The Influence of Asymptomatic Significant Carotid Disease on Mortality and Morbidity in Patients Undergoing Coronary Artery Bypass Surgery

The correlation between severe asymptomatic carotid artery stenosis and severe multi-organ dysfunction after off-pump coronary artery bypass grafting

Background

The current research aimed to demonstrate the independent association between preoperative severe asymptomatic carotid artery stenosis (ACAS) and severe multi-organ dysfunction after off-pump coronary artery bypass grafting (OPCAB), which may further indicate the relationship between severe ACAS and adverse 30-day postoperative outcomes of patients undergoing OPCAB.

Methods

This was a single-center, retrospective observational study including patients without a history of stroke or Transient Ischemic Attacks (TIA) (asymptomatic), who underwent for an isolated OPCAB in the center for operative treatment of coronary artery disease of Beijing Anzhen Hospital from January 2020 to December 2021. All enrolled patients underwent carotid artery ultrasound prior to OPCAB. The information was extracted independently by two authors of the study from the medical records. Both univariate and multivariate analyses were conducted.

Results

A total of 562 patients met the inclusion criteria for the current study. 63 (11.2%) suffered from severe ACAS. The Sequential Organ Failure Assessment (SOFA) maximum in the severe ACAS group was significantly higher than that in the non-severe ACAS group (9.76 ± 3.03 vs. 7.75 ± 2.96, p < 0.0001), and a higher proportion of patients in the severe ACAS group exhibited severe multi-organ dysfunction (44.4% vs. 14.0%, p < 0.0001). In addition, severe ACAS was related to an increased rate of 30-day postoperative major adverse cardiovascular and cerebral events (MACCEs), including a 30-day postoperative stroke. Severe ACAS was associated with an elevated risk of delirium, and acute kidney injury (AKI). The results of the multivariate analysis demonstrated that severe ACAS may be independently associated with severe multi-organ dysfunction (OR, 7.37, 95% CI 4.80-14.30, p < 0.0001) after OPCAB. Also, severe ACAS may be independently associated with 30-day postoperative stroke (OR, 2.83, 95% CI 1.03-7.75, p = 0,043).

Conclusions

Severe ACAS was independently associated with severe multi-organ dysfunction after OPCAB, which may be associated further with an increased rate of 30-day postoperative mortality and complications. This study highlights: (1) the importance of personalized assessment for potential advantages and disadvantages in prognosis of severe ACAS patients undergoing OPCAB with carotid endarterectomy; (2) the role of multi-organ parameters, especially cardio-cerebral factors, should be emphasized during the process of severe ACAS management.

The role of carotid artery stenosis in predicting stroke after coronary artery bypass grafting in a Chinese cohort study

Current guidelines give priority to surgical treatment of carotid artery stenosis (CAS) before coronary artery bypass grafting (CABG), especially in symptomatic patients. Carotid artery stenting is an alternative treatment for narrowing of the carotid arteries. This study sought to demonstrate the role of severe CAS in predicting stroke after CABG and assess the efficacy of carotid artery stenting in preventing postoperative stroke in a Chinese cohort. From 2015 to 2021, 1799 consecutive patients undergoing isolated CABG surgery were retrospectively recruited in a Chinese cohort. The predictive value of severe CAS in postoperative stroke and carotid stenting in preventing postoperative stroke was statistically analyzed. The incidence of postoperative stroke was 1.67%. The incidence of CAS with stenosis ≥ 50% and ≥ 70% was 19.2% and 6.9%. After propensity matching, the incidence of stroke was 8.0% in the severe CAS group and 0% in the non-severe CAS group. We successfully established an optimal predictive nomogram for predicting severe CAS in patients undergoing CABG. Carotid artery stenting was found ineffective in preventing postoperative stroke. The present study provides the incidence of CAS and postoperative stroke in a Chinese cohort, identifies severe CAS as an independent risk factor for postoperative stroke after CABG, constructs a nomogram predicting the incidence of severe CAS, and evaluates the effectiveness of carotid artery stenting in preventing postoperative stroke after CABG.

