting Alone: A Retrospective Review of Outcomes at Our Institution. Vasc Endovascular Surg 2011; 45:130-4. [DOI: 10.1177/1538574410393752] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: It remains controversial whether patients with concomitant carotid and coronary disease should undergo operative repair separately or in combination. Methods: Patients with documented cerebrovascular disease undergoing coronary artery bypass grafting (CABG) alone were matched by propensity scoring with patients undergoing combined carotid endarterectomy (CEA)/CABG procedures and compared for the occurrence of stroke, myocardial infarction (MI), and mortality. Results: Of the 4943 patients undergoing CABG, 908 had known cerebrovascular disease. Among these, 134 underwent concomitant CEA, and these were propensity matched with 134 patients undergoing CABG only. No differences were observed in the perioperative risks of stroke (4% vs 3%, odds ratio [OR] 1.5, 95% confidence interval [CI] 0.4-5.5), MI (0.7% vs 0.7%, not significant [NS]), or combined cardiovascular events (6% vs 10%, OR 0.5, 95% CI [0.2-1.3]), although mortality (1% vs 8%, OR 0.2, 95% CI [0.04-0.8] was higher with CABG only. Discussion: Addition of CEA to CABG did not significantly alter the risk of perioperative stroke relative to propensity-matched patients undergoing CABG alone.
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Affiliation(s)
- Amanda M. Dick
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Thomas Brothers
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA,
| | - Jacob G. Robison
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Bruce M. Elliott
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - John M. Kratz
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - J. Matthew Toole
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Arthur J. Crumbley
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Fred A. Crawford
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
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Assessment of carotid artery stenosis before coronary artery bypass surgery. Is it always necessary? Arch Cardiovasc Dis 2011; 104:77-83. [PMID: 21402341 DOI: 10.1016/j.acvd.2010.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Revised: 11/18/2010] [Accepted: 11/24/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND Extracranial internal carotid artery stenosis is a risk factor for perioperative stroke in patients undergoing coronary artery bypass surgery (CAB). Although selective and non-selective methods of preoperative carotid screening have been advocated, it remains unclear if this screening is clinically relevant. AIM To test whether selective carotid screening is as effective as non-selective screening in detecting significant carotid disease. METHODS The case records of patients consecutively undergoing CAB were reviewed. Patients were stratified retrospectively into high- or low-risk groups according to risk factors for significant carotid stenosis and perioperative stroke: peripheral vascular disease (PVD), carotid bruit, diabetes mellitus, age >70 years and/or history of cerebrovascular disease. Prevalence of carotid stenosis detected by ultrasonography, surgical management and perioperative stroke rates were determined in each group. RESULTS Overall, 205 consecutive patients underwent preoperative carotid screening. The prevalence of significant carotid stenosis was 5.8%. Univariate analysis confirmed that PVD (P=0.005), carotid bruit (P=0.003) and diabetes mellitus (P=0.05) were significant risk factors for stenosis. Carotid stenosis was a risk factor for stroke (P=0.03). Prevalence of carotid stenosis was higher in the high-risk group (9.1%) than the low-risk group (1.2%) (P<0.05). All concomitant or staged carotid endarterectomies/CAB (5/205) and all patients who had perioperative strokes (5/205) were in the high-risk group (P=0.01). CONCLUSION In our cohort, selective screening of patients aged >70 years, with carotid bruit, a history of cerebrovascular disease, diabetes mellitus or PVD would have reduced the screening load by 40%, with trivial impact on surgical management or neurological outcomes.
