Simultaneous Carotid Endarterectomy and Coronary Revascularization: Indications and Results

Czech version

Authors: V. Přibáň; J. Fiedler ^*; V. Chlouba; A. Mokráček ¹; M. Šetina ²
Authors‘ workplace: Neurochirurgické oddělení, Nemocnice České Budějovice a. s., primář MUDr. V. Chlouba ; Neurochirurgická klinika LF MU a FN Brno ^*; Kardiochirurgické oddělení, Nemocnice České Budějovice a. s. ¹; Kardiochirurgická klinika 2. LF UK a FN v Praze-Motole ²
Published in: Rozhl. Chir., 2011, roč. 90, č. 1, s. 67-72.
Category: Monothematic special - Original

Overview

Aim:
Evaluation of operative results and complications in high-risk patients who underwent combined carotid and coronary revascularization.

Patients and Methods:
Combined operation – carotid endarterectomy (CEA) and coronary artery bypass graft (CABG) was performed in the period 2000–2009 in 68 patients. Simultaneous operation was indicated in patients with unstable angina pectoris and l. symtomatic internal carotid artery (ICA) stenosis ≥ 50%, or 2. bilateral asymptomatic ICA stenosis ≥ 60% or 3. asymptomatic ICA stenosis ≥ 60% combined with contralateral ICA occlusion. Combined operations represented 5.8% of whole CEA series. Mean age was 69.9 (51–82) years, men were 46, women 22.

Carotid angiography proved unilateral (always symptomatic) ICA stenosis in 25 patients, bilateral ICA stenosis in 35 patients and ICA stenosis combined with contralateral carotid occlusion in 8 patients. Neurological preoperative symptomatology: TIA was present in u 20 patients, minor stroke in 6 and major stroke in 5 patients. 37 patients were asymptomatic. One CABG was performend in 5 patients, 2 CABG in 20 patients, 3 CABG in 19 patients and 4 CABG in 6 patients. The rest of 18 patients had CABG operation combined with valve procedure. Comorbidity: hypertension 100%, diabetes mellitus 57.3%, hyperlipidemia 60.3%.

Shunt was selectively used in 4.4%. The need for shunt was established using back stump pressure and near infrared spectroscopy.

Results:
Mortality was 8.8% (6/68). The cause of death were multiorgan failure in two cases, ipsilateral stroke in two patients, respiratory insufficiency and cardiac failure due to graft occlusion both in one patient. Good recovery was recorded in 91.2%.

Conclusion:
Combined carotid and coronary revascularization has acceptable neurological morbidity/mortality in high risk patients. Strict requirement is thorough selection of patients.

Key words:
carotid endarterectomy – coronary bypass – simultaneous operations – stroke

Sources

1. North American Symptomatic Carotid Endarterectomy Trial Collaborators.. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N. Eng. J. Med., 1998; 339: 1415–1425.

2. European Carotid Surgery Trialists Collaborative Group. European carotid surgery trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet, 1991; 337: 1235–1243.

3. Asymptomatic Carotid Artery Atherosclerosis Study Group. Endarterectomy for Asymptomatic Carotid Artery Stenosis. JAMA, 1995; 273: 1421–1428.

4. MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by succesfull carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet, 2004; 363: 915–924.

5. AHA/ASA Guidelines. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack. Stroke, 2006; 37: 577–654.

6. Faggiolli, G. L., Curl, G. R., Ricotta, J. J. The role of carotid screening before coronary artery bypass. J. Vasc. Surg., 1990; 12: 722–729.

7. Reul, G. J., Cooley, D. A., Duncan, J. M. The effect of coronary artery bypass on the outcome of peripheral vascular operation in 1903 patients. J. Vasc. Surg., 1986; 3: 788–798.

8. Brener, B. J., Brief, D. K., Alpert, J., et al. A four-year experience with preoperative noninvasive carotid evaluation of two-thousand twenty-six patients undergoing cardiac surgery. J. Vasc. Surg., 1984; 1: 326–338.

9. Hertzer, N. R., Young, J. R., Breven, E. G., et al. Coronary angiography in 506 patients with extracranial cerebrovascular disease. Arch. Int. Med., 1985; 145: 849–851.

10. Hertzer, N. R., Loop, F. D., Beven, E. G., et al. Surgical staging for simultaneous coronary and carotid disease: a study including prospective randomization. J. Vasc. Surg., 1989: 455–463.

11. Ricotta, J. J., O‘Brien, M. S. Late cardiac event after carotid endarterectomy. Stroke, 1996; 27: 4.

12. Ricotta, J. J., Fagiolli, G. Management of concomintant coronary bypass and carotid reconstruction. In: Loftus, C. M., Kresowik, T. E. Carotid artery surgery. New York: 2000; Thieme Medical Publishers; p 137–146.

