Extracorporeal Circulation as an Additional Method for Cerebral Protection in Simultaneous Carotid Endarterectomy and Coronary Artery Surgical Revascularization

Abstract

Surgical management of patients with concomitant carotid and coronary artery stenosis remains controversial. Our policy was always to perform at the same time carotid endarterectomy (CE) and coronary artery bypass grafting (CABG), but it was also considered that extracorporeal circulation (ECC), because of full heparinization, hemodilution, pulsatile flow, and hypothermia could provide better cerebral protection during CE. Retrospective data of 124 patients undergoing simultaneous CE and CABGs between January 1994 and December 2001 were reviewed. CE was performed prior to ECC in 65 patients (Group 1-mean age: 70.4 years; sex ratio: 49 male/16 female) and under ECC, prior to CABGs in 59 patients (Group 2-mean age: 69.9 years; sex ratio: 46 male/13 female). Overall hospital mortality was 7.3% (9/124): cardiac-related in 5 patients, or due to septicemia (1 patient), or ARD syndrome (1 patient), or stroke in two others. Univariate analysis demonstrated overweight, unstable angina, and emergency to be significant risk factors. Bilateral carotid stenosis was a significant risk factor of neurologic event when CE was performed prior to ECC (p < 0.05). In Group 1, mortality was 9.2% (6/65), and the incidence of neurologic events was 10.7% (7/65), and was responsible for two of the early deaths in patients with bilateral carotid stenosis. In Group 2, mortality was 5.1% (3/59) but never related to CE, while the neurologic morbidity was 1.7% (1 transient ischemic attack). It is concluded that (1) hospital mortality in patients undergoing simultaneous CE and CABGs was mainly cardiac-related. (2) The combined approach of both localizations appears to be mandatory, when carotid stenosis, even asymptomatic, was hemodynamically significant, or with ulcerative lesions likely to be responsible for embolism. (3) CE, first performed under ECC, appears to be a safe procedure, combining, in terms of cerebral protection, the benefits previously called up. This approach is all the more interesting when carotid stenosis is bilateral; hypothermia < or = 28 degrees C during the carotid clamping time is obviously the optimal method for cerebral protection when ipsilateral or contralateral supply is reduced, or even absent.

Early Results of Surgical Simultaneous Therapy for Significant Carotid Artery Stenosis and Heart Disease

“…7 Although Ozen et al found no clear evidence of hypothermia in CEA, we used hypothermic ECC because of its beneficial effects in cardiac surgical procedures. 8,9 From our point of view, in case of CS beyond 70% on one side, the simultaneous repair together with coronary bypass is indicated 10 because of an beneficial outcome, even in case of so-called asymptomatic CS. 11 Gansera et al reported occurrence of perioperative symptoms of stroke with hemiplegia in 10 (2.6%) patients.…”

Comparison of Early Outcomes with Three Approaches for Combined Coronary Revascularization and Carotid Endarterectomy

“…Khaitan et al [26] reported simultaneous CEA and CABG during single cross-clamp, under 25°C of hypothermia for further cerebral protection, as a safe technique with a mortality rate of 5.8% and stroke incidence of 5.8%. Guibaud et al [27] also stated hypothermia below 28°C provides better cerebral protection especially for patients with bilateral carotid lesions. Eren et al [28] reported the results of the first 15 patients of our center being operated under 25°C of hypothermia without stroke and mortality.…”

Coronary artery bypass and carotid endarterectomy with mild hypothermia

“…They reported a 2.65% rate of perioperative stroke, 82.5% 5-year survival, 2.6% late stroke, 3.3% myocardial infarction, and 10.5% subsequent CEA. Guibaud and colleagues 17 compared two different techniques of concomitant CABG and CEA and concluded that mortality and stroke events were less in the group in which CEA was carried out while on extracorporeal circulation rather than before extracorporeal circulation. Khaitan and colleagues 18 reported 121 cases of concomitant CABG and CEA; CEA was undertaken while the patient was on cardiopulmonary bypass and cooled to 25 C. They used hypothermia to add increased cerebral protection during the procedure, and 5.8% of the patients experienced sustained perioperative cerebrovascular accidents.…”