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Tsukagoshi J, Yokoyama Y, Fujisaki T, Takagi H, Shirasu T, Kuno T. Systematic review and meta-analysis of the treatment strategies for coronary artery bypass graft patients with concomitant carotid artery atherosclerotic disease. J Vasc Surg 2023; 78:1083-1094.e8. [PMID: 37257673 DOI: 10.1016/j.jvs.2023.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/23/2023] [Accepted: 04/28/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Stroke is one of the devastating complications after coronary artery bypass graft (CABG). Underlying carotid artery atherosclerotic disease is reported to be an independent risk factor. The optimal treatment strategy for these patients remains under debate. METHODS We aimed to perform a network meta-analysis to evaluate the safety and efficacy of additional carotid interventions for patients with concomitant carotid artery atherosclerotic disease who require CABG by comparing perioperative adverse event rates. All articles through February 2022 were searched using MEDLINE and EMBASE to identify studies that investigated outcomes of CABG only as well as additional staged vs combined carotid interventions by both carotid endarterectomy (CEA) and carotid artery stenting (CAS). RESULTS Two randomized controlled trials and 23 observational studies were included, yielding a total of 32,473 patients who underwent combined CEA and CABG (n = 20,204), CEA and staged CABG (n = 6882), CABG and staged CEA (n = 340), CAS and CABG regardless of timing and sequences (n = 1224), and CABG only (n = 3823). No strategy showed a significant advantage over CABG only in all perioperative outcomes. CEA and staged CABG was associated with the lowest perioperative stroke/transient ischemic attack (TIA) rate, significantly lower compared with CAS and CABG (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.36-0.76) as well as CABG and staged CEA (OR, 0.41; 95% CI, 0.23-0.74), but was also associated with the highest perioperative mortality (OR, 2.50; 95% CI, 1.67-3.85, vs CAS and CABG) and myocardial infarction rate (OR, 3.70 [95% CI, 1.16-12.5] and OR, 2.50 [95% CI, 1.35-4.55] vs CAS and CABG, vs combined CEA and CABG, respectively). CONCLUSIONS CEA and staged CABG are associated with low perioperative stroke/transient ischemic attack rates with a tradeoff of higher mortality and myocardial infarction rate. No strategy showed a significant advantage over the CABG-only strategy in all perioperative outcomes, outlining the importance of a tailored approach and determining proper indications for carotid intervention in these patients.
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Affiliation(s)
- Junji Tsukagoshi
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Yujiro Yokoyama
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA
| | - Tomohiro Fujisaki
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and West, New York, NY; Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Takuro Shirasu
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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2
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Sugiyama K, Ato F, Watanuki H, Tochii M, Miyachi S, Matsuyama K. Effective treatment of severe stenosis of the carotid and coronary arteries: a case study. J Cardiothorac Surg 2023; 18:33. [PMID: 36650524 PMCID: PMC9847165 DOI: 10.1186/s13019-023-02135-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/03/2023] [Indexed: 01/19/2023] Open
Abstract
It is considered acceptable to conservatively manage coronary artery bypass grafting patients with carotid artery disease without the need for preoperative corrective carotid revascularization. However, in the present case, rapidly progressive stroke symptoms with penumbra suggested in the arterial spin labeling, carotid artery stenting was performed successfully.
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Affiliation(s)
- Kayo Sugiyama
- grid.510308.f0000 0004 1771 3656Department of Cardiac Surgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi 480-1195 Japan
| | - Fuminori Ato
- grid.510308.f0000 0004 1771 3656Department of Neurosurgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi 480-1195 Japan
| | - Hirotaka Watanuki
- grid.510308.f0000 0004 1771 3656Department of Cardiac Surgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi 480-1195 Japan
| | - Masato Tochii
- grid.510308.f0000 0004 1771 3656Department of Cardiac Surgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi 480-1195 Japan
| | - Shigeru Miyachi
- grid.510308.f0000 0004 1771 3656Department of Neurosurgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi 480-1195 Japan
| | - Katsuhiko Matsuyama
- grid.510308.f0000 0004 1771 3656Department of Cardiac Surgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi 480-1195 Japan
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3
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Ashrafi M, Ball S, Ali A, Zeynali I, Perricone V. Carotid endarterectomy for critical stenosis prior to cardiac surgery: Should it be done? A retrospective cohort study. Int J Surg 2016; 26:53-7. [PMID: 26790974 DOI: 10.1016/j.ijsu.2015.12.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/01/2015] [Accepted: 12/18/2015] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Mohammed Ashrafi
- Department of Vascular Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK.
