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