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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
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Determinants of embolic risk during angioplasty and stenting: neurologic symptoms and coronary artery disease increase embolic risk. Ann Surg 2010; 252:618-24. [PMID: 20881768 DOI: 10.1097/sla.0b013e3181f57ad2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Carotid angioplasty and stenting (CAS) has proven to be a potential alternative to carotid endarterectomy in the treatment of severe carotid disease. Patient selection has emerged as a means of optimizing the outcomes of CAS. OBJECTIVE To determine whether the presence of preprocedural neurologic symptoms and having a history of coronary artery disease (CAD) are associated with greater embolic risk during CAS through analysis of the embolic debris captured within protective filters. METHODS A total of 233 consecutive CAS procedures were performed between 2003 and 2009. Particles of embolic debris within the filters were quantified by photomicroscopy and video imaging software. Particulate size was determined by measuring the length along the longest axis. Preprocedural neurologic symptoms included transient ischemic attack, cerebrovascular accident, and amaurosis fugax. History of CAD included prior myocardial infarction, coronary artery bypass grafting, congestive heart failure, or abnormal stress test. RESULTS Of the 137 (58.8%) filters that were analyzed (mean age, 71.3 ± 9.1 years, 56.9% male), 52 (38.0%) and 80 (58.4%) filters were from symptomatic and CAD patients, respectively. Filters of symptomatic (S) patients contained both a greater number and larger mean particle size compared with those of asymptomatic (AS) patients (S: 15.8 ± 13.5 particles vs. AS: 9.8 ± 8.7 particles, P = 0.002; S: 507 ± 389 μm vs. AS: 398 ± 181 μm, P = 0.03; respectively). Filters from CAD patients also had a greater number of particles, but trended toward smaller minimum size than those in non-CAD patients (CAD: 14.4 ± 12.8 particles vs. non-CAD: 8.8 ± 7.4 particles, P = 0.002; CAD: 167 ± 172 μm vs. 228 ± 203 μm, P = 0.06). CONCLUSIONS These findings suggest that the presence of preprocedural neurologic symptoms and a history of CAD are associated with increased embolization during CAS. Therefore, the benefit of carotid stenting should be tempered by the potential for increased perioperative events in both symptomatic and CAD patients.
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Cheng-Ching E, Fong J, Ontaneda D, Hussain MS, Katzan I, Gupta R. Intracranial Atherosclerosis as a Risk Factor for Ischemic Stroke during Open Heart Surgery. J Stroke Cerebrovasc Dis 2010; 19:257-60. [DOI: 10.1016/j.jstrokecerebrovasdis.2009.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2009] [Revised: 04/20/2009] [Accepted: 04/24/2009] [Indexed: 10/19/2022] Open
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Fenchel M, Scheule AM, Kramer U, Bretschneider C, Klumpp B, Seeger A, Rittig K, Claussen CD, Miller S. Determination of unknown high-grade atherosclerotic lesions by whole-body cardiovascular imaging: assessment of patients with symptomatic atherosclerotic disease of peripheral arteries. Acad Radiol 2010; 17:219-29. [PMID: 19910220 DOI: 10.1016/j.acra.2009.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Revised: 08/02/2009] [Accepted: 08/02/2009] [Indexed: 11/18/2022]
Abstract
RATIONALE AND OBJECTIVES The long-term prospects for patients with peripheral-arterial-occlusive disease (PAOD) must be considered in the context of coexistent generalized atherosclerosis. We sought to determine the added clinical information of noninvasive magnetic resonance imaging (MRI) for detecting asymptomatic atherosclerotic disease in patients already at high risk. MATERIALS AND METHODS Eighty-four patients (64 men, mean age 66.2 + or - 10.0 years, range 34-84 years) with suspected or known PAOD were examined using a comprehensive cardiovascular MRI protocol. Two experienced observers reviewed all MRIs for the presence of "relevant findings," which were defined as pathology requiring immediate therapy or mid-term follow-up. RESULTS Assessment of cardiac structures and function in 84 study patients yielded new pathology in 40 (48%) patients, whereas cerebral imaging revealed new findings in 45 (54%) patients. Previously unsuspected vascular findings were evident in 46 (55%) patients. Using the information from the MRIs, in 54 (64%) of patients mid-term follow-up was required, whereas in 7 (8%) patients a change of therapy or immediate treatment was necessary. CONCLUSION Whole-body cardiovascular MRI is able to detect symptomatic and unsuspected findings in patients with PAOD. This technique was able to detect several vascular abnormalities that necessitated immediate medical attention and intervention in patients already identified as high-risk patients and, therefore, may show an increasing impact to determine individual therapeutic and follow-up concepts.