Contemporary Management of Patients with Concomitant Coronary and Carotid Artery Disease

The ideal management of concomitant carotid and coronary artery occlusive disease remains elusive. Although researchers have advocated the potential benefits of varying treatment strategies based on either concomitant or staged surgical treatment, there is no consensus in treatment guidelines among national or international clinical societies. Clinical studies show that coronary artery bypass grafting (CABG) with either staged or synchronous carotid endarterectomy (CEA) is associated with a high procedural stroke or death rate. Recent clinical studies have found carotid artery stenting (CAS) prior to CABG can lead to superior treatment outcomes in asymptomatic patients who are deemed high risk of CEA. With emerging data suggesting favorable outcome of CAS compared to CEA in patients with critical coronary artery disease, physicians must consider these diverging therapeutic options when treating patients with concurrent carotid and coronary disease. This review examines the available clinical data on therapeutic strategies in patients with concomitant carotid and coronary artery disease. A treatment paradigm for considering CAS or CEA as well as CABG and percutaneous coronary intervention is discussed.

Carotid endarterectomy for critical stenosis prior to cardiac surgery: Should it be done? A retrospective cohort study

INTRODUCTION

Stroke remains a major cause of morbidity and mortality after cardiac surgery affecting 2% of patients. Extra-cranial carotid artery disease has been implicated in the aetiology of post cardiac surgery stroke. The aim of the study was to evaluate and compare the morbidity and mortality in patients undergoing cardiac surgery with or without staged carotid endarterectomy (CEA) in a tertiary referral centre.

METHODS

A 5 year retrospective study was performed. The primary endpoints were defined as peri-operative stroke and myocardial infarction (MI) with secondary outcome defined as death within 30 days of surgery.

RESULTS

In total 5924 cardiac procedures and 29 staged CEA's were performed. The rate of stroke and MI was significantly higher in patients undergoing staged CEA pre-cardiac surgery compared to patients undergoing cardiac surgery with confirmed or presumed normal carotid arteries (10.34% vs 1.43%; P = .008 and 13.79% vs 0.38%; P < .0001, respectively). There was no significant difference in the stroke and MI rate in those patients undergoing cardiac surgery with confirmed or presumed normal carotid arteries compared to those with significant carotid disease undergoing cardiac surgery with no prior carotid intervention (1.43% vs 3.16%; P > .05 and 0.38% vs 1.05%; P > .05, respectively).

CONCLUSIONS

Carotid disease is associated with an increased risk of stroke post cardiac surgery. Staged carotid intervention cannot be justified based on these results. Increased risk of stroke post cardiac surgery in patients with significant carotid disease needs to be accepted, as the risk of stroke and MI during carotid intervention pre cardiac surgery is significantly higher.

Nonselective carotid artery ultrasound screening in patients undergoing coronary artery bypass grafting: Is it necessary?

OBJECTIVES

To determine whether nonselective preoperative carotid artery ultrasound screening alters management of patients scheduled for coronary artery bypass grafting (CABG), and whether such screening affects neurologic outcomes.

METHODS

From March 2011 to September 2013, preoperative carotid artery ultrasound screening was performed on 1236 of 1382 patients (89%) scheduled to undergo CABG. Carotid artery stenosis (CAS) was classified as none or mild (any type 0%-59% stenosis), moderate (unilateral 60%-79% stenosis), or severe (bilateral 60%-79% stenosis or unilateral 80%-100% stenosis).

RESULTS

A total of 1069 (86%) had <moderate; 90 (7.3%) had moderate; and 77 (6.2%) had severe CAS. Of those with moderate CAS, 4 (4.4%) had preoperative confirmatory testing, and 1 (1.1%) underwent combined CABG + carotid endarterectomy (CEA); 11 (12%) had off-pump surgery. Of those with severe CAS, 18 (23%) had confirmatory testing, and 18 (23%) underwent combined CABG + CEA; 6 (7.8%) had off-pump surgery. Stroke occurred in 14 of 1069 (1.3%) patients with <moderate CAS; 2 of 90 (2.2%) of those with moderate CAS; and 2 of 77 (2.6%) of those with severe CAS (P = .3). In patients with ≥moderate CAS, 1 of 19 (5.3%) undergoing CABG + CEA and 3 of 148 (2.0%) undergoing CABG alone experienced stroke (P = .4). In patients with moderate CAS, stroke occurred in 1 of 11 (9.1%) off-pump and 1 of 79 (1.3%) on-pump patients (P = .2). In patients with severe CAS, stroke occurred in 1 of 6 (17%) off-pump and 1 of 71 (1.4%) on-pump patients (P = .15).

CONCLUSIONS

Routine preoperative carotid artery evaluation altered the management of a minority of patients undergoing CABG; this did not translate into perioperative stroke risk. Hence, a more targeted approach for preoperative carotid artery evaluation should be adopted.

