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Ann Thorac Surg 1998;65:79-84
© 1998 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Concomitant Occlusive Disease of the Coronary Arteries and Great Vessels

Thomas J. Takach, MD, George J. Reul, Jr, MD, Denton A. Cooley, MD, James J. Livesay, MD, J. Michael Duncan, MD, David A. Ott, MD, Grady L. Hallman, MD

Department of Cardiovascular Surgery, Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas, USA

Accepted for publication July 6, 1997.

Dr Cooley, Texas Heart Institute, PO Box 20345, Houston, TX 77225-0345.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background. Although an increasing number of elderly and high-risk patients, including those with generalized atherosclerosis, are undergoing coronary revascularization, few reports exist regarding the management of patients who have both occlusive disease of the great vessels and coronary artery disease.

Methods. Between 1972 and 1996, 31 consecutive patients (mean age, 56.5 years; 74% men) with multivessel coronary artery disease and symptomatic occlusive disease of the great vessels (25 single-vessel, 80.6%; 6 multiple-vessel, 19.4%) had 40 great vessels reconstructed by transthoracic bypass (n = 17, 42.5%), transthoracic endarterectomy (n = 8, 20%), or extrathoracic bypass (n = 15, 37.5%). All patients had simultaneous coronary artery bypass grafting (mean, 2.6 grafts per patient), and 8 patients had 10 distal carotid bifurcation endarterectomies (6 staged, 4 simultaneous).

Results. The early primary patency rate was 100%, and symptoms resolved completely in all 31 patients. There was 1 in-hospital death (3.2%) in a patient who had a respiratory arrest 11 days after operation. Perioperative morbidity included two myocardial infarctions (6.5%) and one opposite-hemisphere, embolic stroke (3.2%). Long-term follow-up of the 30 survivors (167.4 patient-years; mean, 5.6 years per patient) documented 5- and 10-year actuarial survival rates of 88.6% and 60.4%, respectively, with a 100% late brachiocephalic primary patency rate. Ten-year actuarial rates of freedom from the following events were as follows: death, 60.4%; myocardial infarction, 82.5%; stroke, 90.9%; percutaneous transluminal coronary angioplasty or redo coronary artery bypass grafting, 95.2%; and vascular operation or amputation, 78.4%.

Conclusions. Depending on the anatomic distribution of the disease, an integrated approach to great vessel reconstruction that incorporated transthoracic and extrathoracic approaches and techniques of endarterectomy and bypass resulted in few adverse outcomes and excellent long-term patency. Simultaneous revascularization of the great vessels and coronary arteries can produce immediate and long-term, symptom-free outcome with acceptably low operative risk.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
During the last decade, the demographic characteristics of patients who present for elective coronary revascularization have changed. More elderly and high-risk patients, including those with generalized atherosclerosis, are undergoing operation [1]. This group includes patients with concomitant occlusive disease of the coronary arteries (CAD) and great vessels (GVOD).

The incidence of patients with symptomatic GVOD who require operative intervention is increasing modestly. The National Center for Health Statistics reported that in 1979, only 2,000 aorta-to-great vessel bypass operations to treat GVOD were performed [2]. However, in 1993, this figure had increased threefold [3]. Although GVOD occurs infrequently, a significant association exists between symptomatic brachiocephalic disease and CAD. Multiple series have documented that 20% to 45% of patients presenting with symptomatic GVOD have concomitant CAD [4][5][6][7].

The literature contains few reports involving the management of patients who have both CAD and GVOD. This report summarizes our experience with the simultaneous revascularization of such lesions over a 24-year period. It examines the clinicopathologic spectrum of such disease and details operative indications, immediate outcomes, and long-term postoperative results.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
We reviewed the hospital records and postoperative clinical charts of 31 consecutive patients with concomitant GVOD and CAD who were treated at our institution between January 1972 and September 1996. Where necessary, supplemental information was obtained from the patient’s private cardiologist and family. The demographic and clinical characteristics of the patients in this report are summarized in Table 1.