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Affiliation(s)
- Michael Fenchel
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany.
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Weisberg AD, Weisberg EL, Wilson JM, Collard CD. Preoperative evaluation and preparation of the patient for cardiac surgery. Anesthesiol Clin 2009; 27:633-48. [PMID: 19942171 DOI: 10.1016/j.anclin.2009.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Cardiac surgery is associated with significant morbidity, mortality, and socioeconomic costs. Preoperative assessment assists the clinician in identifying potential complications and facilitates discussion of these risks with the patient. Careful patient selection and preparation during preoperative evaluation may minimize morbidity, mortality, and resource use. This article outlines a system-based approach to preoperative evaluation and preparation of the patient undergoing cardiac surgery.
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Affiliation(s)
- Alec D Weisberg
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
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Yuan SM, Wu HW, Jing H. Treatment strategy for combined carotid artery stenosis and coronary artery disease: staged or simultaneous surgical procedure? TOHOKU J EXP MED 2009; 219:243-50. [PMID: 19851053 DOI: 10.1620/tjem.219.243] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Nanjing University, Nanjing, Jiangsu Province, People's Republic of China
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Anastasiadis K, Karamitsos TD, Velissaris I, Makrygiannakis K, Kiskinis D. Preoperative screening and management of carotid artery disease in patients undergoing cardiac surgery. Perfusion 2009; 24:257-62. [PMID: 19755466 DOI: 10.1177/0267659109347404] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Carotid artery stenosis (CAS) is a well-known risk factor for perioperative stroke in cardiac surgery. It is unclear whether preoperative carotid screening should be applied to all patients. Carotid intervention concomitantly with cardiac operations is also controversial. Our objective was to identify the prevalence of significant CAS and its related risk factors by applying a protocol of preoperative carotid screening to all patients undergoing cardiac surgery. METHODS We studied 307 patients who were primarily screened preoperatively by duplex Doppler ultrasonography. Catheter carotid angiography or transcranial Doppler was performed on equivocal cases. Univariate and multivariate analyses were applied across selected parameters to identify risk factors for significant CAS (> 70%). The prevalence of CAS and perioperative stroke rates were determined. RESULTS Twenty-two patients with severe and 18 with moderate carotid stenosis were identified. Further radiological evaluation with catheter carotid angiography and transcranial Doppler confirmed the presence of significant CAS in 20 patients who underwent carotid stenting or endarterectomy before the open heart surgery. The cardiac surgeon was free to modify the surgical technique according to the preoperative assessment. No patient had major stroke perioperatively, while two minor strokes with complete neurologic recovery have been documented. The history of stroke and the presence of bruit on clinical examination were the only significant predictors of severe carotid disease. CONCLUSION Careful clinical examination together with detailed previous history taking can identify the majority of patients with CAS. Further data are required for the construction of a scientifically valid policy as a guideline.
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Affiliation(s)
- Kyriakos Anastasiadis
- Department of Cardiovascular Surgery, Kyanous Stavros Hospital, Thessaloniki, Greece.
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Alkan O, Kizilkilic O, Yildirim T, Atalay H. Intracranial cerebral artery stenosis with associated coronary artery and extracranial carotid artery stenosis in Turkish patients. Eur J Radiol 2009; 71:450-5. [DOI: 10.1016/j.ejrad.2008.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2007] [Revised: 04/30/2008] [Accepted: 05/02/2008] [Indexed: 11/15/2022]
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Weisberg AD, Weisberg EL, Wilson JM, Collard CD. Preoperative evaluation and preparation of the patient for cardiac surgery. Med Clin North Am 2009; 93:979-94. [PMID: 19665615 DOI: 10.1016/j.mcna.2009.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Cardiac surgery is associated with significant morbidity, mortality, and socioeconomic costs. Preoperative assessment assists the clinician in identifying potential complications and facilitates discussion of these risks with the patient. Careful patient selection and preparation during preoperative evaluation may minimize morbidity, mortality, and resource use. This article outlines a system-based approach to preoperative evaluation and preparation of the patient undergoing cardiac surgery.