13. Berens, E. S., Kochoukos, N. T., Murphy, S. F., Wareing, T. H. Preoperative carotid artery screening in elderly patients undergoing cardiac surgery. J. Vasc. Surg., 1992; 15: 313–323.

14. Shaw, P. J., Bates, D., Cartlidge, D. E. F. Early neurological complications of coronary artery bypass surgery. Br. J. Med., 1985; 29: 1384–1387.

15. Likosky, D. S., Caplan, L. R., Weintraub, R. M., Hartman, G. S, Malenka, D. J., Ross, C. S., et al. Northern New England Cardiovascular Disease Study Group, Lebanon, New Hampshire. Intraoperative and postoperative variables associated with stroke following cardiac surgery. Heart Surg. Forum, 2004; 7: E 27l–276.

16. Hertzer, N. R. Basic data concerning associated coronary disease in peripheral vascular patients. Ann. Vasc. Surg., 1987; 1: 616–620.

17. Borger, M. A., Fremes, S. E. Management of patients with concomitant coronary and carotid vascular disease. Semin. Thorac. Cardiovasc. Surg., 2001; 13: 192–198.

18. D‘Agostino, R. S., Svensson, L. G., Neumann, D. J. Screening carotid ultrasonography and risk factors for stroke in coronary artery patients. Ann. Thorac. Surg., 2001; 62: 1714–1723.

19. Brener, B. M., Hermans, H., Eisenbud, D., et al. The management of patients requiring coronary bypass and carotid endarterectomy. In: Moore, W. S, ed. Surgery for cerebrovascular disease. Philadelphia: W. B. Saunders, 1996: p. 278–287.

20. Reule, G. J., Cooley, D. A., Duncan, J. M., et al. The effect of coronary bypass on the outcome of peripheral vascular operations in 1093 patients. J. Vasc. Surg., 1986; 3: 788–798.

21. Carrel, T., Stilhard, G., Turina, M. Combined carotid and coronary artery surgery: early and late results. Cardiology, 1992; 80: 118–125.

22. Hertzer, N. R., Loop, F. D., Beven, E. G., et al. Surgical staging for simultaneous coronary and carotid disease: a study including prospective randomization. J. Vasc. Surg., 1989; 9: 455–463.

23. Newman, D. C., Hicks, R., Horton, D. A. Coexisting carotid and coronary artery disease. J. Cardiovasc. Surg., 1987; 28: 599–606.

24. Rosenthal, D., Caudill, D. R., Lamis, P. A., et al. Carotid and coronary arteryy disease: a rational approach. Am. Surg., 1984; 50: 233–235.

25. Bernhard, V. M., Johnson, W. D., Peterson, J. J. Carotid artery stenosis. Association with surgery for coronary artery disease. Arch. Surg., 1972; 105: 837–840.

26. Trachiotis, G. D., Pfister, A. J. Management strategy for simultaneous carotid endarterectomy and coronary revascularization. Ann. Thorac. Surg., 1992; 64: 1113–1118.

27. Evangelopoulos, N., Trenz, M. T., Beckmann, A., Krian, T. Simultaneous carotid endarterectomy and coronary artery bypass grafting in 313 patients. Cardiovasc. Surg., 2000; 8: 31–40.

28. Rizzo, R. J., Whithemoore, A. D., Couper, G. S., et al. Combined carotid and coronary revascularization: the preferred approach to the severe vasculopathy. Ann. Thorac. Surg., 1992; 54: 1099–1109.

29. Kohl, P. H., Comte, L., Tchana-Sato, V., Honore, C., Kerzmann, A., Mauer, M., Limet, R. Concurrent coronary and carotid surgery: factors influencing perioperative outcome and long-term results. European Heart Journal, 2006; 27: 49–56.

30. Akins, C. A., Moncure, A. C., Daggett, W. M., et al. Safety and efficacy of concomitant carotid and coronary artery operations. Ann. Thorac. Surg., 1995; 60: 311–318.

31. Daily, P. O., Freeman, R. K., Dembitsky, W. P., et al. Cost reduction by combined carotid endarterectomy and coronary artery grafting. J. Thorac. Cardiovasc. Surg., 1996; 111: 1185–1193.

32. Byrne, J., Darling, R. C., Roddy, S. P., Mehta, M., Patty, P. S. K., Kreienberg, P. B., Chang, B. B., et al. Combined carotid endarterectomy and coronary artery bypass grafting in patients with asymptomatic high-grade stenoses: An analysis of 758 patients. J. Vasc. Surg., 2006; 72: 67–72.

33. Naylor, R., Cuffe, R. L., Rothwell, P. M., Loftus, I. M., Bell, P. R. F. A systemic review of outcome following synchronous carotid endarterectomy and coronary artery bypass: influence of surgical and patients variables. Eur. J. Vasc. and Endovasc. Surg., 2003; 26: 230–241.