Combined carotid endarterectomy and coronary artery bypass grafting
(Portuguese PDF version)

Domenico Astore, Gloria Esposito, Renata Castellano, Barbara Catenaccio, Germano Melissano, Marcelo R. Liberato de Moura, Roberto Chiesa *

* Department of Vascular Surgery, Vita-Salute University, IRCCS H. San Raffaele, Milan, Italy.

Correspondence:
Domenico Astore
Chirurgia Vascolare - H. San Raffaele
Via Olgettina, 60
20132 Milan, Italy
Phone: 02 26437130
Fax: 02 26437148
E-mail: astore.domenico@hsr.it

ABSTRACT

Objective: To evaluate the perioperative and long-term outcomes of combined coronary artery bypass grafting and carotid endarterectomy performed in our Institute.

Methods: From January 1992 to April 2004, 158 patients with a mean age of 66.3 years (range 42-81) underwent combined carotid endarterectomy and coronary artery bypass grafting. Selection criteria were symptomatic or asymptomatic 70-99% carotid stenosis and unstable coronary symptoms or coronary anatomy judged to preclude safe endarterectomy. Carotid duplex scanning was introduced as a routine screening test from 1996 for patients candidate to coronary artery bypass grafting. Patients presenting for carotid endarterectomy were subjected to further cardiological study only if deemed to be at high cardiac risk.

Results: Perioperative mortality was 5.7%. Causes of death were: myocardial infarction with multiorgan failure (four patients), irreversible left ventricular fibrillation (three patients) and low ejection syndrome complicated by stroke and ventricular fibrillation (two patients). The perioperative stroke rate was 1.3%. Mean follow-up was 49 months (range 1-138): 22 patients were lost at follow-up and of remaining 136 patients 21 (15.4%) died. Causes of late mortality were: eight myocardial infarctions, five cancers, six congestive heart failure and two abdominal aortic aneurysm rupture. Late stroke rate was 2.2% (two patients with contralateral stroke and one with ipsilateral stroke). One asymptomatic carotid occlusion and three carotid restenosis were also observed.

Conclusion: The low stroke rate observed in our series suggest the use of combined carotid endarterectomy and coronary artery bypass grafting in patients with significant symptomatic and asymptomatic carotid artery stenosis that need myocardial revascularization. Poor left-ventricular function, unstable angina and bilateral carotid artery stenosis, account for the high perioperative mortality associated with this approach.

Key-words: coronary artery bypass grafting, carotid artery disease, coronary artery disease.

J Vasc Br 2004;3(4):323-30

Carotid artery stenosis (CAS) and coronary artery diseases (CAD) are frequently associated with important implications for surgical management. The reported incidence of stroke during coronary artery bypass grafting (CABG) varies from 1 to 5%1 and several reports indicate that following CABG postoperative stroke increases with concomitant carotid disease.1-4

On its turn, the myocardial infarction is the most important cause of death associated with carotid endarterectomy (CE). In the Veterans Affairs Cooperative Study5 and in the Asymptomatic Carotid Atherosclerosis Study6 deaths due to cardiac events were found to be respectively 20 and 49% of total deaths, one half of them due to acute myocardial infarction.

These data prompted a combined carotid and myocardial revascularization approach, first described by Bernhard in 1972.7 However, surgical indications for such combined surgery are still controversial.

We report the perioperative and long-term outcomes of combined CE and CABG performed at our institute during the last 12 years.

MATERIALS AND METHODS

We reviewed 158 patients, mean age 66.3 years (range 42-81), who had been submitted to combined CE and CABG from January 1992 to June 2004. In the same period, 5,013 CE were performed.

Selection criteria for combined CE and CABG during the period of this study were defined prospectively. Patients presenting for coronary bypass were deemed eligible for combined CE and CABG in case of recent transient ischemic attacks or stroke referred to a 70 to 99% CAS, or in case of 70 to 99% asymptomatic CAS (unilateral, bilateral or with contralateral occlusion). Patients presenting for CE were candidates for combined CE and CABG if coexisting coronary symptoms were unstable or if their coronary anatomy was judged to preclude safe endarterectomy. Combined CE and CABG was not performed in urgent cases.

One hundred and forty two patients, presented initially for CABG, were found to have incidental CAS; 16 patients, presented for CE, were found to have severe coronary disease requiring coronary bypass.

