Successful Revascularisation for Unstable Angina of a Patient with Asymptomatic Bilateral Internal Carotid Occlusion, 70% Stenoses of the External Carotid Arteries, and Other Circulation Disturbances

Abstract

Nowadays, advanced surgical and anaesthesiological techniques of coronary artery bypass grafting minimize the risk of severe complications in patients with advanced arteriosclerotic cerebrovascular disease. Nevertheless, in case of highly compromised cerebrovascular status, the decision whether to undertake coronary artery bypass grafting or not requires special patient-related consideration. A severe, unstable angina made it necessary to perform coronary bypass grafting in a patient with bilateral internal carotid occlusion, a bilateral mid-stage stenosis of both external carotid arteries, a diminished flow within the right vertebral artery, and a subsequently impaired intracranial blood flow. Intraoperatively, besides the usual hemodynamic measurements, laser-Doppler flow probes were placed on the left and right upper temple to monitor relative changes of the cerebral blood supply. Using an individual perioperative management, the patient experienced a normal postoperative course and was discharged in good condition.

Conventional coronary artery bypass grafting in patients with total occlusion of the internal carotid artery

“…Adequate collateral supply would seem to be the most probable explanation; however, one of these patients had poor collateral flow and reduced cerebral flow confirmed postoperatively. Osswald et al 21 reported successful CABG for a patient with asymptomatic bilateral ICA occlusion without surgical treatment for the cerebral arterial supply, with relative changes in the cerebral blood supply monitored using laser-Doppler flow probes. They used pulsatile highflow extracorporeal circulation under mild hypothermia and maintained a mean pressure of 80 mmHg.…”

Therapeutic Strategies for Patients with Internal Carotid or Middle Cerebral Artery Occlusion Complicated by Severe Coronary Artery Disease

“…Because it is well known that the extraordinary reduction of CPP easily Kawabori 7 induces ischemic attack in the hemodynamically compromised patients 20 , cardiac surgery per se may potentially provoke ischemic stroke in patients with Type 3 ischemia due to ICA or MCA occlusion with or even without cardiopulmonary bypass. Although some anecdotal reports have concluded that CABG can be successfully performed without any cerebrovascular interventions in patients with ICA occlusion 8,9 , it is warranted to establish non-invasive methodology to predict the risk of perioperative ischemic stroke in patients with extracranial and intracranial artery diseases.…”

“…Based on the fact that the patients with impaired cerebral perfusion reserve due to ICA or MCA occlusion are at significantly higher risk for subsequent ischemic stroke 5 , the patient with coexisting ICA or MCA occlusion would also be prone to suffer ischemic stroke during cardiac surgery 6,7 . However, there are few systematic studies that denote optimal therapeutic strategy for patients with total occlusion of the ICA or middle cerebral artery (MCA) complicated by coronary artery disease requiring cardiac surgery 8,9 . Very recently, we have demonstrated that preoperative cerebrovascular screening and prophylactic cerebrovascular interventions significantly contribute to reduce the incidence of perioperative stroke in patients with occlusive carotid or vertebral artery diseases 1 .…”