A Systematic Review of Outcomes in Patients With Staged Carotid Artery Stenting and Coronary Artery Bypass Graft Surgery

Eptifibatide bridging therapy for staged carotid artery stenting and cardiac surgery: Safety and feasibility

BACKGROUND

Prophylactic carotid artery stenting (CAS) is an effective strategy to reduce perioperative stroke in patients with severe carotid stenosis who require cardiothoracic surgery (CTS). Staging both procedures (CAS-CTS) during a single hospitalization presents conflicting demands for antiplatelet therapy and the optimal pharmacologic strategy between procedures is not established. The purpose of this study is to present our initial experience with a "bridging" protocol for staged CAS-CTS.

METHODS

A retrospective review of staged CAS-CTS procedures at a single referral center was performed. All patients had multivessel coronary and/or valvular disease and severe carotid stenosis (>70%). Patients not previously on aspirin were also started on aspirin prior to surgery, followed by eptifibatide during CAS (intraprocedural bolus followed by post-procedural infusion which was continued until the morning of surgery). Pre- and perioperative (30 days) neurologic morbidity and mortality was the primary endpoint.

RESULTS

11 CAS procedures were performed in 10 patients using the protocol. The median duration of eptifibatide bridge therapy was 36 h (range 24-288 h). There was one minor bleeding complication (1/11, 9.1%) and no major bleeding complications during the bridging and post-operative period. There was one post-operative, non-neurologic death and zero perioperative ischemic strokes.

CONCLUSIONS

For patients undergoing staged CAS-CTS, Eptifibatide bridging therapy is a viable temporary antiplatelet strategy with a favorable safety profile. This strategy enables a flexible range of time-intervals between procedures.

Carotid artery stenting prior to coronary artery bypass grafting in patients with carotid stenosis: Clinical outcomes

OBJECTIVES

Management of patients undergoing coronary artery bypass grafting (CABG) with obstructive disease of the carotid arteries is still a matter of debate. We compared the results of staged carotid artery stenting (CAS) before CABG in patients with carotid lesions.

MATERIALS AND METHOD

Patients with significant carotid artery disease who were deemed to simultaneously suffer from an obstructive coronary artery disease requiring CABG from 2008 to 2018 were screened and enrolled in this study. We performed a staged CAS in cases with ≥60% stenosis and neurological symptoms or asymptomatic patients with ≥80% carotid artery stenosis. Patients with bilateral carotid lesions received sequential CAS within three weeks. Six weeks after the CAS procedure, all patients underwent CABG.

RESULTS

A total of 142 patients were included. Eighty-five of these had neurological symptoms, while the remaining 40% were asymptomatic. Thirty-one patients underwent sequential CAS for bilateral lesions. The cerebrovascular event (CVE) following CAS (3 patients) and CABG (3 patients) was 4.2%. There was only a single case of mortality in this cohort. Although it was not statistically significant, CVE after CABG was more frequent in patients with bilateral carotid disease.

CONCLUSIONS

Our results showed that staged CAS could be performed with minimal adverse outcomes in patients suffering from a simultaneous occlusive disease of carotids and coronary arteries before CABG. Bilateral CAS will further decrease cerebrovascular events and could be performed consequently or concomitantly.

Synchronous versus staged carotid artery stenting and coronary artery bypass graft for patients with concomitant severe coronary and carotid artery stenosis: A systematic review and meta-analysis

BACKGROUND

Coronary artery disease requiring coronary artery bypass graft (CABG) frequently coexists with critical carotid stenosis. The most optimized strategy for treating concomitant carotid and coronary artery disease remains debatable.

OBJECTIVE

The aim of this meta-analysis was to compare synchronous CAS and CABG versus staged CAS and CABG for patients with concomitant coronary artery disease and carotid artery stenosis in terms of peri-operative (30-day) and long-term clinical outcomes.

METHODS

This study was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane database until December 2019. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess heterogeneity.

