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Emmanouil I. Kapetanakis
Sotiris C. Stamou
Mercedes K.C. Dullum
Peter C. Hill
Steven W. Boyce
Ammar S. Bafi
Kathleen R. Petro
Paul J. Corso
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Ann Thorac Surg 2004;78:1564-1571
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

The Impact of Aortic Manipulation on Neurologic Outcomes After Coronary Artery Bypass Surgery: A Risk-Adjusted Study

Emmanouil I. Kapetanakis, MDa, Sotiris C. Stamou, MD, PhDa, Mercedes K.C. Dullum, MDa, Peter C. Hill, MDa, Elizabeth Haile, MSb, Steven W. Boyce, MDa, Ammar S. Bafi, MDa, Kathleen R. Petro, MDa, Paul J. Corso, MDa,*

a Department of Surgery, Section of Cardiac Surgery, Washington Hospital Center, Washington, DC, USA
b Department of Epidemiology and Statistics, MedStar Research Institute, Washington, DC, USA

Accepted for publication May 7, 2004.

* Address reprint requests to Dr Corso, Section of Cardiac Surgery, Department of Surgery, Washington Hospital Center, 106 Irving St NW, Suite 316, Washington, DC 20010–2975, USA
paul.j.corso{at}medstar.net

BACKGROUND: Cerebral embolization of atherosclerotic plaque debris caused by aortic manipulation during conventional coronary artery bypass grafting (CABG) is a major mechanism of postoperative cerebrovascular accidents (CVA). Off-pump CABG (OPCABG) reduces stroke rates by minimizing aortic manipulation. Consequently, the effect of different levels of aortic manipulation on neurologic outcomes after CABG surgery was examined.

METHODS: From January 1998 to June 2002, 7,272 patients underwent isolated CABG surgery through three levels of aortic manipulation: full plus tangential (side-biting) aortic clamp application (on-pump surgery; n = 4,269), only tangential aortic clamp application (OPCABG surgery; n = 2,527) or an "aortic no-touch" technique (OPCABG surgery; n = 476). A risk-adjusted logistic regression analysis was performed to establish the likelihood of postoperative stroke with each technique. Preoperative risk factors for stroke from the literature, and those found significant in a univariable model were used.

RESULTS: A significant association for postoperative stroke correspondingly increasing with the extent of aortic manipulation was demonstrated by the univariable analysis (CVA incidence respectively increasing from 0.8% to 1.6% to a maximum of 2.2%, p < 0.01). In the logistic regression model, patients who had a full and a tangential aortic clamp applied were 1.8 times more likely to have a stroke versus those without any aortic manipulation (95% confidence interval: 1.15 to 2.74, p < 0.01) and 1.7 times more likely to develop a postoperative stroke than those with only a tangential aortic clamp applied (95% confidence interval: 1.11 to 2.48, p < 0.01).

CONCLUSIONS: Aortic manipulation during CABG is a contributing mechanism for postoperative stroke. The incidence of postoperative stroke increases with increased levels of aortic manipulation.




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