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Affiliation(s)
- Alec D Weisberg
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
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Aboyans V, Lacroix P. Indications for carotid screening in patients with coronary artery disease. Presse Med 2009; 38:977-86. [DOI: 10.1016/j.lpm.2009.02.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Accepted: 02/17/2009] [Indexed: 10/20/2022] Open
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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]
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Archbold RA, Barakat K, Magee P, Curzen N. Screening for carotid artery disease before cardiac surgery: is current clinical practice evidence based? Clin Cardiol 2009; 24:26-32. [PMID: 11195603 PMCID: PMC6655147 DOI: 10.1002/clc.4960240105] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND There is no clear consensus as to the correct screening procedure to identify patients undergoing cardiac surgery and who are at greatest risk of stroke because of the presence of significant carotid artery stenosis. Such screening is important because some patients benefit from combined carotid and cardiac surgery and, regardless of this, the information gained puts the cardiac surgeon in a position to provide an accurate assessment of surgical risk. Our objective was to examine current clinical practice of carotid artery investigation prior to urgent cardiac surgery and to review this illustrative practice in the context of the world literature. HYPOTHESIS The study aimed to establish that current typical practice for screening cardiac surgical patients for carotid artery disease is illogical according to the evidence in the world literature. METHODS The study consisted of a retrospective assessment of all patients undergoing urgent cardiac surgery and a Medline-derived literature review, and included all patients undergoing urgent cardiac surgery at a tertiary cardiothoracic center between January 1 and December 31, 1997. RESULTS Of 529 patients undergoing urgent cardiac surgery, 44 (8%) were screened preoperatively by duplex Doppler ultrasonography for carotid disease. The indications for screening were asymptomatic carotid bruit in 24 patients, history of stroke or transient ischemic attack (TIA) in 12 patients, and neither stroke, TIA, or bruit in 7 patients. The tests were requested either by the attending cardiologists or by the cardiac surgeon to whom they were referred. One patient had already been diagnosed as having carotid artery disease in the past. Thirteen patients underwent additional carotid investigations. Eleven patients were demonstrated to have internal carotid artery stenosis > or = 60% and 3 patients underwent combined cardiac and carotid surgery. Review of the literature revealed the following groups to be at increased risk of future stroke unrelated to surgery, and of postoperative stroke: those with a history of stroke or TIA, those with carotid bruits, and, of importance, all patients with significant carotid stenosis. Recent data suggest that symptomatic patients and the elderly are at greatest risk. CONCLUSIONS Only 8% of patients undergoing urgent cardiac surgery in a 1-year period were screened for carotid artery disease. We suggest that screening should definitely be performed in all patients with a history of stroke or TIA, all patients with a bruit, and all patients aged > 65 years. The literature suggests, however, that significant reductions in stroke rate could be achieved by screening the whole cardiac surgical population, although there is a paucity of data that are specifically pertinent to this patient subgroup. Further data are therefore required for the construction of a scientifically valid and medicolegally sound policy.
