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

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

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

Contemporary Management of Patients with Concomitant Coronary and Carotid Artery Disease

The ideal management of concomitant carotid and coronary artery occlusive disease remains elusive. Although researchers have advocated the potential benefits of varying treatment strategies based on either concomitant or staged surgical treatment, there is no consensus in treatment guidelines among national or international clinical societies. Clinical studies show that coronary artery bypass grafting (CABG) with either staged or synchronous carotid endarterectomy (CEA) is associated with a high procedural stroke or death rate. Recent clinical studies have found carotid artery stenting (CAS) prior to CABG can lead to superior treatment outcomes in asymptomatic patients who are deemed high risk of CEA. With emerging data suggesting favorable outcome of CAS compared to CEA in patients with critical coronary artery disease, physicians must consider these diverging therapeutic options when treating patients with concurrent carotid and coronary disease. This review examines the available clinical data on therapeutic strategies in patients with concomitant carotid and coronary artery disease. A treatment paradigm for considering CAS or CEA as well as CABG and percutaneous coronary intervention is discussed.

Association between the Gensini Score and Carotid Artery Stenosis

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.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Should patients with asymptomatic significant carotid stenosis undergo simultaneous carotid and cardiac surgery?

A best evidence topic in cardiovascular surgery was written according to a structured protocol. The question addressed was whether patients with severe asymptomatic carotid and coronary artery diseases should undergo simultaneous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG). A total of 624 papers were found using the reported search, of which 20 represent the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study results of these papers are tabulated. Previous cohort studies showed mixed results, while advocating for the necessity of a randomized controlled trial (RCT). A recent RCT showed that patients undergoing prophylactic or simultaneous CEA + CABG had lower rates of stroke (0%) compared with delayed CEA 1-3 months after CABG (7.7%), without significant perioperative mortality difference. This study included patients with unilateral severe (>70%) asymptomatic carotid stenosis requiring CABG. An earlier partly randomized trial also showed better outcomes for patients undergoing simultaneous procedures (P = 0.045). Interestingly, systematic reviews previously failed to show compelling evidence supporting prophylactic CEA. This could be partly due to the fact that these reviews collectively analyse different cohort qualities. Neurological studies have, however, shown reduced cognitive and phonetic quality and function in patients with unilateral and bilateral asymptomatic carotid artery stenosis. Twenty-one RCTs comparing lone carotid artery stenting (CAS) and CEA informed the American Heart Association guidelines, which declared CAS comparable with CEA for symptomatic and asymptomatic carotid stenosis (CS). However, the risk of death/stroke for CAS alone is double that for CEA alone in the acute phase following onset of symptoms, while CEA alone is associated with a doubled risk of myocardial infarction. There is, however, no significant difference for combined 30-day risk of death/stroke/myocardial infarction. Outcomes of hybrid or simultaneous CAS/CABG procedures show comparable results, albeit from rather small cohorts. While current evidence leans towards simultaneous CEA/CABG, the emergence of hybrid operating theatres in various institutions may allow larger cohorts with subsequent significant data on simultaneous CAS/CABG. A randomized controlled trial comparing both approaches would be crucial in informing future updates of existing guidelines.

Early results after synchronous carotid stent placement and coronary artery bypass graft in patients with asymptomatic carotid stenosis

BACKGROUND

The optimal management of patients with combined carotid and coronary artery disease requiring cardiac surgery is still unknown. Staged carotid endarterectomy and carotid artery stenting (CAS), each followed by coronary artery bypass graft (CABG), are options frequently employed. However, for patients with severe carotid artery disease in urgent need of open cardiac revascularization, staged operations may not be the most appropriate alternative. The aim of this study was to describe our experience using a synchronous CAS-CABG method with minimal interprocedural time. We used this synchronous combination of procedures in patients with combined carotid and coronary artery disease admitted for urgent CABG.

