A modified combined approach to operative carotid and coronary artery disease: 82 cases in 8 years.
ABSTRACT A significant number of patients undergoing coronary artery surgery have severe carotid artery disease. It is also true that up to half of the patients undergoing carotid endarterectomy (CEA) have severe treatable coronary lesions. This study aims to review data regarding 82 patients of combined approach in 8 years; the second half consists of 44 patients whose CEA was performed under local anesthesia. It compares results of the conventional and the modified approaches to simultaneous surgery.
All 82 patients who planned to have a concomitant procedure were recorded prospectively between 1995 and 2003. From 1998, the surgical technique has been modified to switch to local anesthesia for CEA, rather than perform under a single general anesthetic period. All pre-and perioperative data as well as in-hospital and outpatient control (mid- to long-term) data were recorded. A P-value of less than .05 was considered as significant. Analysis of survival was performed by using the Kaplan-Meier method and the log-rank test.
The 30-day follow-up was 100% complete for all patients. All patients were followed for 59.59 to 114 months) months postoperatively. Three patients (6.8%) in the modified and 2 (5.2%) in the standard group had intraluminal shunting (P > .05). In the standard group, 3 patients expired and 3 had perioperative stroke; only 1 patient had a stroke in the modified group and two expired (P > .05). Mean survival time according to Kaplan-Meier test was 109.97, SE 2.84, 95% CI (104.41-115.52) months for the former group, whereas it was 62.79, SE 1.20, 95% CI (60.4565.13) months for the latter. Actuarial estimates of survival during ten-year follow up were 94.44% SE 3.83 in ten-year follow-ups and 97.67% SE 2.30 in 5-year follow-ups for the modified group (P > .05).
Avoidance from extended periods of general anesthesia and cardiopulmonary bypass periods as well as immediate recognition of impaired cerebral flow during CEA and the time it provides to take preventive measures are the most important benefits of the modified technique without significantly changing hospital and long-term mortality and stroke. It may also reduce the cost and the waiting period for the suffering patient.
- SourceAvailable from: Shi-Min Yuan[Show abstract] [Hide abstract]
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.The Tohoku Journal of Experimental Medicine 11/2009; 219(3):243-50. · 1.37 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: (i) Prevalence of stroke in neurologically symptomatic/asymptomatic patients with unilateral/bilateral carotid disease (including occlusion) undergoing cardiac surgery without prophylactic carotid endarterectomy (CEA) or carotid stenting (CAS). (ii) Prevalence of stroke in asymptomatic patients with unilateral/bilateral carotid disease (excluding occlusion) who underwent isolated cardiac surgery. (iii) Prevalence of stroke in the hemisphere ipsilateral to a non-operated asymptomatic stenosis in patients with severe bilateral carotid disease undergoing a synchronous unilateral CEA + cardiac procedure. Systematic Review and meta-analysis. Cardiac surgery patients with a symptomatic/asymptomatic 50-99% stenosis or occlusion incurred a 7.4% stroke risk (95%CI 4.8-9.9), increasing to 9.1% (95%CI 4.8-16) in those with 80-99% stenoses or occlusion. After excluding patients with a history of stroke/TIA and those with isolated/bilateral occlusions, the stroke risk fell to 3.8% (95%CI 2.0-4.8) in patients with asymptomatic 50-99% stenoses and 2.0% in those with 70-99% stenoses (95%CI 1.0-5.7). The prevalence of ipsilateral stroke in patients with a unilateral, asymptomatic 50-99% stenosis was 2.0% (1.0-3.8), while the risk of any stroke was only 2.9% (2%-5.7%). These risks did not increase with stenosis severity (70-99%, 80-99%). Patients with bilateral, asymptomatic 50-99% stenoses or a 50-99% stenosis + contralateral occlusion incurred a 6.5% stroke risk following cardiac surgery, while the risk of death/stroke was 9.1% (3.8%-20.6%). Patients with bilateral 80-99% stenoses undergoing a unilateral synchronous cardiac/carotid revascularisation incurred a 5.7% risk of stroke in the hemisphere ipsilateral to the non-operated, contralateral stenosis. There is no compelling evidence supporting a role for prophylactic CEA/CAS in cardiac surgery patients with unilateral asymptomatic carotid disease. Prophylactic CEA/CAS might still be considered in patients with severe, bilateral asymptomatic carotid disease, but such a strategy would only benefit 1-2% of all cardiac surgery patients.European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery 03/2011; 41(5):607-24. · 2.92 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: To assess the benefits of carotid artery stenting before coronary artery bypass surgery to reduce the risk of stroke occurring during the cardiac procedure. A prospective cohort study was performed in patients undergoing carotid artery stenting before coronary artery bypass surgery, or combined bypass and valve replacement procedures, to assess the procedures effectiveness in stroke prevention. Outcome measures including 30-day post stenting and cardiac surgery neurological complication and all-cause mortality rates were assessed. A total of 52 patients were included. Two patients underwent aortic valve replacements at the same time as coronary revascularization. No neurological complications occurred because of the stenting procedure. One cardiac death not related to coronary artery bypass surgery occurred in the 30-day follow-up period for the stent procedure. An additional 6 (11.5%) outcome events (3 strokes and 3 deaths) occurred in the 30-day follow-up period after the cardiac procedure. Three patients died of cardiac causes while awaiting their cardiac bypass procedure. Our results are comparable to those in patients that undergo staged or combined carotid endarterectomy before cardiac surgery. Our small cohort study adds to the limited world literature on the subject but is not sufficiently powered to recommend alterations in practice.Stroke 03/2006; 37(2):435-9. · 6.16 Impact Factor