Stroke associated with coronary artery bypass grafting

While coronary artery bypass grafting (CABG) has been playing a significant role in the revascularization for ischemic heart disease, neurological complications associated with CABG have been a primary concern. Stroke, although the incidence is low, is one of the most devastating complication of CABG. Many studies have identified the risk factors for stroke with CABG, such as prior stroke, carotid artery stenosis, aortic atherosclerosis, atrial fibrillation and cardiopulmonary bypass. Various rational approaches focusing on individual risk factor have been proposed for the stroke. Prophylactic carotid revascularization is an important strategy, and the diagnosis of carotid stenosis has to be established correctly. Prevention of emboli from aortic plaque is also an essential issue. Intraoperative monitoring with transesophageal or epiaortic ultrasound is useful to identify mobile atheromatous plaques and to select appropriate aortic manipulations. Maintenance of cerebral blood flow and blood pressure during cardiopulmonary bypass might be critical issues. Besides, there are conflicting two opinions regarding off-pump CABG; one supports an efficiency for the prevention of stroke while the other advocates no effect. This discrepancy might be explained by the difference of the risk of stroke in the population of the individual study and by the variation of the percentage of aortic clamping or aortic anastomosis in each study. Pharmaceutical therapies such as statin, preventive medication for atrial fibrillation, or antiplatelet are promising methods. Although it is hard to decrease the incidence of the stroke with any single countermeasure, sustained effort should be continued to overcome the stroke associated with CABG.

Cerebral lesions in patients undergoing coronary artery bypass grafting in relation to asymptomatic carotid and vertebral artery stenosis

OBJECTIVES

Carotid artery stenosis (CAS) and vertebral artery stenosis (VAS) are associated with cerebral infarction after coronary artery bypass graft surgery (CABG). It remains unclear whether this association is causal. We investigated the associations between neurologically asymptomatic CAS and VAS and the occurrence of subclinical cerebral lesions after CABG verified by magnetic resonance imaging.

METHODS

CABG patients were included and CAS and VAS were identified by magnetic resonance angiography. Cerebral magnetic resonance imaging was performed to identify new post-operative subclinical cerebral lesions. The associations between CAS/VAS post-operative cerebral lesions were investigated.

RESULTS

Forty-six patients were included in the study. 13% had significant CAS and 11% had significant VAS. Thirty-five percent had new cerebral infarction postoperatively. We found a significant association between the presence of cerebral vessel stenosis and acute cerebral infarction (67% vs. 27%, p = 0.047). However none of the patients with stenosis had isolated cerebral lesions in the ipsilateral vascular territory.

CONCLUSION

Asymptomatic CAS and VAS is common in CABG patients and is associated with an increased risk of postoperative cerebral infarction. Our study suggests that asymptomatic CAS and VAS primarily are risk markers rather than causal factors for cerebral infarction after CABG.

Does preoperative carotid stenosis screening reduce perioperative stroke in patients undergoing coronary artery bypass grafting?

A number of institutions routinely perform carotid artery ultrasound screening before coronary artery bypass grafting (CABG) to identify carotid artery disease requiring revascularization before or during CABG, with the expectation of reducing perioperative neurologic events. The assumptions are that carotid disease is causally related to perioperative stroke and that prophylactic carotid revascularization decreases the risk of post-CABG neurologic events. Although carotid artery stenosis is a known risk factor for perioperative stroke in patients undergoing CABG, it might be a surrogate marker for diffuse atherosclerotic disease rather than a direct etiologic factor. Moreover, the benefit of prophylactic carotid revascularization in patients with asymptomatic unilateral carotid disease is uncertain. Therefore, we have reviewed the literature for evidence that preoperative carotid artery screening, by identifying patients with significant carotid artery stenosis and altering their management, reduces perioperative neurologic events in those undergoing CABG.

Carotid Artery Stenosis Associated with Increased Mortality in Patients who Underwent Coronary Artery Bypass Grafting: A Single Center Experience

BACKGROUND

Vascular disease resulting from arteriosclerosis is a severe worldwide health risk. Early diagnosis and intervention is important to control adverse cerebral and cardiovascular events. The aim of this study was to assess the potential predictors of mortality in patients submitted to coronary bypass surgery.

METHODS

Cohort study included asymptomatic cerebrovascular disease patients scheduled for coronary artery bypass grafting admitted to the cardiology reference center. All patients were submitted to carotid artery ultrasound assessment prior to surgery and were followed up during the entire in-hospital postoperative period. Carotid artery stenosis was considered clinically significant when cross sectional area ≥50%. Significance was set at p <0.05. Logistic regression was used to identify independent predictors of mortality.