| | - Stephen Ball
- Department of Vascular Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Abid Ali
- Department of Vascular Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Iraj Zeynali
- Department of Vascular Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Vittorio Perricone
- Department of Vascular Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
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4
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Adams BC, Clark RM, Paap C, Goff JM. There is No Benefit to Universal Carotid Artery Duplex Screening before a Major Cardiac Surgical Procedure. Ann Vasc Surg 2014; 28:93-101. [DOI: 10.1016/j.avsg.2013.06.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 05/16/2013] [Accepted: 06/16/2013] [Indexed: 10/26/2022]
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Mahmoudi M, Hill PC, Xue Z, Torguson R, Ali G, Boyce SW, Bafi AS, Corso PJ, Waksman R. Patients With Severe Asymptomatic Carotid Artery Stenosis Do Not Have a Higher Risk of Stroke and Mortality After Coronary Artery Bypass Surgery. Stroke 2011; 42:2801-5. [PMID: 21817149 DOI: 10.1161/strokeaha.111.618082] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Michael Mahmoudi
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Peter C. Hill
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Zhenyi Xue
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Gholam Ali
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Steven W. Boyce
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Ammar S. Bafi
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Paul J. Corso
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Ron Waksman
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
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Anselmi A, Gaudino M, Risalvato N, Lauria G, Glieca F. Asymptomatic Carotid Artery Disease in Valvular Heart Surgery. Angiology 2011; 63:171-7. [DOI: 10.1177/0003319711409921] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We evaluated the prevalence of asymptomatic carotid artery disease in patients scheduled for valvular cardiac surgery. Preoperative screening of the carotid arteries was performed. Among 1012 patients scheduled for valvular cardiac surgery, 267 (26.4%) had carotid stenosis graded >50%; 37 had carotid stenosis >70% and underwent combined valvular surgery and carotid endarterectomy (CEA); and 230 (86%) had carotid stenosis >50% to ≤69% and received valvular cardiac surgery under hypothermic cardiopulmonary bypass. Operative mortality and the rate of perioperative adverse neurological events were comparable among the groups. During 6.8 years of follow-up, patients with carotid stenosis not exceeding 69% at the time of surgery had CEA more frequently ( P < .05) and stroke/transient ischemic attack ([TIA] P < .05) versus patients treated with combined surgery. The prevalence of asymptomatic carotid stenosis is not negligible in patients undergoing isolated valvular surgery. Combined valvular and carotid surgery is safe and reduces the incidence of CEA and stroke/TIA during follow-up.
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Affiliation(s)
- Amedeo Anselmi
- Division of Cardiac Surgery, Catholic University, Rome, Italy
| | - Mario Gaudino
- Division of Cardiac Surgery, Catholic University, Rome, Italy
| | | | - Giuseppe Lauria
- Division of Cardiac Surgery, Catholic University, Rome, Italy
| | - Franco Glieca
- Division of Cardiac Surgery, Catholic University, Rome, Italy
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7
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Naylor AR, Bown MJ. Stroke after Cardiac Surgery and its Association with Asymptomatic Carotid Disease: An Updated Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2011; 41:607-24. [PMID: 21396854 DOI: 10.1016/j.ejvs.2011.02.016] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 02/13/2011] [Indexed: 11/19/2022]
Affiliation(s)
- A R Naylor
- The Department of Vascular Surgery at Leicester Royal Infirmary, Leicester LE2 7LX, UK.
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8
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Is carotid artery disease responsible for perioperative strokes after coronary artery bypass surgery? J Vasc Surg 2011; 52:1716-21. [PMID: 21146753 DOI: 10.1016/j.jvs.2010.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 09/01/2010] [Accepted: 09/01/2010] [Indexed: 11/20/2022]
Abstract
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.
