Elsevier

Cardiovascular Surgery

Volume 8, Issue 5, August 2000, Pages 355-365
Cardiovascular Surgery

Coexistent coronary and cerebrovascular disease: results of simultaneous surgical management in specific patient groups

https://doi.org/10.1016/S0967-2109(00)00027-2Get rights and content

Abstract

Objective: Results of synchronous combined revascularization were examined in specific patient groups with coexistent coronary and cerebrovascular diseases.

Methods: Between 1.1.1980 and 31.12.1998, 408 patients underwent a synchronous combined carotid endarterectomy (CEA)+myocardial revascularization (CABG). In 259 (63.5%) patients, carotid disease was asymptomatic. Remaining patients presented with a previous stroke (n=35) or a transient ischemic episode (TIA) (n=114). In 245 (60%) patients, carotid stenosis was bilateral (Group A: bilateral ≥80% stenosis, Group B: contralateral occlusion, Group C: contralateral subcritical disease). A synchronous ipsilateral CEA+CABG was performed in all patients with an unilateral disease (n=163) and also in all Group B (n=33) and Group C (n=142) patients with bilateral disease. A simultaneous bilateral CEA+CABG was performed in 12 high risk Group A patients. Remaining Group A patients (n=58), initially underwent an ipsilateral CEA for most dominant lesion+CABG, soon followed by the contralateral CEA. Results were examined in above specific patient Groups.

Results: Overall combined hospital mortality from stroke+myocardial infarction was 2.45%. No independent predictor of stroke was identified. In general, initial prophylactic CEA, subdued the risk of subsequent strokes for 7–8 yr. Predictors of a late stroke were: progression of bilateral (P=0.007) and intracranial (P=0.04) cerebrovascular disease. Highest risk of an early stroke was recorded in Group A patients. A composite high risk group of patients with multiple risk factors (n=155) demonstrated a higher risk of both early and late strokes, as compared to the remaining patients (n=253) (P<0.04). Observed risk of early and late strokes, in specific patient groups was lower than standard predictions.

Conclusions: A regular use of combined approach was justified in the above patient groups.

Introduction

Presence of coexistent extracoronary atherosclerotic lesions have been well documented in patients undergoing myocardial revascularization [1]. In patients with a coexistent coronary and carotid disease, a staged intervention involving carotid endarterectomy first, followed by myocardial revascularization, leaves these patients exposed to a risk of perioperative myocardial infarction [1]. Similarly, a reversed stage intervention would leave such patients exposed to a potential risk of stroke [1]. In view of these limitations of the staged intervention procedures, a synchronous combined approach was introduced [2]. Since its early days, synchronous combined approach has remained controversial, but still preferred over staged procedures, by most workers [3]. In order to conduct a comparative evaluation of staged versus combined approach, a meta analysis of 50 earlier reports was conducted [4]. This report has confirmed an absolute reduction in the incidence of perioperative myocardial infarction with combined approach, but has failed to confirm a similar reduction in the risk of perioperative stroke [4]. These findings may be attributed to a multifactorial origin of stroke 5, 6. A coexistent cerebrovascular disease has been identified as an incremental risk factor of perioperative stroke in patients undergoing a CABG procedure on cardiopulmonary bypass (CPB) [5]. However, even in the absence of this important risk factor, incidence of perioperative stroke has ranged between 2 and 3% following an isolated CABG procedure [5]. Thus, in view of insufficient evidence in support of combined approach, several earlier workers continued to prefer staged intervention procedures and have reported variable results [4]. Therefore, in order to establish a clear superiority of combined approach over staged procedures, it was considered necessary to conduct randomized studies [3]. Unfortunately, in view of background knowledge and ethical constrains, only a few of such studies have been completed. One such study [3]has clearly demonstrated a lower incidence of perioperative stroke following combined approach as compared to the staged intervention procedures. Despite a wider and prolonged use of combined approach, it has been difficult to evaluate its risks and benefits in specific high risk patient groups. In most earlier studies, either the number of patients was insufficient or the follow up was inadequate. Only a few studies have conducted a long term evaluation of combined approach in high risk patients groups 7, 8, 9. In this retrospective study, which lasted for almost two decades, an attempt has been made to examine results of combined surgical approach in following specific groups of patients with carotid disease:

  • 1.

    Asymptomatic patients with unilateral/bilateral disease

  • 2.

    Patients with bilateral disease, with/without occlusion, with/ without ulcerative lesion/haemorrhagic plaque

  • 3.

    Patients with/without a previous stroke

  • 4.

    Composite groups of patients with multiple risk factors

Section snippets

Methods

Between 1.1.1980 and 31.12 1998, all candidates for surgical myocardial revascularization (CABG) were subjected to a non invasive screening preoperatively. This policy was pursued to exclude the presence of a coexistent extracoronary atherosclerotic disease. In 3.4% (408/11 862) patients, Duplex Ultrasound Scan detected the presence of a coexistent critical internal carotid stenosis. In view of known limitations of this method [4], a cerebral angiography was performed in all such cases for an

Results

The management strategy pursued in this study was based on characteristics of the carotid lesions and not on presenting symptoms (Table 3). Overall hospital mortality was 3.4% (14/408), and combined hospital mortality from stroke (n=6) plus myocardial infarction (n=4) was 2.45%.

Screening for extracoronary atherosclerosis prior to CABG

Atherosclerosis is a generalized disease. A frequent coexistence of extracoronary atherosclerotic lesions has been well documented in patients undergoing myocardial revascularization 14, 15. Prior to myocardial revascularization a routine screening for extracoronary atherosclerosis has been strongly recommended 7, 8, 9. This policy was strictly observed in the authors' unit. With Duplex Ultrasound Scanning the authors have identified a coexistent critical carotid stenosis in 3.4% of patients,

Conclusions

The following measures could help in achieving a lower incidence of stroke:

  • 1.

    Routine preoperative screening with non invasive methods, followed by angiographic confirmation of the base line status of cerebrovascular disease, prior to myocardial revascularization 38, 39

  • 2.

    Routine maintenance of a higher perfusion pressure during combined CEA+CABG procedure, and in select high risk patients a continuous monitoring of cerebral perfusion pressure and cerebral activity by electro encephalography (EEG)

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