METHODS

Patients with concomitant severe carotid and coronary artery disease scheduled for synchronous CAS and urgent CABG between December 2006 and January 2010 were included in the study. All procedures were performed at a single center: the Cardiovascular Foundation of Colombia, in Floridablanca, Santander, Colombia. The study cohort was characterized according to demographic and clinical characteristics, which included degree of carotid stenosis, presence/absence of preoperative neurological symptoms, and cardiac operative risk profile. All patients underwent CAS under embolic protection devices and then CABG within the next 2 hours. Patients received aspirin pre- and postprocedure but were started on clopidogrel only after CABG. The primary end point of the study was the composite incidence rate of myocardial infarction, stroke, and death 30 days after CAS-CABG.

RESULTS

Fifteen patients with concomitant severe carotid and coronary artery disease underwent synchronous CAS-CABG. Most patients (60%) were men, and mean (± standard deviation) age was 65.2 (± 8.4) years. Most patients (93%) were neurologically asymptomatic. The median (interquartile range) ejection fraction and logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) for the cohort were 55% (36%-62%) and 9.7% (4.6%-14.8%), respectively. There were no deaths, major strokes, minor strokes, or myocardial infarctions during the procedure or within 30 days of CAS-CABG. One patient experienced neurological symptoms likely as a result of transient ischemic attack ipsilateral to the CAS procedure. None of the patients required cardiac or carotid reinterventions, and there were no cases of postoperative bleeding requiring reoperation.

CONCLUSIONS

Synchronous CAS-CABG, when CABG is performed within the 2 hours of the CAS procedure, may be a viable alternative to the more generally accepted staged combination, particularly among patients for whom CABG cannot be postponed. We hope that this strategy will be further evaluated in larger prospective studies and adequately powered randomized clinical trials.

Early and long-term outcomes after combined percutaneous revascularization in patients with carotid and coronary artery stenoses

OBJECTIVES

This study sought to evaluate the 30-day and long-term clinical outcomes of patients with carotid obstructive disease (COD) and concomitant coronary artery disease (CAD) undergoing a combined percutaneous revascularization, in 4 high-volume centers skilled for the treatment of multilevel vascular disease.

BACKGROUND

The optimal management of patients with COD and concomitant CAD remains controversial. A variety of therapeutic strategies, including coronary artery bypass grafting, alone or in combination with carotid artery revascularization, have been reported.

METHODS

Between January 2006 and April 2010, 239 consecutive patients with COD (symptomatic carotid stenosis in 20.5%) and concomitant CAD were treated with staged or simultaneous carotid artery stenting and percutaneous coronary intervention, and enrolled in this prospective registry. The primary endpoint was the incidence of major cardiac and cerebrovascular events, including any death, myocardial infarction, or stroke occurring between the first revascularization procedure and 30 days after treatment of the second vascular territory affected.

RESULTS

The incidence of the primary endpoint at 30 days was 4.2% (95% confidence interval [CI]: 2.02 to 7.56). The rate of death, myocardial infarction, and stroke at long-term follow-up (median 520 days) was 4.2%, 2.1%, and 3.8%, respectively. At long-term follow-up, patients with previous cardiovascular disease had significantly higher rates of major cardiac and cerebrovascular events than did patients with a first clinical episode (17% vs. 6%, hazard ratio: 3.34; 95% CI: 1.46 to 7.63; p = 0.004).

CONCLUSIONS

In patients with COD and concomitant CAD, a combined percutaneous treatment compares favorably with previous surgical or hybrid experiences. Such strategy may be particularly suited to complex patients at high surgical risk.

Asymptomatic carotid disease and cardiac surgery consensus

The Carotid Disease and Cardiac Surgery Consensus Meeting was convened as a multidisciplinary gathering to consider the management of patients undergoing cardiac surgery who are found to have asymptomatic carotid artery disease. There are no randomized trials concerning whether carotid interventions are of value in this situation and the natural history is unclear. Bilateral carotid artery disease (≥70% stenosis) should be regarded clinically relevant when considering hemodynamic and short-term surgical stroke risk. However, this may be because the presence of significant carotid disease is also a marker for aortic arch and intracerebral disease. A natural history study is urgently needed to determine the incidence, predictive factors, and natural history of asymptomatic carotid disease in patients undergoing contemporary cardiac surgical interventions to inform the design of any future randomized trial.