RESULTS

Four studies comprising 357 patients were included in this meta-analysis. Patients who were treated with the synchronous approach had a statistically significant higher risk for peri-operative stoke (OR: 3.71; 95% CI: 1.00-13.69; I² = 0%) compared tο the staged group. Peri-operative mortality (OR: 4.50; 95% CI: 0.88-23.01; I² = 0%), myocardial infarction (MI) (OR: 1.54; 95% CI: 0.18- 13.09; I² = 0%), postoperative bleeding (OR: 0.27;95% CI: 0.02-3.12; I² = 0%), transient ischemic attacks (TIA) (OR: 0.60; 95% CI: 0.04- 9.20; I² = 0.0%), acute kidney injury (AKI) (OR: 0.34; 95% CI: 0.03-4.03; I² = 0.0%) and atrial fibrillation rates (OR:0.27; 95% CI: 0.02-3.12; I² = 0.0%) were similar between the two groups. Synchronous CAS-CABG and staged CAS followed by CABG were associated with similar rates of late mortality (OR: 3.75; 95% CI: 0.50-27.94; I² = 0.0%), MI (OR: 0.33; 95% CI: 0.01-12.03; I² = 0.0%) and stroke (OR:3.58; 95% CI:0.84-15.20; I² = 0.0%) after a mean follow-up of 47 months.

CONCLUSION

The simultaneous approach was associated with an increased risk of 30-day stroke compared to staged CAS and CABG. However, no statistically significant difference was found in long-term results of mortality, MI and stroke between the two approaches. Future studies are warranted to validate our results.

Perioperative management of combined carotid and coronary artery bypass grafting procedures

The objective of this review is to provide a high level overview on current thinking for treatment of patients with combined carotid and coronary artery disease given that these patients are at higher risk of adverse cardiac events, stroke, and death. This review discusses (1) the current literature addressing perioperative stroke risk in the setting of coronary artery bypass graft, (2) the literature regarding different surgical approaches when both carotid and coronary revascularization are being considered, and (3) the data available to guide optimal management of this complex patient population to minimize complications regardless of the surgical approach taken.

Comparison between proximal versus distal protection devices in 287 cases of carotid revascularization using angioplasty and stenting: periprocedure complications, morbidity, and mortality

BACKGROUND

Embolic protection devices may decrease periprocedural thromboembolic complications during carotid angioplasty and stenting (CAS). When using proximal-protection devices (PPDs), protection starts before crossing the lesion. However, in the medical literature, its use is scarcely reported compared with that of distal-protection filters (DPDs). The objective of this study was to compare periprocedure complications, morbidity, and mortality among 287 consecutive cases of CAS performed with PPDs or DPDs.

PATIENTS AND METHODS

This was a retrospective analysis of 287 patients treated with CAS at our hospital between January 2006 and March 2012. Periprocedure complications, morbidity, and mortality at 30 days, including ischemic stroke or transient ischemic attack, reperfusion syndrome, myocardial infarction (MI), and death, were globally registered, and the results in PPD and DPD groups were compared.

RESULTS

Two hundred eight patients were treated with DPD and 79 with PPD; 80.8 % were symptomatic. CAS procedures performed with PPD presented a statistically significant greater grade of stenosis than those with DPD (82.5 vs. 74.5 %, p < 0.001). Death rates were 1.9 and 1.3 %; stroke rates were 4.3 and 3.8 %; MI rates were 1.4 and 1.3 %; and total morbidity and mortality rates were 6.2 and 5 % (DPD and PPD groups, respectively); all differences were nonstatistically significant. No statistical difference was found between symptomatic and asymptomatic patients.

CONCLUSION

Carotid angioplasty and stenting is a safe procedure to treat carotid disease in our patients. PPDs are not always associated with a greater risk of periprocedure complications, morbidity, and mortality than DPDs despite the greater grade of carotid stenosis in the PPD group. This observation may be of interest in the design of future studies with CAS.

Long-term outcomes of synchronous carotid endarterectomy and coronary artery bypass grafting versus solely carotid endarterectomy

OBJECTIVE

To compare the effect of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) with solely CEA.

METHODS

During a five-year period ending December 2009, 25 consecutive patients received concomitant CEA and CABG, whereas, 62 consecutive patients underwent only CEA. They were followed at the median for 64.5 months. The Kaplan-Meier method was used to evaluate the survival rate of patients in both groups.

RESULTS

There was no significant difference in terms of age, proportion of gender, risk factors of coronary artery disease and carotid artery stenosis. The degree of carotid artery stenosis was identical in both study groups. One patient in CEA/CABG group had 60% stenosis of carotid artery with ulcerative plaque. There was no early death in the short postoperative period. Restenosis was found on ultrasonography in 4 patients in the CEA/CABG group, and 12 patients in the CEA group; no statistical difference was found between both groups (P = 0.952). The intubation time, ICU stay, and hospital stay in CEA/CABG group were longer than in solely CEA group (P <0.001). The median duration of follow-up was 64.5 months (IQR 24-84 months). The survival rate was 88 %(22/25) in CEA/CABG group and 80.6 %(50/62) in CEA group, product-limit analysis showed that there was no significant difference in survival rates between two groups (P >0.05).