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9
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Surgical Management of Asymptomatic Carotid Stenosis. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10076-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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10
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Part Two: Against the Motion Carotid Disease is Responsible for the Increased Risk of Stroke after Coronary Bypass Surgery. Eur J Vasc Endovasc Surg 2010; 40:693-5. [DOI: 10.1016/j.ejvs.2010.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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11
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Yuan SM, Wu HW, Jing H. Treatment strategy for combined carotid artery stenosis and coronary artery disease: staged or simultaneous surgical procedure? TOHOKU J EXP MED 2009; 219:243-50. [PMID: 19851053 DOI: 10.1620/tjem.219.243] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Patients with combined carotid and coronary arterial diseases pose a high risk of cerebrovascular events, and the treatment of choice with either a simultaneous or a staged surgical procedure remains controversial. The literature of combined carotid and coronary arterial diseases of a recent decade in English was retrieved. Totally 41,901 patients undergoing simultaneous or staged carotid and coronary procedures from 53 reports were included. As a result, carotid endarterectomy plus coronary artery bypass remained the most commonly used procedure for the intervention of combined carotid artery stenosis and coronary artery disease, and was associated with higher incidences of perioperative transient ischemic attack, stroke and hospital mortality, but with less perioperative myocardial infarction comparing with the staged procedures. Patients with a simultaneous carotid endarterectomy and coronary artery bypass were generally related more to an advanced atherosclerotic coronary artery disease, so that a pure comparison between the two strategies was not always possible. To compare the efficacy of different surgical methods for combined carotid and coronary arterial diseases is of pronounced importance. The new hybrid approach consisting of the simultaneous carotid artery stenting and subsequent on-pump coronary artery bypass can be a safe approach, with the aim to reduce the surgical trauma as compared to surgical procedures, and to reduce the risk of myocardial infarction in the interval period required for the staged operations. Thus, for patients with combined carotid artery stenosis and coronary artery disease, the simultaneous surgical procedure, rather than the staged procedure, is recommended.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Nanjing University, Nanjing, Jiangsu Province, People's Republic of China
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Mortaz Hejri S, Mostafazadeh Davani B, Sahraian MA. Carotid endarterectomy for carotid stenosis in patients selected for coronary artery bypass graft surgery. Cochrane Database Syst Rev 2009; 2009:CD006074. [PMID: 19821353 PMCID: PMC7389211 DOI: 10.1002/14651858.cd006074.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Carotid stenosis and coronary artery disease can occur simultaneously. In patients with coronary artery disease who are scheduled for coronary artery bypass graft (CABG) surgery, but who also have carotid artery stenosis, there is controversy about the role of carotid surgery. It is not known whether any benefit from prophylactic carotid endarterectomy (by avoiding stroke and neurological dysfunction complicating CABG surgery) outweighs the risks. OBJECTIVES To assess, in patients undergoing CABG surgery with a carotid stenosis more than 50%, the effects of carotid endarterectomy plus best medical therapy compared with best medical therapy alone on the overall risk of major clinical outcomes including death, stroke, and myocardial infarction. SEARCH STRATEGY We searched the trials registers of the Cochrane Stroke Group (searched October 2008) and the Cochrane Heart Group (searched November 2008). In addition, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2008), MEDLINE (1966 to November 2008), EMBASE (1980 to November 2008), reference lists of identified trials, and ongoing trials and research registers (last searched November 2008). SELECTION CRITERIA We planned to include all truly randomised controlled trials comparing carotid endarterectomy plus best medical therapy with best medical therapy alone in patients selected for CABG surgery. The main outcome was perioperative death. DATA COLLECTION AND ANALYSIS We planned for two review authors to independently assess the methodological quality of included studies, and extract data. MAIN RESULTS We did not find any eligible studies. AUTHORS' CONCLUSIONS We found no evidence from randomised trials by which to assess the benefits and risks of prophylactic carotid surgery before CABG surgery. Randomised controlled trials are required to reliably document the risks and benefits of such procedures.