RESULTS

Of 455 patients with a mean age of 62.2 years 65.6% were males. The prevalence of carotid artery stenosis was 18.7%. It was absent in 3.6% of the patients, below 50% in 77.8%, between 50 and 69% in 11.6%, and between 70 and 99% in 6.9%. The carotid artery was occluded in 0.2% of the sample. An overall mortality of 12%, affecting 35 men (P=0.001) with stenosis ≥50%. After logistic regression analysis, carotid artery stenosis ≥50% was confirmed as being an independent predictor of mortality (P=0.005).

CONCLUSION

In this series carotid artery stenosis showed a high prevalence in the sample assessed and was an independent predictor of mortality.

Advances in the management of carotid artery disease: focus on recent evidence and guidelines

Recent landmark randomized trials and society guidelines have significantly revised the management of carotid artery disease. Duplex ultrasonography is the recommended initial diagnostic test for the assessment of extracranial carotid artery stenosis. Carotid artery imaging is reasonable in select patients scheduled for coronary artery bypass graft (CABG) surgery. Carotid revascularization can be achieved safely and effectively with carotid endarterectomy or carotid artery stenting. Because each procedure has a different risk/benefit profile, the optimal approach is to match the particular patient to the intervention that maximizes outcome benefit. Carotid revascularization is recommended in patients scheduled for CABG surgery when the carotid artery stenosis is symptomatic and/or bilateral. Further trials are required to guide the management of asymptomatic unilateral carotid artery stenosis in patients undergoing CABG surgery. Aggressive medical therapy remains the gold standard for intracranial carotid artery disease because landmark trials have shown no outcome improvement with vascular bypass or percutaneous angioplasty and stenting. A large recent trial showed that local anesthesia, as compared with general anesthesia, for carotid endarterectomy has no major clinical outcome advantage. Although carotid artery stenting is associated with a reduced risk of myocardial ischemia, it still has important risks of stroke and hemodynamic instability that significantly affect clinical outcome. The timing and choice of carotid revascularization technique ultimately depends on multiple clinical factors.

Importance of strict patient selection criteria for combined carotid endarterectomy and coronary artery bypass grafting

BACKGROUND

Management of patients with severe concomitant carotid and coronary disease remains controversial. We report our experience of combined carotid endarterectomy (CEA) and coronary artery bypass surgery (CABG) over a fifteen year period using strict patient selection criteria.

METHODS

From 1st January 1995 to December 31st 2009 165 patients underwent combined CABG/CEA procedures at the Mater Hospital. Mean age was 68.2 years (range 43-88) and 127 (77%) were male. Fifty-three (32%) had symptomatic carotid disease. Indications for combined procedures were the presence of symptomatic >70% or asymptomatic >80% internal carotid artery stenosis in a patient requiring urgent CABG because of either unstable angina, recent MI, severe triple vessel disease or severe Left Anterior Descending or Left Main Stem stenosis.

RESULTS

Thirty-day stroke and death rate was 3%. All neurological events were in the hemisphere contralateral to the carotid surgery and symptoms had completely resolved prior to discharge from hospital. One patient required evacuation of a cervical haematoma and there were two transient XII nerve palsies.

CONCLUSION

Combined CEA/CABG can be performed safely with acceptable morbidity and mortality in patients selected in accordance with strict criteria in a centre with a large experience of both cardiac and carotid surgery.

Regional use of combined carotid endarterectomy/coronary artery bypass graft and the effect of patient risk

INTRODUCTION

Although carotid artery stenosis and coronary artery disease often coexist, many debate which patients are best served by combined concurrent revascularization (carotid endarterectomy [CEA]/coronary artery bypass graft [CABG]). We studied the use of CEA/CABG in New England and compared indications and outcomes, including stratification by risk, symptoms, and performing center.

METHODS

Using data from the Vascular Study Group of New England from 2003 to 2009, we studied all patients who underwent combined CEA/CABG across six centers in New England. Our main outcome measure was in-hospital stroke or death. We compared outcomes between all patients undergoing combined CEA/CABG to a baseline CEA risk group comprised of patients undergoing isolated CEA at non-CEA/CABG centers. Further, we compared in-hospital stroke and death rates between high and low neurologic risk patients, defining high neurologic risk patients as those who had at least one of the following clinical or anatomic features: (1) symptomatic carotid disease, (2) bilateral carotid stenosis >70%, (3) ipsilateral stenosis >70% and contralateral occlusion, or (4) ipsilateral or bilateral occlusion.

