Staged carotid endarterectomy under local anaesthetic in patients requiring cardiac surgery

Abstract

This study demonstrates that a policy of selective screening for significant carotid artery disease in cardiac surgical patients combined with a strategy of CEA under local anaesthesia prior to unselected cardiac surgery (CABG with or without valve surgery) leads to rates of peri-operative CVA, myocardial infarction and death comparable to rates published for CEA prior to isolated CABG surgery. Furthermore, it reduces the risk of peri-operative stroke and 30-day mortality to that observed in patients undergoing cardiac surgery without significant carotid arterial disease.

Twenty-Four Hour Staged Carotid Endarterectomy Followed by Off-Pump Coronary Bypass Grafting for Patients With Concomitant Carotid and Coronary Disease

“…Stroke risk has been shown to decrease more for patients staged to CEA before CABG than those staged to CABG before CEA [9]. Staged procedures reduce the stroke risk of CABG patients with carotid disease to that of CABG patients without carotid disease [10]. Nevertheless, completing carotid surgery several days to weeks before CABG leaves the patient at risk for postoperative MI, the highest incidence of perioperative MI occurring on postoperative day 3 [11].…”

“…Nevertheless, completing carotid surgery several days to weeks before CABG leaves the patient at risk for postoperative MI, the highest incidence of perioperative MI occurring on postoperative day 3 [11]. Many studies reporting staged results do not report the length of time between operations, while those that do range from 2 to 32 days [5,10,[12][13][14][15]. One study compared early and late outcomes with 3 approaches (synchronous CEA and open heart surgery, staged CEA and open heart surgery and staged carotid artery stenting and open heart surgery), including interstage events as a risk factor for outcomes after open heart surgery [16].…”

Surgical treatment of acquired valvular heart disease in elderly patients

“…There were no lethal outcomes, cerebral circulation disorder in the postoperative period was revealed in 1 patient (6.7%) (24). Several studies analyzed outcomes of different timing of interventions in patients with combined pathologies (25,26). In 2010, Kar et al (25) published the results of aortic stenosis treatment (AV area <1.0 cm²) among patients with carotid artery stenosis in Cleveland Clinic, USA from 1998 to 2005.…”

“…At the same time, in the group of patients in whom only AVR was performed, there were no lethal cases or acute disturbance of cerebral circulation during the 1-year of follow-up. Birchley et al (26) presented the results of treatment of patients with carotid disease and VHD: 100 patients underwent CE before open-heart surgery (in a screening study of 11394 patients, critical carotid stenosis was revealed in 100 -0.87%); then, CABG was performed in 80 patients, the rest underwent CABG in combination with VHD surgery. Stroke developed in 1% of patients after carotid endarterectomy and before CABG, and in2% after CABG.…”

“…The combined end-point (redo-CABG, myocardial infarction and / or death) was 7.5% after CABG and 10.2% after all operations. The performance of step-bystep operations led to a decrease in the absolute risk of perioperative acute cerebrovascular event-by 0.3% compared with the operation without CE and 30-day mortality rate was 1.4% (26). According to Anselmi et al (27), among patients who underwent surgical correction of valvular defects, asymptomatic carotid artery stenosis (>50%) was detected in 26.4% and stenosis > 70% -in 3.6% of patients.…”