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Affiliation(s)
- Sara Mortaz Hejri
- Tehran University of Medical SciencesStudent's Scientific Research CenterPursina AveKeshavarz BlvdTehranIran
| | - Babak Mostafazadeh Davani
- Tehran University of Medical SciencesStudent's Scientific Research CenterPursina AveKeshavarz BlvdTehranIran
| | - Mohamad Ali Sahraian
- Tehran University of Medical SciencesDepartment of NeurologySina HospitalHassan Abad SquareTehranIran
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Manabe S, Shimokawa T, Fukui T, Fumimoto KU, Ozawa N, Seki H, Ikenaga S, Takanashi S. Influence of carotid artery stenosis on stroke in patients undergoing off-pump coronary artery bypass grafting. Eur J Cardiothorac Surg 2008; 34:1005-8. [PMID: 18783959 DOI: 10.1016/j.ejcts.2008.08.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 07/13/2008] [Accepted: 08/04/2008] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE It is well known that the presence of carotid artery stenosis increases the risk of perioperative stroke in patients undergoing cardiac surgery with cardiopulmonary bypass. Although off-pump coronary artery bypass grafting (CABG) can avoid the adverse effects of cardiopulmonary bypass, the influence of carotid artery stenosis on the incidence of stroke in patients undergoing off-pump CABG has not been well clarified. METHODS We conducted a retrospective study of 461 patients who underwent elective off-pump CABG after screening for carotid artery stenosis at our institute between September 2004 and May 2007. The incidence and etiologies of stroke were identified. Preoperative screening revealed significant carotid artery stenosis in 49 patients. Clinical results were compared between patients with and without carotid artery stenosis. RESULTS Postoperative stroke occurred in two (0.43%) of the 462 study patients, and in-hospital mortality occurred in three (0.65%). Stroke was due to decreased perfusion resulting from hypovolemic shock in one and thrombosis in the other. There was neither stroke nor in-hospital mortality in patients with carotid artery stenosis, although there were two strokes (0.49%) and three in-hospital mortalities (0.73%) in patients without carotid artery stenosis. CONCLUSIONS The influence of carotid artery stenosis on the incidence of perioperative stroke may be little in off-pump CABG, especially in patients with moderate carotid artery stenosis.
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Affiliation(s)
- Susumu Manabe
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Fuchu, Tokyo 183-0003, Japan.
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14
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Nakamura M, Okamoto F, Nakanishi K, Maruyama R, Yamada A, Ushikoshi S, Terasaka S, Kuroda S, Sakai K, Higami T. Does Intensive Management of Cerebral Hemodynamics and Atheromatous Aorta Reduce Stroke After Coronary Artery Surgery? Ann Thorac Surg 2008; 85:513-9. [DOI: 10.1016/j.athoracsur.2007.08.056] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Revised: 08/23/2007] [Accepted: 08/27/2007] [Indexed: 10/22/2022]
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Redondo-López S, Lamas-Hernández M, Utrilla-López A, Centella-Hernández T, Mendieta-Azcona C, Núñez de Arenas-Baeza G, Marín-Manzano E, Rubio-Montaña M, Gallo-González P, Bernal-Bernal C, Haurie-Girelli J, Chinchilla-Molina A, Aracil-Sanus E, Ocaña-Guaita J, Gandarias-Zúñiga C, Cuesta-Gimeno C. Evaluación de estenosis carotídea en pacientes subsidiarios de revascularización miocárdica. ANGIOLOGIA 2006. [DOI: 10.1016/s0003-3170(06)74958-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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16
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Chiappini B, Dell' Amore A, Di Marco L, Di Bartolomeo R, Marinelli G. Simultaneous Carotid and Coronary Arteries Disease: Staged or Combined Surgical Approach? J Card Surg 2005; 20:234-40. [PMID: 15854084 DOI: 10.1111/j.1540-8191.2005.200420.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients suffering from a concomitant coronary and carotid artery occlusive disease represent a high-risk population whose management remains controversial. METHODS Between April 1979 and June 2002, 202 patients (163 men and 39 women, mean age 65 +/- 7 years) were admitted at the Department of Cardiovascular Surgery of the University of Bologna for coronary artery bypass graft and carotid endarterectomy (CEA). In Group 1 (140 patients) coronary artery bypass graft and carotid endarterectomy were performed simultaneously while in Group 2 (62 patients) they were performed as two-staged procedures. RESULTS The rate of postoperative stroke was 6.4% in Group 1 (9/140) and 4.8% in Group 2 (3/62). Significant univariate predictors of myocardial infarction were smoking history and previous myocardial infarction; for stroke they were older, greater than 70 years, and a smoking history; for death the significant predictors were the operative approach, the low ejection fraction, smoking history, renal failure, and peripheral vascular occlusive disease. The hospital mortality was 6.4% in Group 1 versus 12.9% in Group 2. CONCLUSIONS Despite the highly selected populations, the contemporary surgical results indicate that the management of these patients needs careful pre-, intra-, and postoperative assessment and timing aimed at reducing the ischemic injuries, both cerebral and cardiac, therefore we believe that the surgical technique should be individualized for each patient.