RESULTS

Overall, compared to patients undergoing isolated CEA at non-CEA/CABG centers (n = 1563), patients undergoing CEA/CABG (n = 109) were more likely to have diabetes (44% vs 29%; P = .001), creatinine >1.8 mg/dL (11% vs 5%; P = .007), and congestive heart failure (23% vs 10%; P < .001). Patients undergoing CEA/CABG were also more likely to take preoperative beta-blockers (94% vs 75%; P < .001) and less likely to take preoperative clopidogrel (7% vs 25%; P < .001). Patients undergoing CEA/CABG had higher rates of contralateral carotid occlusion (13% vs 5%; P = .001) and were more likely to undergo an urgent/emergent procedure (30% vs 15%; P < .001). The risk of complications was higher in CEA/CABG compared to isolated CEA, including increased risk of stroke (5.5% vs 1.2%; P < .001), death (5.5% vs 0.3%; P < .001), and return to the operating room for any reason (7.6% vs 1.2%; P < .001). Of 109 patients undergoing CEA/CABG, 61 (56%) were low neurologic risk and 48 (44%) were high neurologic risk but showed no demonstrable difference in stroke (4.9% vs 6.3%; P = .76), death, (4.9 vs 6.3%; P = .76), or return to the operating room (10.2% vs 4.3%; P = .25).

CONCLUSIONS

Although practice patterns in the use of CEA/CABG vary across our region, the risk of complications with CEA/CABG remains significantly higher than in isolated CEA. Future work to improve patient selection in CEA/CABG is needed to improve perioperative results with combined coronary and carotid revascularization.

Randomized comparison of synchronous CABG and carotid endarterectomy vs. isolated CABG in patients with asymptomatic carotid stenosis: the CABACS trial

RATIONALE

High-grade carotid artery stenosis is present in 6-8% of patients undergoing coronary artery bypass graft surgery. Many cardiovascular surgeons advocate staged or synchronous carotid endarterectomy to reduce the high perioperative and long-term risk of stroke associated with multivessel disease. However, no randomized trial has assessed whether a combined synchronous or staged carotid endarterectomy confers any benefit compared with isolated coronary artery bypass grafting in these patients.

AIMS

The objective of this study is to compare the safety and efficacy of isolated coronary artery bypass grafting vs. synchronous coronary artery bypass grafting and carotid endarterectomy in patients with asymptomatic high-grade carotid artery stenosis.

DESIGN

Coronary Artery Bypass graft surgery in patients with Asymptomatic Carotid Stenosis (CABACS) is a randomized, controlled, open, multicenter, group sequential trial with two parallel arms and outcome adjudication by blinded observers. Patients with asymptomatic high-grade carotid stenosis scheduled for elective coronary artery bypass grafting will be assigned to either isolated coronary artery bypass grafting or synchronous coronary artery bypass grafting and carotid endarterectomy by 1 : 1 block-stratified randomization with three different stratification factors (age, gender, modified Rankin scale).

STUDY

The trial started in December 2010 aiming at recruiting 1160 patients in 25 to 30 German cardiovascular centers. The composite primary efficacy end point is the number of strokes and deaths from any cause (whatever occurs first) within 30 days after operation. A 4·5% absolute difference (4% compared to 8·5%) in the 30-day rate of the above end points can be detected with >80% power.

OUTCOMES

The results of this trial are expected to provide a basis for defining an evidence-based standard and will have a wide impact on managing this disease.

Patients With Severe Asymptomatic Carotid Artery Stenosis Do Not Have a Higher Risk of Stroke and Mortality After Coronary Artery Bypass Surgery

Background and Purpose—

Stroke development is a major concern in patients undergoing coronary artery bypass grafting (CABG). Whether asymptomatic severe carotid artery stenosis (CAS) contributes to the development of stroke and mortality in such patients remains uncertain.

Methods—

A retrospective analysis of 878 consecutive patients with documented carotid duplex ultrasound who underwent isolated CABG in our institution from January 2003 to December 2009 was performed. Patients with severe CAS (n=117) were compared with those without severe CAS (n=761) to assess the rates of stroke and mortality during hospitalization for CABG. The 30-day mortality rate was also assessed.

Results—

Patients with severe CAS were older and had a higher prevalence of peripheral arterial disease and heart failure. Patients with severe CAS had similar rates of in-hospital stroke (3.4% versus 3.6%; P =1.0) and mortality (3.4% versus 4.2%; P =1.0) compared with patients without severe CAS. The 30-day rate of mortality was also similar between the 2 cohorts (3.4% versus 2.9%; P =0.51).

Conclusions—

Severe CAS alone is not a risk factor for stroke or mortality in patients undergoing CABG. The decision to perform carotid imaging and subsequent revascularization in association with CABG must be individualized and based on clinical judgment.