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Affiliation(s)
- R A Archbold
- Department of Cardiology, London Chest Hospital, UK
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41
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Zayed H, Ali A, Wendler O, Rashid H. Selective Screening for Asymptomatic Carotid Artery Disease Prior to Isolated Heart Valve Surgery. Angiology 2008; 60:633-6. [DOI: 10.1177/0003319708325446] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Hany Zayed
- King's College Hospital, Denmark Hill, London
| | - Ahmad Ali
- King's College Hospital, Denmark Hill, London
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Screening for carotid stenosis in patients with ischaemic heart disease. J Clin Neurosci 2008; 5:58-62. [PMID: 18644289 DOI: 10.1016/s0967-5868(98)90203-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/1995] [Accepted: 02/26/1996] [Indexed: 11/22/2022]
Abstract
In screening for carotid stenosis, an oblique cervical intra-arterial digital subtraction angiogram (IA-DSA) was obtained in 30 consecutive patients who underwent coronary angiography for work-up of myocardial infarction and/or follow-up of the status of previous percutaneous transluminal coronary angioplasty (PTCA) or revascularization (PTCR). In cases where carotid artery stenosis was suspected from IA-DSA, conventional angiography was obtained concurrently. Of 30 cases, three cases of severe carotid artery stenosis were detected. Carotid artery stenoses were in the right carotid bifurcation, and the extents of the stenoses were 70%, 75% and 90%. Ulceration was seen in the case with 75% stenosis. There were no complications associated with the coronary angiography, nor with the additional cervical IA-DSA which required less than 5 min to perform in all cases. Patients with ischaemic heart disease are a high risk group for carotid stenoses. This method of screening carotid stenosis is safe and requires only 20 ml of additional contrast media giving excellent resolution. The value of performing cervical IA-DSA in patients undergoing coronary angiography to screen for carotid stenosis is discussed.
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Surgery Insight: carotid endarterectomy--which patients to treat and when? ACTA ACUST UNITED AC 2007; 4:621-9. [PMID: 17957209 DOI: 10.1038/ncpcardio1008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2006] [Accepted: 08/10/2007] [Indexed: 11/08/2022]
Abstract
Over the past 15 years, we have witnessed a resurgence of surgery for prevention of ischemic stroke. Landmark trials including the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial have explored the role of carotid endarterectomy in this context, comparing the procedure with best medical treatment in patients with high-grade stenosis of the internal carotid artery and transient ischemic attack or minor nondisabling stroke in the same territory. Here, we discuss the lessons learnt from these trials, and review the Asymptomatic Carotid Atherosclerosis Study and the Asymptomatic Carotid Surgery Trial, which attempted to resolve the rather vexing issue of surgical treatment for patients with asymptomatic internal carotid artery stenosis. We also review the best medical treatment for patients undergoing carotid endarterectomy in the perioperative period, and examine the risk of ischemic stroke after CABG surgery, both when this procedure is performed alongside endarterectomy and when CABG surgery and endarterectomy are performed as a two-staged procedure.
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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]
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Kougias P, Kappa JR, Sewell DH, Feit RA, Michalik RE, Imam M, Greenfield TD. Simultaneous Carotid Endarterectomy and Coronary Artery Bypass Grafting: Results in Specific Patient Groups. Ann Vasc Surg 2007; 21:408-14. [PMID: 17502133 DOI: 10.1016/j.avsg.2006.12.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2006] [Accepted: 12/26/2006] [Indexed: 10/21/2022]
Abstract
We examined the safety of performing synchronous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) in specific groups of patients with coexistent cerebral and coronary vascular disease. Between 1981 and 2003, 8,277 patients who underwent CABG in our institution had noninvasive screening for carotid disease. Two hundred seventy-seven (3.34%) patients were found to have severe (>70%) carotid stenosis. This patient population was divided into three subgroups: group A had unilateral carotid disease (n = 200), group B had bilateral carotid disease (n = 55), and group C had contralateral carotid occlusion (n = 22). In 29 patients (10.4%), the carotid disease was symptomatic. A simultaneous CABG and CEA was performed in all three subgroups. Patients in group B underwent initially repair of the most dominant lesion, soon followed by contralateral CEA. Patients who underwent only CABG (n = 8,000) served as controls. Overall combined hospital mortality regardless of etiology for the combined group was 3.61% vs. 1.7% for the patients who had CABG only (P > 0.1). The stroke and/or myocardial infarction-associated mortality for the simultaneous CEA-CABG group was 2.52%. There were six deaths in group A (3%), two in group B (3.6%), and two in group C (9.09%). Early stroke complicated the course of four (2%) patients in group A, one (1.8%) patient in group B, and three (13.64%) patients in group C compared to a stroke rate of 1.28% in controls. Overall stroke rate in the combined group was 2.8%. History of previous stroke and age 70-80 were the most important predictors of postoperative stroke and death. In the combined surgery group, the postoperative myocardial infarction rate was 0.72% vs. 0.58% in the control group. The mean length of hospital stay was 9 days for patients who had the combined procedure vs. 8.1 days for patients who had CABG only. Use of the combined procedure for patients with concomitant carotid and coronary artery disease was justified in the patients under study.