CONCLUSION

concomitant carotid endarterectomy and CABG can be safely performed, it could prevent stroke and would not increase the overall risk of surgery.

Importance of strict patient selection criteria for combined carotid endarterectomy and coronary artery bypass grafting

BACKGROUND

Management of patients with severe concomitant carotid and coronary disease remains controversial. We report our experience of combined carotid endarterectomy (CEA) and coronary artery bypass surgery (CABG) over a fifteen year period using strict patient selection criteria.

METHODS

From 1st January 1995 to December 31st 2009 165 patients underwent combined CABG/CEA procedures at the Mater Hospital. Mean age was 68.2 years (range 43-88) and 127 (77%) were male. Fifty-three (32%) had symptomatic carotid disease. Indications for combined procedures were the presence of symptomatic >70% or asymptomatic >80% internal carotid artery stenosis in a patient requiring urgent CABG because of either unstable angina, recent MI, severe triple vessel disease or severe Left Anterior Descending or Left Main Stem stenosis.

RESULTS

Thirty-day stroke and death rate was 3%. All neurological events were in the hemisphere contralateral to the carotid surgery and symptoms had completely resolved prior to discharge from hospital. One patient required evacuation of a cervical haematoma and there were two transient XII nerve palsies.

CONCLUSION

Combined CEA/CABG can be performed safely with acceptable morbidity and mortality in patients selected in accordance with strict criteria in a centre with a large experience of both cardiac and carotid surgery.

Treatment strategies in severe symptomatic carotid and coronary artery disease

Coexistent carotid artery stenosis (CS) and multivessel coronary artery disease (CAD) is not infrequent. One in 5 patients with multivessel CAD has a severe CS, and CAD incidence reaches 80% in those referred for carotid revascularization. We reviewed treatment strategies for concomitant severe CS and CAD.

We performed a literature search (MEDLINE) with terms including carotid artery stenting (CAS), coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), stroke, and myocardial infarction (MI).

The main therapeutic option for CS-CAD has been (simultaneous or staged) CEA-CABG. This, however, is associated with a high risk of MI (in those with CEA prior to CABG) or stroke (CABG prior to CEA), and the cumulative major adverse event rate (MAE – death, stroke or MI) reaches 10–12%. With increasing adoption of CAS, a sequential strategy of CAS followed by CABG has emerged. Registries (usually single-centre) indicate an MAE rate of ≈7% for CAS followed by CABG (frequently after >30 days, due to double antiplatelet therapy). Recently, 1-stage CAS-CABG has been introduced. This involves different antiplatelet regimens and, in some centers, preferred off-pump CABG, with a cumulative MAE of 1.4–4.5%.

No randomized trial comparing different treatment strategies in CS-CAD has been conducted, and thus far reported series are prone to selection/reporting bias. In addition to the established surgical treatment (CEA-CABG, sequential/simultaneous), hybrid revascularization (CAS-CABG) is emerging as a viable therapeutic option. Larger, preferably multi-centre, studies are required before this can become widely applied.

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.

Surgical outcome of simultaneous carotid and cardiac surgery

PURPOSE

The surgical outcome of a simultaneous carotid endarterectomy and cardiac surgery has not been clarified. This study retrospectively reviewed short- and mid-term outcomes after a carotid endarterectomy combined with valvular surgery or coronary artery bypass grafting (CABG).

METHODS

Fifteen patients (12 males and 3 females, mean age 68.9 ± 6.7, range 59-86 years) underwent a carotid endarterectomy combined with cardiac surgery. The main indication for carotid endarterectomy was more than 75% carotid stenosis with or without cerebral ischemic symptom. Eight patients had a history of stroke or transient ischemic attack. Endarterectomy was performed under mild hypothermia and controlled hemodynamics with pulsatile perfusion with cardiopulmonary bypass in all cases. Concomitant cardiac procedures were aortic valve replacement in 1 patient and CABG in 14 patients.