Is carotid artery disease responsible for perioperative strokes after coronary artery bypass surgery?

The coronary and extracranial carotid vascular beds are often simultaneously affected by significant atherosclerotic disease, and stroke is one of the potential major complications of coronary artery surgery. As a result, there is no shortage of reports in the vascular surgery literature describing simultaneous coronary and carotid artery revascularizations. Generally, these reports have found this combination of operations safe, but have stopped short of proving that it is necessary. Intuitively, simultaneous carotid endarterectomy and coronary artery bypass surgery could be justified if most perioperative strokes were the result of a significant carotid stenosis, either directly or indirectly. At first glance this appears to be a fairly straightforward issue; however, much of the evidence on both sides of the argument is circumstantial. One significant problem in analyzing outcome by choice of treatment in patients presenting with both coronary and carotid disease is the multiple potential causes of stroke in coronary bypass patients, which include hemorrhage and atheroemboli from aortic atheromas during clamping. But this controversial subject is now open to discussion, and our debaters have been given the challenge to clarify the evidence to justify their claims.

Synchronous cardiac and carotid revascularisation: the devil is in the detail

BACKGROUND

Studies reporting outcomes following staged/synchronous carotid revascularisation prior to cardiac surgery have generally concluded that procedural strokes are reduced. However, virtually none have commented specifically on the risk of stroke in patients with bilateral carotid disease who then undergo their cardiac procedure in the presence of an unoperated, contralateral stenosis. If carotid disease really was an important cause of peri-operative stroke, these patients should incur a much higher risk of stroke following their cardiac procedure.

METHODS

Retrospective audit of prospectively acquired data in 132 consecutive patients undergoing synchronous carotid endarterectomy and cardiac surgery.

RESULTS

Overall 30-day rates of mortality, ipsilateral stroke and any stroke were 5.3%, 1.5% and 3% respectively. The 30-day rate of death/stroke was 6.8%. In 51 patients with a prior history of stroke/TIA, the 30-day rate of death/stroke was 5.9%, compared with 7.4% in neurologically asymptomatic patients. The majority (57%) had significant bilateral disease and underwent their combined procedure in the presence of a significant, non-operated (asymptomatic) contralateral stenosis (50-99% = 75, 60-99% = 54, 70-99% = 32). Only one patient (90-99% stenosis) suffered a post-operative stroke in the hemisphere ipsilateral to the non-operated, contralateral stenosis.

CONCLUSIONS

Patients undergoing synchronous procedures incurred a low rate of procedural stroke, perhaps justifying this management approach. However, an alternative and more critical analysis suggested that the risk of procedural stroke in patients with significant (non-operated) contralateral asymptomatic carotid disease was extremely low. This challenges the assumption that asymptomatic carotid disease is an important cause of stroke during cardiac surgery.

Combined carotid and cardiac surgery: improving the results

BACKGROUND

Aim of this study was to analyze our experience in the last 5 years of combined carotid and cardiac surgery.

METHODS

During a 5-year period (January 2002-December 2006), 111 patients underwent combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) (group 1), while 1,446 patients underwent isolated CEA (group 2). Perioperative outcomes in the two groups were compared using chi(2) and Fisher's exact tests to analyze neurological deficits, cardiac events, and death at 30 days. Results during follow-up were analyzed using Kaplan-Meier survival curves, and both groups were compared using the log-rank test.

RESULTS

Immediate postoperative neurological deficits occurred more frequently in group 1 patients (2.5 vs. 0.4%, p = 0.002), with a higher incidence of transient ischemic attacks in group 1; however, there was no difference in the incidence of stroke (1% group 1 vs. 0.6% group 2, p = n.s.). Mortality rate was increased in the combined surgery group (3.5 vs. 0.5%, p < 0.001). Combined stroke/myocardial infarction/death rate at 30 days was 6.3% in group 1 compared with 1.4% in group 2, p = 0.001. Perioperative stroke/myocardial infarction/death rate was much improved in the 55% (61/111) of patients undergoing CABG off-pump (3.3 vs. 10%, p = 0.001). Mean follow-up was 18.7 months (range, 1-60). Survival at 24 months was significantly higher in patients of group 2 compared with group 1 (99.4 vs. 91.3% respectively, p < 0.001). At 24 months, there was no significant difference between the two groups in the risk of developing ipsilateral or contralateral neurologic events (3.1% group 1 vs. 1.7% group 2).