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Affiliation(s)
- Panagiotis Kougias
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 1709 Dryden Street, Houston, TX 77030, USA.
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Tarzamni MK, Afrasyabi A, Farhoodi M, Karimi F, Farhang S. Low prevalence of significant carotid artery disease in Iranian patients undergoing elective coronary artery bypass. Cardiovasc Ultrasound 2007; 5:3. [PMID: 17214901 PMCID: PMC1785365 DOI: 10.1186/1476-7120-5-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2006] [Accepted: 01/10/2007] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Coronary artery bypass grafting ranks as one of the most frequent operations worldwide. The presence of carotid artery stenosis may increase the stroke rate in the perioperative period. Routine preoperative noninvasive assessment of the carotid arteries are recommended in many institutions to reduce the stroke rate. METHODS 271 consecutive patients undergoing coronary artery bypass grafting at Shaheed Madani hospital of Tabriz, Iran (age, 58.5 Y; 73.1% male) underwent preoperative ultrasonography for assessment of carotid artery wall thickness. RESULTS Plaque in right common, left common, right internal and left internal carotid arteries was detected in 4.8%, 7.4%, 43.2% and 42.1% of patients respectively. 5 patients (1.8%) had significant (<50%) and 3 (1.1%) patients had critical (<70%) stenosis in internal carotid arteries. Plaque formation in common carotid was not significantly different between two genders but the stenosis of left internal carotid was more frequently seen among men. Patients with plaques in right or left internal carotid arteries were significantly older. CONCLUSION Consecutive Iranian patients undergoing elective coronary artery bypass surgery show a very low prevalence of significant carotid artery disease.
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Affiliation(s)
- Mohammad K Tarzamni
- Associate professor of Radiology, Department of Radiology, Tabriz university of medical sciences, Tabriz, Iran
| | - Abbas Afrasyabi
- Professor of Cardiothoracic surgery, department of cardiothoracic surgery, Tabriz University of medical sciences, Tabriz, Iran
| | - Mehdi Farhoodi
- Associate professor Neurology, Neurology department, Tabriz University of medical sciences, Tabriz, Iran
| | - Fatemeh Karimi
- Radiologist, Department of Radiology, Tabriz University of medical sciences, Tabriz, Iran
| | - Sara Farhang
- General Practitioner, Department of Radiology, Tabriz University of medical sciences, Tabriz, Iran
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Preoperative carotid artery screening in patients undergoing coronary artery bypass graft surgery. Arch Med Res 2007; 37:987-90. [PMID: 17045115 DOI: 10.1016/j.arcmed.2006.06.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2006] [Accepted: 06/02/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND The incidence of stroke is 2.1-5.2% in bypass surgery patients with a mortality of 0-38%. This study was designed to evaluate the incidence of significant carotid artery stenosis and its related risk factors in candidates for coronary artery bypass graft (CABG) surgery. METHODS One thousand forty five consecutive candidates for CABG underwent carotid artery Doppler examination in a prospective study. The relation of age, sex, smoking and diabetes history, as well as lipid profile with carotid stenosis, was evaluated. RESULTS In 1045 CABG candidates with a mean age of 60 years, prevalence of significant carotid stenosis (>60%) was 6.9%. In the patients aged 65 years and older, the rate of significant stenosis was 12.5%. Age >50 years, female gender, hypercholesterolemia and diabetes mellitus are independent risk factors for significant carotid stenosis. CONCLUSIONS Significant carotid stenosis has an earlier appearance in our study. Cost-effectiveness studies are recommended for revising the previous screening protocols.