Current outcomes of simultaneous carotid endarterectomy and coronary artery bypass graft surgery in North America

OBJECTIVE

Management of patients with concomitant carotid and coronary artery disease has been controversial. Divergent strategies have been employed, including simultaneous carotid endarterectomy and coronary bypass (SCC) versus various staged procedures. Although no strict comparison group is available, this study defines current outcomes of SCC, compared qualitatively to two reference categories.

METHODS

Utilizing the STS database from 2003 to 2007, patients who had SCC were compared with patients with cerebrovascular disease who had coronary bypass (CABG) with prior carotid endarterectomy (CEA), and those with carotid Doppler stenosis >75% and no carotid intervention. Logistic regression analysis adjusted for differences in baseline characteristics and operative mortality (OM), and a composite of neurological complications (NC) was assessed.

RESULTS

Of 745,769 patients who underwent isolated CABG with/without CEA, 108,212 (14%) had cerebrovascular disease. Of this group, 5,732 (5%) underwent SCC. The SCC group had more males and lower preoperative risk factors. After statistical adjustment for all baseline differences, SCC had clinically and statistically higher OM and NC compared with any of the reference groups, with 20-40% higher event risk.

CONCLUSIONS

Although no quantitative control group exists for comparison, SCC as recently performed in North America has a high risk compared with any of the reference groups. Suboptimal results associated with the SCC strategy suggest a need for quality improvement and research on the optimal management of patients with simultaneous carotid and coronary disease.

Combined carotid and cardiac surgery: improving the results

BACKGROUND

Aim of this study was to analyze our experience in the last 5 years of combined carotid and cardiac surgery.

METHODS

During a 5-year period (January 2002-December 2006), 111 patients underwent combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) (group 1), while 1,446 patients underwent isolated CEA (group 2). Perioperative outcomes in the two groups were compared using chi(2) and Fisher's exact tests to analyze neurological deficits, cardiac events, and death at 30 days. Results during follow-up were analyzed using Kaplan-Meier survival curves, and both groups were compared using the log-rank test.

RESULTS

Immediate postoperative neurological deficits occurred more frequently in group 1 patients (2.5 vs. 0.4%, p = 0.002), with a higher incidence of transient ischemic attacks in group 1; however, there was no difference in the incidence of stroke (1% group 1 vs. 0.6% group 2, p = n.s.). Mortality rate was increased in the combined surgery group (3.5 vs. 0.5%, p < 0.001). Combined stroke/myocardial infarction/death rate at 30 days was 6.3% in group 1 compared with 1.4% in group 2, p = 0.001. Perioperative stroke/myocardial infarction/death rate was much improved in the 55% (61/111) of patients undergoing CABG off-pump (3.3 vs. 10%, p = 0.001). Mean follow-up was 18.7 months (range, 1-60). Survival at 24 months was significantly higher in patients of group 2 compared with group 1 (99.4 vs. 91.3% respectively, p < 0.001). At 24 months, there was no significant difference between the two groups in the risk of developing ipsilateral or contralateral neurologic events (3.1% group 1 vs. 1.7% group 2).

CONCLUSION

In our experience, combined CEA and cardiac surgery carries a higher risk of perioperative mortality than patients undergoing isolated CEA. Whenever possible, CEA combined with off-pump CABG seems to be the therapeutic strategy of choice.