CONCLUSION

In our experience, combined CEA and cardiac surgery carries a higher risk of perioperative mortality than patients undergoing isolated CEA. Whenever possible, CEA combined with off-pump CABG seems to be the therapeutic strategy of choice.

Known knowns, known unknowns and unknown unknowns: a 2010 update on carotid artery disease

The management of carotid artery disease never ceases to attract controversy. The last 12 months has seen publication of a number of important studies which have informed debate and 2010 holds the prospect of much more. This update offers a personal review of a number of contemporary issues including; (i) guidelines for non-invasive imaging in rapid access clinics, (ii) whether improvements in best medical therapy have rendered many of the conclusions from ACAS and ACST obsolete, (iii) is carotid disease really just a marker for increased stroke risk following cardiac surgery (rather than being an important cause), (iv) what is the current status of endarterectomy and stenting in patients with symptomatic carotid disease and (v) why we must offer expedited interventions to TIA/minor stroke patients. The available evidence suggests that while most 'known knowns' will endure, quite a few may be returning to the category of 'known unknowns' once again. Who knows what 'unknown unknowns' await us in 2010 and beyond.

Patients undergoing cardiac surgery with asymptomatic unilateral carotid stenoses have a low risk of peri-operative stroke

BACKGROUND

There is considerable controversy regarding the optimal management of patients undergoing cardiac surgery who are found to have an asymptomatic, unilateral carotid artery stenosis. Prior to 2004, the policy of this Unit was to perform a synchronous cardiac and carotid revascularisation. After January 2004, the policy was changed and patients underwent their cardiac procedure without carotid revascularisation. The aim of this study was to audit the incidence of stroke in the peri-operative period following this change in practice.

METHODS

Five-year audit of the 30-day risk of stroke after 61 consecutive open cardiac procedures in patients with unilateral, asymptomatic 70-99% (NASCET) stenoses who did not undergo prophylactic carotid endarterectomy.

RESULTS

61 cardiac procedures; coronary artery bypass grafting (CABG)=44, valve replacement=6, CABG+valve replacement=9, CABG+repair of left ventricular aneurysm=2 were undertaken and the 30-day outcomes audited. There were three deaths (4.9%), all due to myocardial infarction. No strokes occurred in any patient in the 30-day post-operative period.

CONCLUSION

These results challenge the opinion that the presence of a unilateral, asymptomatic carotid stenosis in patients undergoing open cardiac surgery is associated with an increased risk of peri-operative stroke, sufficient to warrant routine prophylactic carotid revascularisation.

Screening Carotid Sonography Before Elective Coronary Artery Bypass Graft Surgery: Who Needs It

OBJECTIVE

The purpose of this study was to determine whether selection criteria for performing carotid sonographic screening before elective coronary artery bypass graft surgery can decrease the number of negative examinations without overlooking patients with significant carotid disease.

SUBJECTS AND METHODS

A history of peripheral vascular disease, a prior cerebrovascular event, smoking, diabetes, hypertension, cervical carotid disease, left main coronary disease, and patient sex were criteria prospectively gathered for 295 consecutive patients undergoing screening carotid sonography before elective coronary artery bypass surgery. Logistic regression modeling was used to determine if any single criterion or combination of criteria could be applied to decrease the number of screening examinations without sacrificing detection of significant (> or = 50% cross-sectional narrowing) carotid stenosis.

RESULTS

Smoking, diabetes, hypertension, a previous cerebrovascular event, peripheral vascular disease, left main coronary artery disease, and a history of cervical carotid disease were associated with significant carotid disease (chi-square test) in our subject population. Logistic modeling showed that the probability of detecting significant carotid disease increases 2.98 times for each additional selection criterion present. Possessing at least one selection criterion would still yield 100% examination sensitivity while increasing specificity to 30.0%.

CONCLUSION

Selection criteria should be applied when choosing patients for carotid sonographic screening before elective coronary artery bypass surgery. This approach would decrease the number of noncontributory examinations but would have little effect on the detection of significant carotid stenosis in this target population.

Combined carotid endarterectomy and coronary artery bypass grafting in patients with asymptomatic high-grade stenoses: An analysis of 758 procedures

PURPOSE

Surgical treatment of hemodynamically significant carotid artery stenoses has been well documented, especially in the asymptomatic patient. However, in those patients presenting with hemodynamically significant asymptomatic carotid artery disease who are to undergo cardiac surgery, optimal treatment remains controversial. In this study, we analyze our experience with patients who underwent synchronous carotid endarterectomy (CEA) and coronary artery bypass graft procedures (CABG) for hemodynamically significant (>70%) asymptomatic carotid artery stenosis and coronary artery disease (CAD).