Demographic and risk factors data are shown in Table 1.

click hereTable 1 - Demographic data and risk factors

n %
Male 131 82.9
Female 27 17.1
Hypercholesterolemia 109 64
Hypertension 106 67.1
History of smoking 92 58.2
Diabetes mellitus 60 38

Between 1992 and 1995 the CABG group was not routinely screened with carotid duplex scanning and only a history of transient cerebral ischemia or stroke obtained at preoperative evaluation or the clinical finding of a neck bruit had led to further evaluation. Systematic screening with Duplex ultrasound was introduced from 1996 on. Moreover, the CE group was not routinely screened with stress testing before undergoing surgery, in the absence of clinical evidence of coexisting coronary disease.

Cardiac and carotid symptoms at presentation are shown in Table 2.

click hereTable 2 - Distribution of cardiac and cerebrovascular symptoms

n %
Cardiac
Unstable angina 44 27.8
Effort angina 106 67.1
Prior MI 76 48.1
Asymptomatic 7 5.1
Cerebrovascular
TIA 53 33.5
Amaurosis fugax 10 6.3
Prior stroke 20 12.7
Asymptomatic 75 47.5
MI = myocardial infarction; TIA = transient ischemic attack.

Cardiac catheterization demonstrated a three vessels disease in 113 patients (72%), a > 70% left main stenosis in 25 (16%) and low left ventricular ejection fraction (< 45%) in 46 cases (26%).

Since 1995, the Duplex ultrasound finding of a > 70% CAS was an indication for carotid angiography or angio-MR. A monolateral > 70% CAS was found in 97 cases (61%), a bilateral CAS in 44 (28%) and a CAS with contralateral carotid occlusions in 17 (11%).

Perioperative events were defined as those occurring during the hospital stay. Follow-up data were obtained in outpatient clinics or by telephone interview.

RESULTS

All patients underwent carotid surgery under general anesthesia with continuous electroencephalographic monitoring. Carotid standard endarterectomy with Dacron patch insertion was performed in 123 cases (77.8%) and with direct suture in 17 (10.8%). The eversion technique was performed in 18 cases (11.4%). Carotid shunt (Javid) was used in 47 cases (29.7%). Mean clamping time was 12 minutes in CE performed without shunting. In CE with shunting mean artery closure time was 16 minutes.

Intraaortic balloon pump was required in 14 patients (8.9%); seven during surgery, one before and six after the procedure. Valvular disease was present in 37 patients (23.4%) and valve replacements were performed in 19 (12%): six mitral and 13 aortic. The aorta was judged to be heavily calcified in 22 patients (13.9%). Intraoperative epiaortic or transesophageal ultrasound imaging was not routinely used.

One to seven aortic-coronary grafts (mean 3.3) per patient were performed. A single internal thoracic artery was used in 117 cases (74%) and both thoracic arteries were used in 20 cases (12.7%); three patients (1.9%) underwent left ventricular aneurysmectomy. Twelve patients (7.5%) underwent beating heart surgery.

Surgical timing of each procedure required two operating teams. Cardiac anesthetics anaesthetized the patients. While the cardiac team harvested the vein, the vascular team performed the endarterectomy with partial heparinization, before sternotomy. Selective shunting was used in case of electroencephalographic changes. Routine shunting was only used from 1992 to 1996, always associated with electroencephalographic monitoring. Cervical incisions were sutured only after CABG and heparin activity was neutralized with protamine sulphate administration. An aspirative drainage was inserted in all cervical wounds.

Perioperative mortality was 5.7% (nine cases) all due to cardiogenic shock. Four patients had fatal myocardial infarction with multi-organ failure and three died due to untreatable left ventricular fibrillation. Two patients died because of low ejection syndrome complicated by stroke and ventricular fibrillation, both had an ipsilateral stroke with carotid patency (perioperative stroke rate 1.3%).

Other perioperative complications were: six myocardial infarctions; three left ventricular fibrillation and 13 atrial fibrillations that reverted spontaneously to sinus rhythm; two transient ischemic attack with left arm hypostenia contralateral to CE with complete recover in 6 hours; four cranial nerve injuries (one hypoglossal, three recurrent laryngeal); two large cervical hematomas which required surgical drainage; one laterocervical wound infection; nine renal insufficiencies that required plasma ultrafiltration in three cases; five sternal infection; two pneumothorax treated with draining.

Perioperative mortality and morbidity data are summarized in Table 3.

click hereTable 3 - Perioperative mortality and morbidity

Cardiac n %
Cardiac death 9 5.7
Arrhythmia 16 10.1
Perioperative MI 9 5.6
Sternal infection 3 1.8
Bleeding 5 3.2
Reoperation 2 1.2
Neurologic
Ipsilateral stroke 2 1.3
Ipsilateral TIA 2 1.3
Other
Cranial nerve injury 4 2.5
Cervical hematomas 2 1.2
Cervical wound infection 1 0.6
Renal insufficiency 9 5.7
Pneumothorax 2 1.2
MI = Myocardial infarction; TIA = transient ischemic attack.