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  		Demographic, Clinical, and Operative Characteristics of 31 Patients

 
All the patients in this study were admitted to the hospital because of cardiac symptoms; their GVOD was diagnosed incidentally. All patients had evidence of coronary insufficiency and a combination of cerebrovascular insufficiency and upper extremity vascular insufficiency or emboli (Table 2). Myocardial perfusion was assessed and the presence of ischemia was documented in patients with stable angina by exercise electrocardiography, thallium stress testing, or dipyridamole infusion imaging. Symptoms of ischemia in the upper extremities and hemodynamic changes were reproduced in patients with a stable cardiac status using the method described by Grosveld and colleagues [8]. Ultrasonic duplex scanning with hemodynamic measurements before and after exercise differentiated hemodynamically significant and nonsignificant lesions. Cerebral hemisphere symptoms were classified using the CHAT system described by Baker and colleagues (Table 2) [9].


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  		Presenting Symptoms of 40 Great Vessel Lesions in 31 Patients1

 
One patient presented with combined symptoms of coronary and cerebrovascular insufficiency, both of which were secondary to a subclavian steal syndrome (Fig 1A) [10]. On exercising his left upper extremity during angiography, reversal of flow ("steal") was noted in both the left vertebral artery and a previously placed left internal mammary artery-to-left anterior coronary artery bypass graft. This maneuver reproduced symptoms of both cerebral and coronary insufficiency.



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  		Preoperative and postoperative findings in selected patients with concomitant multiple great vessel disease and multiple-vessel coronary artery disease. (A) Solid arrows indicate primary and collateral blood flow; dashed arrows indicate reversal of flow ("steal") occurring during left arm exercise. (B) Reconstruction using concomitant extrathoracic and transthoracic approaches.

 
All patients underwent full invasive radiologic evaluation, including cineangiography of the coronary vessels and arch aortography with runoff views of the carotid, subclavian, and vertebral circulations. Vessel stenosis was determined angiographically by the following formula: [1 - (diameter at point of greatest stenosis/diameter at point of greatest patency)] x 100%. Significant stenosis in the brachiocephalic vascular distribution was defined as an 80% narrowing of the vessel lumen.

Operative interventions were classified as elective, urgent, and emergent (Table 1). Urgent operations were defined as operative procedures performed in patients whose accelerated symptoms required immediate hospital admission for evaluation and who were judged to be too unstable to discharge before operative intervention. Emergent operations were defined as operative procedures performed in patients with accelerated symptoms so unstable as to require immediate operative intervention.

All patients underwent simultaneous coronary artery bypass grafting and reconstruction of at least one great vessel. Eight patients were found to have concomitant occlusive disease at the carotid bifurcation. Four simultaneous (one bilateral) and six staged (one bilateral) carotid endarterectomies were performed in these patients. In every case, symptoms specific to the great vessel disease were distinct from symptoms related to the carotid bifurcation disease.

All patients received general anesthesia during the procedure and high-dose barbiturates during clamp occlusion of the aorta. Intraoperative electroencephalography was used to control the depth of anesthesia and the administration of barbiturates. The position of each patient’s head was monitored strictly to prevent compromise of the collateral blood supply. Intraoperative blood pressure and cardiac rhythm were monitored and maintained continuously, especially during periods of arterial clamping.

In every case, a median sternotomy was performed to expose the heart and proximal great vessels. Hypothermic, hyperkalemic cardioplegia was administered for myocardial protection. Coronary artery bypass grafting was completed and normal sinus rhythm was reinstituted off bypass before the great vessels were revascularized. The left internal mammary artery was used in the coronary revascularization of 5 patients, 3 of whom required revascularization of the left subclavian artery because of proximal occlusion or stenosis. Carotid bifurcation endarterectomy was performed before coronary artery bypass grafting in the 3 patients who underwent simultaneous carotid, brachiocephalic, and coronary procedures.

Endarterectomy and bypass techniques were used in both transthoracic and extrathoracic approaches. Preoperative angiography documented the distribution of disease, which dictated the various operative methods and approaches used (Table 3; Fig 2). The primary goal was to revascularize completely all areas affected by the occlusive disease. Whenever possible, transthoracic direct revascularization using either bypass or endarterectomy was favored, providing inflow from the aorta.


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  		Operative Procedures

 


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  		Various brachiocephalic reconstruction techniques and approaches. (A through E) Extrathoracic bypass. (E through G) Transthoracic endarterectomy. (D and H through N) Transthoracic bypass.