METHODS

Demographics and outcomes of all patients undergoing synchronous CEA/CABG for asymptomatic carotid stenosis between April 1980 and January 2005 were reviewed from our vascular registry and patient charts. We included patients who underwent standard patching of their carotid artery and those undergoing eversion CEA. All neurologic events within the first 30 days that persisted >24 hours were considered a stroke. For purposes of comparison, we also reviewed outcomes for patients undergoing synchronous CEA/CABG for symptomatic carotid stenosis.

RESULTS

Asymptomatic carotid artery stenosis (>70%) was the indication in 702 patients (276 women and 426 men) undergoing 758 CEAs. In the asymptomatic group, 22 patients, of which 21 succumbed to cardiac dysfunction, and one died from a hemorrhagic stroke. The overall mortality rate was 3.1%. Seven permanent nonfatal neurologic deficits occurred in this series (1 woman, 6 men). The combined stroke mortality was 4.3%. This compares to a 30-day stroke mortality of 6.1% in 132 symptomatic combined CEA/CABG patients. The difference in stroke mortality in women compared with men was not significant.

CONCLUSION

In this experience, patients presenting with hemodynamically significant (>70%) asymptomatic carotid artery stenosis can undergo synchronous CEA/CABG with low morbidity and mortality.

Is There Any Benefit From Staged Carotid and Coronary Revascularization Using Carotid Stents?

Background and Purpose— To assess the benefits of carotid artery stenting before coronary artery bypass surgery to reduce the risk of stroke occurring during the cardiac procedure.

Methods— A prospective cohort study was performed in patients undergoing carotid artery stenting before coronary artery bypass surgery, or combined bypass and valve replacement procedures, to assess the procedures effectiveness in stroke prevention. Outcome measures including 30-day post stenting and cardiac surgery neurological complication and all-cause mortality rates were assessed.

Results— A total of 52 patients were included. Two patients underwent aortic valve replacements at the same time as coronary revascularization. No neurological complications occurred because of the stenting procedure. One cardiac death not related to coronary artery bypass surgery occurred in the 30-day follow-up period for the stent procedure. An additional 6 (11.5%) outcome events (3 strokes and 3 deaths) occurred in the 30-day follow-up period after the cardiac procedure. Three patients died of cardiac causes while awaiting their cardiac bypass procedure.

Conclusions— Our results are comparable to those in patients that undergo staged or combined carotid endarterectomy before cardiac surgery. Our small cohort study adds to the limited world literature on the subject but is not sufficiently powered to recommend alterations in practice.

Neurologic complications of cardiac surgery: Current concepts and recent advances

Neurologic complications following cardiac surgery result in increased morbidity and mortality. The incidence of stroke is 2% to 4%, but is substantially higher in patients with a prior history of stroke. The success of off-pump techniques in altering this risk is controversial. The efficacy and safety of simultaneous carotid endarterectomy and coronary artery bypass surgery are still debated. Mechanical clot retrievers may offer new opportunity to treat postoperative large, middle cerebral artery strokes. The risk of cognitive deficits is debatable but may be due to factors other than the use of bypass and may not differ from similar deficits after noncardiac surgery. Short-term cognitive deficits usually resolve by 1 to 3 months. Long-term risks are not clearly established. Novel approaches may decrease the incidence of neurocognitive dysfunction. Postoperative seizures may result from global or focal cerebral ischemia due to hypoperfusion, particulate or air emboli, or metabolic causes. Newer anticonvulsant drugs may offer additional management opportunities.

Synchronous carotid stenting and cardiac surgery: An initial single-center experience

Concurrent severe carotid and cardiac disease is a challenging situation where staged surgery is probably the most common strategy, although it is still controversial. We report in-hospital and midterm outcome of 30 patients who received carotid stenting and synchronous cardiac surgery. All received carotid stenting under aspirin and regular unfractioned heparin (UFH) and were immediately transferred to the operating room for coronary and/or cardiac valve surgery. All patients received aspirin and clopidogrel once bleeding was ruled out, after surgery. In-hospital complications were: three surgical related deaths, one TIA, and no patient suffered stroke or myocardial infarction. Hospital stay was 14 +/- 11.8 days. Survivors were followed for 18.4 +/- 14 months. There were two non-related deaths, but no stroke nor cardiac or carotid reinterventions. In conclusion, this small series showed that synchronous carotid stenting and cardiac surgery was feasible with an acceptable complication rate in a high-surgical-risk population which could not undergo staged procedures.