RESULTS

There was no early death. Early neurological complications occurred in only 1 patient (6.7%). The ratio of heart-type fatty acid binding protein increased significantly in those that suffered postoperative neurological complications. One patient died 6 months after the operation due to pneumonia. There was no myocardial infarction, and no events were observed in the late postoperative periods.

CONCLUSIONS

Carotid endarterectomy can be safely performed in combination with cardiac surgery. Furthermore, the heat-type fatty acid binding protein levels might be useful for predicting early neurological complications.

Stroke and death after carotid endarterectomy and carotid artery stenting with and without high risk criteria

OBJECTIVE

Centers for Medicare and Medicaid Services (CMS) reimbursement criteria for carotid artery stenting (CAS) require that patients be high surgical risk or enrolled in a clinical trial. This may bias comparisons of CAS and carotid endarterectomy (CEA). We evaluate mortality and stroke following CAS and CEA stratified by medical high risk criteria.

METHODS

The Nationwide Inpatient Sample (2004-2007) was queried by ICD-9 code for CAS and CEA with diagnosis of carotid artery stenosis. Medical high risk criteria were identified for each patient including patients undergoing a coronary artery bypass and/or valve repair (CABG/V) during the same admission. Symptom status was defined by history of stroke, transient ischemic attack (TIA), and/or amarosis fugax. The primary outcome was postoperative death, stroke (complication code 997.02), and combined stroke or death, stratified by high risk vs non-high risk status and symptom status.

RESULTS

Patient totals of 56,564 (10.5%) CAS and 482,394 (89.5%) CEA were identified. Half of the patients in each group were high risk. CABG/V was performed less commonly with CAS than CEA (2.8% vs 4.0%, P < .001). Patients undergoing CAS were more likely symptomatic than those undergoing CEA (13.1% vs 9.4%, P < .001). Mortality was higher after CAS than CEA for both high risk and non-high risk patients. Stroke was also higher after CAS for both high risk and non-high risk patients. Combined stroke or death was higher after CAS again for both high risk (asymptomatic 1.5% vs 1.2%, P < .05, symptomatic 14.4% vs 6.9%, P < .001) and non-high risk (asymptomatic 1.8% vs 0.6%, P < .001, symptomatic 11.8% vs 4.9%, P < .001). Combined stroke or death for patients undergoing CABG/V during the same admission was similar for CAS and CEA (4.8% vs 3.2%, P = .19). Multivariate predictors of combined stroke or death adjusted for age and gender included CAS vs CEA (odds ratio [OR] 2.4, P < .001), symptom status (OR 6.8, P < .001), high risk (OR 1.6, P < .001), and earlier year of procedure (OR 1.1, P < .01).

CONCLUSIONS

In the United States from 2004 to 2007, CAS has a higher risk of stroke and death than CEA after adjustment for medical high risk criteria. Further analysis with prospective assessment of risk factors is needed to guide appropriate patient selection for CEA and CAS in the general population.

Therapeutic strategies for patients with internal carotid or middle cerebral artery occlusion complicated by severe coronary artery disease

BACKGROUND/OBJECTIVES

Ischemic stroke is one of major complications of cardiac surgery. Although a current American Heart Association (AHA) guideline states that carotid endarterectomy is probably recommended before or concomitant to coronary artery bypass grafting (CABG) for the carotid stenosis, there is no report that analyzed optimal strategies in cardiac surgery for patients with total occlusion of the internal carotid artery (ICA) or the middle cerebral artery (MCA). Therefore, this preliminary study was aimed to clarify whether preoperative blood flow measurements and prophylactic superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis could reduce the incidence of perioperative ischemic stroke during cardiac surgery in patients with total occlusion of the ICA or MCA.

METHODS

This prospective study included eight patients who were admitted to undergo cardiac surgery including CABG. All of them had total ICA or MCA occlusion on preoperative magnetic resonance (MR) examinations. Preoperative cerebral blood flow and its reactivity to acetazolamide were quantitatively determined in all eight patients using single photon emission computed tomography or positron emission tomography.

RESULTS

Preoperative blood flow measurements revealed that two (25%) of eight patients had normal cerebral hemodynamics because of well-developed collaterals. They safely underwent cardiac surgery. However, a marked impairment of cerebral perfusion reserve was identified in six (75%) of eight patients in the ipsilateral hemispheres. Of these, four patients underwent prophylactic STA-MCA anastomosis prior to CABG. Subsequently, they safely underwent CABG without perioperative ischemic stroke.