Since CE and CABG were performed in combination, mortality rate for CE alone was 0.3% (21/6,331) and stroke rate was 1.2% (75/6,331).

The mean postoperative hospital stay for combined CE and CABG was 8.9 days with a range of 5 to 107 days.

Mean follow-up was 49 months (range 1-138). Twenty-two patients were lost at follow-up. Twenty one late deaths occurred in the 136 remaining patients (14.7%). Causes of death were: myocardial infarction in eight patients, cancer in five, congestive hearth failure in six and abdominal aortic aneurysm rupture in two. Five patients (3.7%) had myocardial infarction. Four patients (2.9%) underwent coronary percutaneous transluminal angioplasty, because of recurrence of myocardial ischemia, and two (1.5%) because of CABG redo. One case of asymptomatic carotid occlusion was detected by Duplex ultrasound after 2 years from CE (0.7%). We recorded three cases (2.2%) of critical internal carotid restenosis, successfully treated with percutaneous transluminal angioplasty. Two patients (1.5%) had a contralateral stroke. Six patients (4.4%) underwent contralateral carotid endarterectomy. All the remaining patients are alive and well.

DISCUSSION

In recent years, the finding of CAS in candidate patients to CABG has significantly increased.8,9 This is due to the older age of the patients and to improvements in diagnostic imaging.2,10

Asymptomatic and symptomatic CAS are potential risk factors for intraoperative stroke because of flow reduction and thromboembolism,11-13 however, CAS does not represent the sole etiological factor. Post-mortem studies have allowed several authors to demonstrate that a half of all patients with severe CAS had severe associated aortic disease.14 Emboli can arise from cannulation of an atheromatous aorta.15 Other identified causes of stroke during CABG are intra-operative hypotension, difficulty in coming off bypass, long cross clamp time, arrhythmias and poor left ventricular function with the subsequently need of balloon pump.

Many authors have reported the presence of CAS as a risk factor for stroke during CABG. However, the different stroke risk during CABG for symptomatic and asymptomatic CAS has not been proven and the importance of CAS degree, bilaterality and occlusions remain still controversial.10,11,16-18

Considering the higher stroke risk related to the presence of CAS, it is not yet clear if CE should be performed before (prior staging), associated to or after CABG (reverse staging). CE performed before CABG is related to a higher risk of cardiac complications. For prior staging, Barnes calculated a mean stroke rate of 3.1%, a mean myocardial infarction (MI) rate of 11.8% and a mean mortality rate of 11.1%.19 Indeed, in 1995 the American ad hoc committee found that MI and mortality rates related to prior staging were higher than those observed for reverse or combined staging (P < 0.01 and P < 0.02).20

Some authors assert that CE in patients undergoing CABG is not justified and that it should be performed at a later stage. However, the small number of prior staging available cases is not sufficient for making a really reliable statement as it is possible for reverse staging.10,11,21

The results of combined CE and CABG are reported in Table 4. Bass et al.,22 comprising patients from three centers over a period of 15 years, obtained a stroke rate of 16% and a mortality of 12%.A large number of cases undergoing emergency surgery (46/99) was included in the study further demonstrating that emergency procedures are associated with additional risks. In a retrospective review of 100 consecutive combined procedures, Mackey et al.23 reported a high stroke rate (9%) and mortality rate (8%). They concluded that selection criteria for combined procedures greatly influence the perioperative risk. Chang et al. achieved a 1% stroke rate and a 2% mortality rate in 189 patients, obtaining the most remarkable result for combined procedures.24 Seventeen of these cases underwent bilateral CE at the time of CABG. However, 75% patients had asymptomatic CAS. Darling et al. subsequently reported their experience on 470 patients obtaining similar results: about 70% of cases were asymptomatic, operative mortality was 2.4% and stroke rate was 1%.25 Estes et al. recently compared the outcomes of two groups of patients: Group 1 operated with combined procedure between 1984 and 1994 (n = 100) and Group 2 between 1994 and 1999 (n = 74). More patients in Group 2 were asymptomatic (55 vs 31%). The incidence of stroke and mortality was higher in Group 1 than in Group 2, respectively 9 vs 1.4% and 8 vs 3%.4

