Surgical Risk Factors for Ischemic Stroke Following Coronary Artery Bypass Grafting. A Multi-Factor Multimodel Analysis

Benefits of prophylactic carotid revascularization in patients with asymptomatic carotid artery stenosis undergoing coronary artery bypass surgery: A narrative review

Patients undergoing coronary artery bypass grafting (CABG) are at increased risk of perioperative stroke. Carotid atherosclerosis has been identified as an independent risk factor for stroke during and in the early postoperative period of cardiac surgery. However, the pathogenesis of peri-CABG stroke is multifactorial and frequently involves other noncarotid causes, such as cardiac emboli and aortic atheroma. Therefore, routine population-wide screening of carotid stenosis is not recommended, but target screening of patients at high risk of carotid-related perioperative stroke can have benefits. Carotid duplex sonography is recommended as an initial screening tool. Elimination of carotid stenosis before cardiac surgery is indicated in patients in whom carotid atherosclerosis is suspected to be the primary contributor to perioperative stroke. In patients with advanced carotid atherosclerosis, an individualized revascularization approach, including simultaneous or staged procedures, is advocated. The prevailing consensus is that synchronous surgery is safer than staged procedures. Carotid artery stenting represents a less invasive alternative, but its role in high-risk patients requires further investigation. In conclusion, the risk of perioperative stroke in patients undergoing CABG involves different factors, and carotid artery stenosis is involved in its pathogenesis only in some patients. Therefore, individualized approaches and careful consideration of patient risk factors are essential in determining the need for carotid screening and revascularization before CABG.

Minimally invasive coronary artery bypass grafting using the skeletonized right gastroepiploic artery

Objective

To evaluate the clinical outcomes of right gastroepiploic artery use in minimally invasive coronary artery bypass grafting.

Methods

A total of 428 patients who underwent minimally invasive coronary artery bypass grafting from February 2012 to February 2024 were included into this retrospective cohort study. The selection criteria for right gastroepiploic artery use included satisfactory artery size and length, significant stenosis (99% to 100%) of the right coronary artery, and unsuitable ascending aorta for partial clamping.

Results

The study cohort comprised 70 men and 8 women, with an average age of 63.6 ± 10.5 years. The right gastroepiploic artery was used in 18.2% (78 out of 428) of cases, without the aorta being touched in all these cases. Total arterial revascularization was achieved in 93.6% of cases and complete revascularization was achieved in 98.7%. Notable postoperative outcomes included zero in-hospital mortality, an incidence of new-onset atrial fibrillation of 9.0%, and a median intensive care unit stay of 2 days. Surgical site infections occurred in 7.5% of patients.

Conclusions

The use of the right gastroepiploic artery in minimally invasive coronary artery bypass grafting is a viable option for achieving total arterial revascularization without touching the ascending aorta, enhancing the rate of optimal clinical outcomes.

Endovascular Treatment of Acute Ischemic Stroke After Cardiac Interventions in the United States

Importance

Ischemic stroke is a serious complication of cardiac intervention, including surgery and percutaneous procedures. Endovascular thrombectomy (EVT) is an effective treatment for ischemic stroke and may be particularly important for cardiac intervention patients who often cannot receive intravenous thrombolysis.

Objective

To examine trends in EVT for ischemic stroke during hospitalization of patients with cardiac interventions vs those without in the United States.

Design, Setting, and Participants

This cohort study involved a retrospective analysis using data for 4888 US hospitals from the 2016-2020 National Inpatient Sample database. Participants included adults (age ≥18 years) with ischemic stroke (per codes from the International Statistical Classification of Diseases, Tenth Revision, Clinical Modification), who were organized into study groups of hospitalized patients with cardiac interventions vs without. Individuals were excluded from the study if they had either procedure prior to admission, EVT prior to cardiac intervention, EVT more than 3 days after admission or cardiac intervention, or endocarditis. Data were analyzed from April 2023 to October 2023.

Exposures

Cardiac intervention during admission.

Main Outcomes and Measures

The odds of undergoing EVT by cardiac intervention status were calculated using multivariable logistic regression. Adjustments were made for stroke severity in the subgroup of patients who had a National Institutes of Health Stroke Scale (NIHSS) score documented. As a secondary outcome, the odds of discharge home by EVT status after cardiac intervention were modeled.

Results

Among 634 407 hospitalizations, the mean (SD) age of the patients was 69.8 (14.1) years, 318 363 patients (50.2%) were male, and 316 044 (49.8%) were female. A total of 12 093 had a cardiac intervention. An NIHSS score was reported in 218 576 admissions, 216 035 (34.7%) without cardiac intervention and 2541 (21.0%) with cardiac intervention (P < .001). EVT was performed in 23 660 patients (3.8%) without cardiac intervention vs 194 (1.6%) of those with cardiac intervention (P < .001). After adjustment for potential confounders, EVT was less likely to be performed in stroke patients with cardiac intervention vs those without (adjusted odds ratio [aOR], 0.27; 95% CI, 0.23-0.31), which remained consistent after adjusting for NIHSS score (aOR, 0.28; 95% CI, 0.22-0.35). Among individuals with a cardiac intervention, receiving EVT was associated with a 2-fold higher chance of discharge home (aOR, 2.21; 95% CI, 1.14-4.29).

Conclusions and Relevance

In this study, patients hospitalized with ischemic stroke and cardiac intervention may be less than half as likely to receive EVT as those without cardiac intervention. Given the known benefit of EVT, there is a need to better understand the reasons for lower rates of EVT in this patient population.