CONCLUSION

This is the first report suggesting that preoperative identification of hemodynamic compromise and prophylactic STA-MCA anastomosis may reduce perioperative ischemic stroke during cardiac surgery in patients with ICA or MCA occlusion, although further studies are needed to assess the validity.

Preoperative evaluation and preparation of the patient for cardiac surgery

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.

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.

Carotid endarterectomy for carotid stenosis in patients selected for coronary artery bypass graft surgery

BACKGROUND

Carotid stenosis and coronary artery disease can occur simultaneously. In patients with coronary artery disease who are scheduled for coronary artery bypass graft (CABG) surgery, but who also have carotid artery stenosis, there is controversy about the role of carotid surgery. It is not known whether any benefit from prophylactic carotid endarterectomy (by avoiding stroke and neurological dysfunction complicating CABG surgery) outweighs the risks.

OBJECTIVES

To assess, in patients undergoing CABG surgery with a carotid stenosis more than 50%, the effects of carotid endarterectomy plus best medical therapy compared with best medical therapy alone on the overall risk of major clinical outcomes including death, stroke, and myocardial infarction.

SEARCH STRATEGY

We searched the trials registers of the Cochrane Stroke Group (searched October 2008) and the Cochrane Heart Group (searched November 2008). In addition, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2008), MEDLINE (1966 to November 2008), EMBASE (1980 to November 2008), reference lists of identified trials, and ongoing trials and research registers (last searched November 2008).

SELECTION CRITERIA

We planned to include all truly randomised controlled trials comparing carotid endarterectomy plus best medical therapy with best medical therapy alone in patients selected for CABG surgery. The main outcome was perioperative death.

DATA COLLECTION AND ANALYSIS

We planned for two review authors to independently assess the methodological quality of included studies, and extract data.

MAIN RESULTS

We did not find any eligible studies.

AUTHORS' CONCLUSIONS

We found no evidence from randomised trials by which to assess the benefits and risks of prophylactic carotid surgery before CABG surgery. Randomised controlled trials are required to reliably document the risks and benefits of such procedures.

Preoperative evaluation and preparation of the patient for cardiac surgery

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.

Cerebral hemodynamics during coronary artery bypass graft surgery: the effect of carotid stenosis

Carotid stenosis is a frequent coexisting condition in patients undergoing coronary artery bypass graft (CABG) surgery. The impact of carotid stenosis on cerebral perfusion is not fully understood. The purpose of this study was to determine the impact of carotid stenosis on cerebral blood flow velocity in patients undergoing CABG. Seventy-three patients undergoing CABG were prospectively recruited and underwent preoperative Duplex carotid ultrasound to evaluate the degree of carotid stenosis. Intraoperatively, transcranial Doppler ultrasound was used to record the mean flow velocity (MFV) within the bilateral middle cerebral arteries. In addition, during the period of cardiopulmonary bypass, regulators of cerebral hemodynamics such as hematocrit, partial pressure of carbon dioxide and temperature were recorded. The ipsilateral middle cerebral artery mean flow velocity was compared in arteries with and without carotid stenosis using a repeated measures analysis. Seventy-three patients underwent intraoperative monitoring during CABG and 30% (n=22) had carotid stenosis. Overall, MFV rose throughout the duration of CABG including when the patient was on cardiopulmonary bypass. However, there was no significant MFV difference between those arteries with and without stenosis (F=1.2, p=.21). Further analysis during cardiopulmonary bypass, demonstrated that hemodilution and partial pressure of carbon dioxide may play a role in cerebral autoregulation during CABG. Carotid stenosis did not impact mean cerebral blood flow velocity during CABG. The cerebrovascular regulatory process appears to be largely intact during CABG.

Asymptomatic severe carotid stenosis undergoing staged carotid artery stent and coronary artery bypass grafting: decisive role of brain single photon emission computed tomography

Effort angina of a 70-year-old man was diagnosed as due to triple coronary vessel disease, and he was scheduled to undergo coronary artery bypass surgery. Preoperative carotid duplex scan revealed more than 75% stenosis of the right internal carotid artery, which was functionally proven to be significantly ischemic on brain single photon emission computed tomography. Although he was neurologically asymptomatic, we chose staged surgery for fear of stroke during coronary artery bypass surgery. He had successful carotid artery stenting first by neurosurgeons; then, 2 months later he underwent uneventful coronary artery bypass surgery. This experience prompted us to report the case.