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Hanel RA, Levy EI, Hopkins LN. Cervical carotid revascularization: the case for carotid angioplasty with stenting. Neurosurgery 2006; 59:S228-41; discussion S3-13. [PMID: 17053608 DOI: 10.1227/01.neu.0000237457.79690.11] [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: 11/19/2022] Open
Abstract
Carotid artery angioplasty with or without stent placement has evolved as an alternative to carotid endarterectomy, particularly for those patients in whom carotid endarterectomy is associated with a higher risk of complications. This article summarizes the selection criteria for participation in and the results of several carotid intervention trials, reviews the relative indications and limitations for both surgical and endovascular revascularization approaches, and describes the technique for and results associated with carotid stenting. The discussion is presented from the vantage of neurosurgeons who are experienced in both revascularization approaches.
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Affiliation(s)
- Ricardo A Hanel
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, State University of New York, Buffalo 14209-1194, USA
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Rijbroek A, Wisselink W, Vriens EM, Barkhof F, Lammertsma AA, Rauwerda JA. Asymptomatic Carotid Artery Stenosis: Past, Present and Future. Eur Neurol 2006; 56:139-54. [PMID: 17035702 DOI: 10.1159/000096178] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2006] [Accepted: 07/17/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND The role of carotid endarterectomy (CEA) for asymptomatic carotid artery stenosis (aCAS) remains a matter of debate. It seems that not only the degree of stenosis, but also other factors have to be taken in account to improve patient selection and increase the benefit of CEA for aCAS. METHODS AND RESULTS The literature pertaining aCAS was reviewed in order to describe the natural history, risk of stroke and benefit of CEA for patients with aCAS in regard to several factors. CONCLUSION The benefit of CEA for aCAS is low. Current factors influencing the indication for CEA are severity of stenosis, age, contralateral disease, stenosis progression to >80%, gender, concomitant operations and life expectancy. To improve patient selection investigations will concentrate on plaque characteristics and instability and cerebral hemodynamics and metabolism.
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Affiliation(s)
- A Rijbroek
- Department of General Surgery, Kennemer Gasthuis, NK-2000 AK Haarlem, The Netherlands.
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Arai S, Utsunomiya H, Tashiro T, Ishida K, Okazaki M. Preoperative extracranial carotid artery examination with ultrasonography in patients undergoing coronary artery bypass grafting in Japan. ACTA ACUST UNITED AC 2006; 24:210-6. [PMID: 16875309 DOI: 10.1007/s11604-005-1555-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE We investigated the incidence, degree, and plaque characteristics of extracranial carotid stenosis with carotid ultrasonography (CUS) in patients undergoing coronary artery bypass grafting (CABG). MATERIALS AND METHODS Preoperative CUS was performed on 221 patients (442 carotid arteries) undergoing CABG. The degree of extracranial carotid stenosis was calculated based on the area stenosis, and it was classified into six grades as follows: grade (G) 0, G1 (1%-29%), G2 (30%-49%), G3 (50%-69%), G4 (70%-99%), and G5 (occlusion). RESULTS The incidence of G4 was 4.1% and G5 1.6%. There were 48 arteries rated G3 or G4. Hypoechoic plaque was detected in 28 of the 48 arteries (58%), and heterogeneous plaque was detected in 37 arteries (73%). Ulcerative plaque was detected in 27 arteries (56%); when comparing the G3 and G4 groups, ulcerative plaque was found more frequently in G4 than in G3 (14/18 vs 13/30 arteries, P < 0.02). CONCLUSION Our study demonstrated that patients undergoing CABG with extracranial severe carotid stenosis tend to have heterogeneous, hypoechoic, and ulcerative plaque. We believe that preoperative CUS should be used to evaluate the plaque characteristics of extracranial carotid stenosis.
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Affiliation(s)
- Syouichi Arai
- Department of Neuroradiology, Hakujyuji Hospital, 3-2-1 Ishimaru, Nishi-ku, Fukuoka 814-0180, Japan.
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