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

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

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

Aim:

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

Material and method:

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

Results:

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

Conclusion:

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

Análise crítica das indicações e resultados do tratamento cirúrgico da doença carotídea

O tratamento da doença carotídea tem ganhado enfoque nos últimos anos, principalmente com o advento da técnica endovascular, que defende o emprego da angioplastia e stent de carótida (CAS), principalmente em pacientes considerados de "alto risco" para a endarterectomia carotídea (ECA). Através da revisão bibliográfica, analisamos os resultados do tratamento da lesão carotídea em ambas as técnicas, realizando comentários embasados na experiência pessoal e nos dados da literatura, sobretudo nos pacientes de alto risco. Até o presente momento, não há evidência e justificativa para o emprego da CAS em larga escala nos pacientes com doença carotídea, inclusive nas situações de alto risco, tais como nos octogenários. No entanto, acreditamos que a CAS possa ser um coadjuvante no tratamento de pequeno número de pacientes com lesão carotídea (até 4% dos casos), como na presença de pescoço hostil, radioterapia prévia e alguns casos de estenose carotídea alta. Quando realizada com os cuidados técnicos necessários, a ECA ainda continua a melhor opção terapêutica aos doentes com lesão carotídea.

Combined coronary artery bypass grafting and phaeochromocytoma excision

We report two patients who had successful combined coronary artery bypass grafting and excision of phaeochromocytoma. These cases represent the first reports of combined coronary artery bypass grafting and laparoscopic adrenalectomy for phaeochromocytoma and of combined coronary artery bypass grafting and excision of extra-adrenal phaeochromocytoma. With careful peri- and intra-operative management, especially in regard to haemostasis, combined operations for coronary artery disease and phaeochromocytoma are both feasible and safe.

Effects of preoperative smoking cessation on the incidence and risk of intraoperative and postoperative complications in adult smokers: a systematic review

OBJECTIVES

To establish the effect of preoperative smoking cessation on the risk of postoperative complications, and to identify the effect of the timing of preoperative cessation.

DATA SOURCES

The Cochrane Library Database, PsycINFO, EMBASE, Medline, and CINAHL databases were searched, using the terms: "smoking", "smoking-cessation", "tobacco-use", "tobacco-abstinence", "cigarett$", "complication$", "postoperative-complication$", "preoperative", "perioperative" and "surg$". Further articles were obtained from reference lists. The search was limited to articles on adults, written in English and published up to November 2005.

STUDY SELECTION

Prospective cohort designs exploring the effects of preoperative smoking cessation on postoperative complications were included. Two reviewers independently scanned abstracts of relevant articles to determine eligibility. Lack of agreement was resolved through discussion and consensus. Twelve studies met the inclusion criteria.

DATA EXTRACTION

Methodological quality was assessed by both reviewers, exploring validation of smoking status, clear definition of the period of smoking cessation, control for confounding variables and length of follow-up.

DATA SYNTHESIS

Only four of the studies specified the exact period of smoking cessation, with six studies specifying the length of the follow-up period. Five studies revealed a lower risk or incidence of postoperative complications in past smokers than current smokers or reported that there was no significant difference between past smokers and non-smokers.

CONCLUSIONS

Longer periods of smoking cessation appear to be more effective in reducing the incidence/risk of postoperative complications; there was no increased risk in postoperative complications from short term cessation. An optimal period of preoperative smoking cessation could not be identified from the available evidence.

Synchronous carotid stenting and cardiac surgery: An initial single-center experience

Concurrent severe carotid and cardiac disease is a challenging situation where staged surgery is probably the most common strategy, although it is still controversial. We report in-hospital and midterm outcome of 30 patients who received carotid stenting and synchronous cardiac surgery. All received carotid stenting under aspirin and regular unfractioned heparin (UFH) and were immediately transferred to the operating room for coronary and/or cardiac valve surgery. All patients received aspirin and clopidogrel once bleeding was ruled out, after surgery. In-hospital complications were: three surgical related deaths, one TIA, and no patient suffered stroke or myocardial infarction. Hospital stay was 14 +/- 11.8 days. Survivors were followed for 18.4 +/- 14 months. There were two non-related deaths, but no stroke nor cardiac or carotid reinterventions. In conclusion, this small series showed that synchronous carotid stenting and cardiac surgery was feasible with an acceptable complication rate in a high-surgical-risk population which could not undergo staged procedures.