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Affiliation(s)
- Bruno Chiappini
- Department of Cardiovascular Surgery, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
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17
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Thompson SK, Southern DA, McKinnon JG, Dort JC, Ghali WA. Incidence of perioperative stroke after neck dissection for head and neck cancer: a regional outcome analysis. Ann Surg 2004; 239:428-31. [PMID: 15075662 PMCID: PMC1356243 DOI: 10.1097/01.sla.0000114130.01282.26] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the incidence of perioperative stroke in patients undergoing a neck dissection. SUMMARY BACKGROUND DATA The incidence of perioperative stroke in non-head and neck surgery is between 0.08 and 0.2%. In contrast, a critical review of the literature identified 2 studies stating the incidence of perioperative stroke in head and neck surgery to be 3.2% and 4.8%. The implications of these results are significant because they suggest a potential need for preoperative screening and/or intervention for carotid artery pathology. METHODS This historical cohort study was conducted using discharge data for all neck dissections performed in a geographically-defined health region in Alberta, Canada, from 1994 to 2002. Subjects were selected for study if they had an assigned ICD-9CM procedure code for a neck dissection at one of the region's 3 adult-care hospitals. Our main outcome measure was perioperative stroke. RESULTS Patients (n = 499) were identified as having had a neck dissection (mean age 56.5 +/- 15.3 SD, 65.3% male). Seven patients had ICD-9CM codes for postoperative central nervous system complications (incidence of 1.4%). However, on chart review, only one had had a true perioperative stroke corresponding to an incidence of 0.2% (95% confidence interval 0.01, 1.12). No missed strokes were found in a confirmatory random review of 10% of charts. CONCLUSIONS The incidence of perioperative stroke in this study is significantly lower than that previously stated in the literature. This suggests that preoperative screening and/or intervention for carotid artery disease may not be necessary in this patient population.
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Affiliation(s)
- Sarah K Thompson
- Department of Surgery, the Centre for Health and Policy Studies, University of Calgary, Calgary, Alberta, Canada
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18
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Abstract
PURPOSE OF REVIEW The purpose of this review is to evaluate the current indications and results of treatment of combined coronary and carotid disease. Synchronous carotid stenosis in patients with coronary artery disease poses a management challenge in patients with advanced atherosclerosis. RECENT FINDINGS Recent case series continue to demonstrate concomitant coronary and carotid disease with significant carotid stenosis greater than 70% in approximately 8% of patients evaluated for coronary artery bypass grafting. Surgical management options include staged operations addressing the carotid stenosis first, reverse staged operations addressing the coronary disease first, and combined synchronous operations addressing both territories during the same anesthetic. Recent reports demonstrate safety and acceptable risks with each operative approach. Lower trends in stroke rates were noted following staged procedures when compared with combined procedures. However, several metaanalyses showed no significant difference in rates of combined morbidity and mortality for all three strategies. Total morbidity and mortality risks for combined disease tended to be higher than for isolated coronary artery bypass grafting or carotid endarterectomy procedures performed for disease in a single vascular territory. SUMMARY Despite a large volume of data present in the literature, the treatment indications and surgical options remain controversial. We currently advocate treatment of symptomatic territory first in favor of staged procedures and reserve combined procedures for patients with critical stenosis or symptoms in both territories.
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Affiliation(s)
- Joseph Huh
- Division of Cardiothoracic Surgery, Houston Veterans Affairs Medical Center, Ben Taub General Hospital, Baylor College of Medicine, Houston, Texas 77401, USA.