click hereTable 4 - Stroke and mortality rate for combined CE and CABG

Author Year Cases Stroke (%) Mortality (%)
Char et al.26 2002 154 6 (3.9) 6 (3.9)
Estes et al.4 2001 174 10 (5.7) 10 (5.7)
Bilfinger et al.27 2000 84 4 (4.7) 5 (5.9)
Evangelopoulos et al.28 2000 313 7 (2.2) 28 (8.9)
Plestis et al.29 1999 213 11 (5.1) 12 (5.6)
Brow et al.30 1999 23 2 (8.6) 1 (4.3)
Takach et al.31 1997 106 2 (1.9) 4 (3.8)
Jahangiri et al.32 1997 64 1 (1.6) 0 (0)
Daily et al.33 1996 100 0 (0) 4 (4)
Mackey et al.23 1996 100 9 (9) 8 (8)
Giangola et al.34 1995 28 4 (13) 0 (0)
Akins et al.35 1995 200 6 (3) 7 (3.5)
Craver et al.36 1995 60 1 (1.3) 0 (0)
Vassilidize et al.37 1994 33 2 (6) 2 (6)
Kouchoukos et al.17 1994 50 0 (0) 3 (6)
Chang et al.24 1994 186 2 (1) 4 (2)
Halpin et al.38 1994 133 2 (1.5) 2 (1.5)
Waering et al.39 1993 23 0 (0) 3 (13)
Sayers et al.40 1993 18 1 (5.5) 1 (5.5)
Vermeulen et al.41 1992 230 10 (4.3) 7 (3)
Rizzo et al.16 1992 127 7 (5.5) 7 (5.5)
Bass et al.22 1992 99 16 (16) 12 (12)
Saccani et al.42 1992 17 0 (0) 0 (0)
Weiss et al.43 1992 23 0 (0) 1 (4.3)
Pome et al.44 1991 52 1 (1.9) 0 (0)
Gugulakis et al.45 1991 28 1 (3.6) 1 (3.6)
Duchateau et al.46 1989 82 3 (3.7) 6 (7.3)
Hertzer et al.47 1989 170 9 (5.3) 9 (5.3)
Cambria et al.48 1989 71 3 (4.2) 2 (2.8)
Minami et al.49 1989 47 0 (0) 1 (1.1)
Newman & Hicks50 1988 12 0 (0) 0 (0)
Perler et al.51 1988 61 3 (4.8) 7 (11)
Delaria & Nafaji52 1986 47 1 (2.1) 4 (8.5)
Lord et al.53 1986 78 4 (5.1) 5 (6.4)
Brenner et al.11 1986 57 1 (1.8) 6 (10.5)
Cosgrove et al.54 1985 74 6 (8.1) 3 (4.1)
Takach et al.55 1985 149 8 (5.4) 6 (4)
Jones et al.56 1984 132 2 (1.6) 4 (3)
O'Donnel et al.57 1983 22 1 (4.5) 1 (4.5)
Hertzer et al.58 1983 331 12 (3.6) 19 (5.7)
Rice et al.59 1980 54 1 (1.9) 0 (0)
Ennix et al.21 1979 51 3 (5.9) 0 (0)
Urshel et al.60 1976 8 0 (0) 0 (0)
Okies et al.61 1975 16 1 (6.2) 1 (6.2)
Bernhard et al.7 1972 15 0 (0) 0 (0)
Total 1972-2002 4,115 163 (4) 212 (5.2)

 

We have found a perioperative mortality rate of 5.7% and a stroke incidence of 1.3% with combined carotid and myocardial revascularization. The perioperative mortality is in line with those reported in the international literature (Table 4), but we have observed a very limited neurological morbidity, in our experience comparable to that of isolated CEA (1.2%). Moreover the two strokes reported in our series were probably related to low cardiac output syndrome complicated by ventricular fibrillation, as indicated by carotid patency documented angiographically after surgery.

We have performed only elective intervention and about a half of the patients had asymptomatic CAS. These conditions with the accurate electroencephalographic intraoperative monitoring and the use of Javid shunt in case of electroencephalographic line changes should have contributed to the low stroke rate.

The low neurological complication observed in our series suggests that in patients with significant symptomatic and asymptomatic CAS that need myocardial revascularization combined CE and CABG should be given serious consideration. Single anesthetic management, reduction in-patient hospital stay and lower costs are other advantages related to the combined procedure. Whereas in the past this approach was criticized for increased morbidity and mortality, it shouldn't be forgotten that combined management was generally reserved to bilateral CAS and symptomatic CEA associated to unstable angina and poor cardiac parameters, such as poor left ventricular and left main steam disease. Such selection criteria played surely an important role in determining the high morbidity and mortality rates that used to be associated with this approach.

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