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Naylor R, Cuffe RL, Rothwell PM, Loftus IM, Bell PR. A systematic review of outcome following synchronous carotid endarterectomy and coronary artery bypass: Influence of surgical and patient variables. Eur J Vasc Endovasc Surg 2003; 26:230-41. [PMID: 14509884 DOI: 10.1053/ejvs.2002.1975] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Outcomes after synchronous carotid endarterectomy (CEA) plus coronary artery bypass (CABG) relative to surgical and patient based variables. DESIGN Systematic review of 94 published series (7863 synchronous procedures). RESULTS 11.5% of patients died or suffered a stroke/myocardial infarction in the peri-operative period (95% CI 10.1-12.9). The risk of death/stroke appeared to significantly diminish in studies published between 1993-2002, compared with 1972-1992 (7.2% (95% CI 6.5-9.1) versus 10.7% (95% CI 8.9-12.5), p = 0.03). However, increasing operative experience was not associated with significantly lower risks of death/stroke; (1-49 cases (9.6% (95% CI 7.5-11.8); 50-99 cases (9.1% (95% CI 6.4-11.8); 100+ cases (8.4% (95% CI 6.9-10.1) (p = 0.64)). Patients with severe bilateral carotid disease were significantly more likely to suffer death and/or stroke compared to patients with unilateral disease (odds ratio 2.5, 95% CI 1.4-5.0, p = 0.001). Similarly, patients with a prior history of stroke/transient ischaemic attack (TIA) were significantly more likely to suffer a further stroke than asymptomatic patients (odds ratio 1.8, 95% CI 1.1-2.8, p = 0.008). There was no difference in the risk of death/stroke relative to the timing of CEA (pre- versus on-cardiopulmonary bypass), but recent small studies indicate that improved outcomes might be achieved by performing CABG 'off-bypass'. CONCLUSIONS Synchronous CEA + CABG is associated with a not insignificant cardiovascular risk. No comparable information is available for similar patients undergoing CABG without prophylactic CEA.
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Affiliation(s)
- R Naylor
- Department of Vascular Surgery at Leicester Royal Infirmary, Clinical Neurology, The Radcliffe Infirmary, P.O. Box 65, Leicester Royal Infirmary, Leicester, U.K
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Barr JD, Connors JJ, Sacks D, Wojak JC, Becker GJ, Cardella JF, Chopko B, Dion JE, Fox AJ, Higashida RT, Hurst RW, Lewis CA, Matalon TAS, Nesbit GM, Pollock JA, Russell EJ, Seidenwurm DJ, Wallace RC. Quality Improvement Guidelines for the Performance of Cervical Carotid Angioplasty and Stent Placement. J Vasc Interv Radiol 2003; 14:S321-35. [PMID: 14514840 DOI: 10.1097/01.rvi.0000088568.65786.e5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- John D Barr
- Society of Interventional Radiology, 10201 Lee Highway, Suite 500, Fairfax, VA 22030, USA
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Naylor AR, Cuffe RL, Rothwell PM, Bell PRF. A systematic review of outcomes following staged and synchronous carotid endarterectomy and coronary artery bypass. Eur J Vasc Endovasc Surg 2003; 25:380-9. [PMID: 12713775 DOI: 10.1053/ejvs.2002.1895] [Citation(s) in RCA: 196] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to determine the overall cardiovascular risk for patients with combined cardiac and carotid artery disease undergoing synchronous coronary artery bypass (CABG) and carotid endarterectomy (CEA), staged CEA then CABG and reverse staged CABG then CEA. DESIGN systematic review of 97 published studies following 8972 staged or synchronous operations. RESULTS mortality was highest in patients undergoing synchronous CEA+CABG (4.6%, 95% CI 4.1-5.2). Reverse staged procedures (CABG-CEA) were associated with the highest risk of ipsilateral stroke (5.8%, 95% CI 0.0-14.3) and any stroke (6.3%, 95% CI 1.0-11.7). Peri-operative myocardial infarction (MI) was lowest following the reverse staged procedure (0.9%, 95% CI 0.5-1.4) and highest in patients undergoing staged CEA-CABG (6.5%, 95% CI 3.2-9.7). The risk of death+/-any stroke was highest in patients undergoing synchronous CEA+CABG (8.7%, 95% CI 7.7-9.8) and lowest following staged CEA-CABG (6.1%, 95% CI 2.9-9.3). The risk of death/stroke or MI was 11.5% (95% CI 10.1-12.9) following synchronous procedures versus 10.2% (95% CI 7.4-13.1) after staged CEA then CABG. CONCLUSIONS 10-12% of patients undergoing staged or synchronous procedures suffered death or major cardiovascular morbidity (stroke, MI) within 30 days of surgery. Overall, there was no significant difference in outcomes for staged and synchronous procedures and no comparable data for patients with combined cardiac and carotid disease not undergoing staged or synchronous surgery.
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Affiliation(s)
- A R Naylor
- Department of Vascular Surgery, Clinical Sciences Building, PO Box 65, Leicester Royal Infirmary, Leicester LE2 7LX, UK
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Reply to Ali. Eur J Cardiothorac Surg 2002. [DOI: 10.1016/s1010-7940(02)00306-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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