 
Perioperative myocardial infarction was defined as either new Q waves, elevation of the myocardial fraction of creatine kinase in association with persistent ST segment changes, or new conduction abnormalities. Perioperative stroke was defined as a new neurologic, focal change on physical examination with radiologic (computed tomographic scan) confirmation of infarction.

Long-term follow-up of the 30 survivors totaled 167.4 patient-years (mean, 5.6 years per patient). To describe the long-term results, actuarial curves were obtained by Kaplan-Meier statistical analysis (Fig 3). Late and total (perioperative plus late) actuarial event-free rates were calculated (Table 4). Statistical analysis was performed using SAS software (Statistical Analysis Systems Institute, Cary, NC).



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  		Kaplan-Meier distribution of actuarial event-free outcomes over time. (CABG/PTCA = coronary artery bypass grafting or percutaneous transluminal angioplasty.)

 

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  		Five- and 10-Year Late and Total Actuarial Event-free Rates

 

   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
The demographic data illustrate a group of relatively young patients (mean age, 56.5 years) with severe vasculopathy. In addition to concomitant, symptomatic atherosclerotic disease of the coronary and brachiocephalic circulations, 64.5% of these patients had additional peripheral vascular disease of the carotid bifurcation, abdominal aorta, or lower extremity vascular distribution. Previous myocardial infarctions were noted in 48.4% of this population. Atherosclerosis alone (n = 27, 87.1%) or in combination with chest irradiation (n = 1, 3.2%) was identified as the major cause of GVOD in this patient population. Takayasu’s arteritis (n = 1, 3.2%) and trauma (n = 2, 6.5%) affected a minority of the patients.

There was 1 in-hospital death (3.2%); a patient who had chronic obstructive pulmonary disease died of respiratory arrest 11 days after an otherwise successful revascularization. After revascularization, the patient’s preoperative symptoms of coronary and brachiocephalic insufficiency had resolved completely. Perioperative morbidity included 2 patients (6.5%) who had myocardial infarctions and 1 patient (3.2%) who had a stroke. The stroke occurred in the cerebral hemisphere supplied by the vascular distribution of a nondiseased carotid artery and presumably was embolic in origin. The patient’s neurologic recovery after this stroke was only partial.

All 31 patients experienced complete resolution of their presenting symptoms. The early primary patency rate for revascularized vessels was 100%. Long-term follow-up of the 30 survivors documented a continuing late brachiocephalic primary patency rate of 100% (Table 4). Actuarial survival rates (Fig 3) at 5 and 10 years after operation were 88.6% ± 6.2% and 60.4% ± 14.3%, respectively. Ten-year late and total actuarial event-free rates for death, myocardial infarction, stroke, percutaneous transluminal coronary angioplasty or repeated coronary artery bypass grafting, and vascular operation or amputation are summarized in Table 4.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
The optimal surgical approach and reconstruction technique for treating an individual patient with brachiocephalic disease is influenced by the clinical findings and anatomic distribution of the disease. A median sternotomy provides optimum exposure for both coronary artery and great vessel revascularization, and enables the use of either endarterectomy or a bypass technique for arch vessel reconstruction. Each technique maintains proximal inflow from the aorta and may account for the excellent long-term patency rates that have been reported in recent series using either of these two methods [4][11][12]. Each method may provide excellent results in selected patients with anatomically suited lesions. In specific situations, however, one technique may be preferred over the other. Transthoracic endarterectomy is of limited use in the presence of panmural arteritides, radiation injury, distal vessel occlusive disease, and diffuse multivessel disease [6][11][12]. Likewise, a heavily calcified ascending aorta may hamper the placement of a bypass conduit.

Series using extrathoracic approaches to reconstruct arch vessels have reported mixed results with regard to long-term patency [13][14][15][16][17][18][19]. Suboptimal long-term patency results using these approaches have been attributed to continued inflow from diseased brachiocephalic vessels and to the use of long grafts [6][14][18]. In selected situations, however, short extrathoracic grafts may be useful. In 2 patients in this report, we used carotid-to-carotid bypass to revascularize the distribution of a diseased common carotid artery before instituting cardiopulmonary bypass (Fig 1B). Each of these patients had a severely calcified ascending aorta and arch. We also have used carotid-to-subclavian artery bypass in patients with isolated, proximal subclavian artery lesions. This approach is justified in that clinical situation by the acceptable long-term patency rates reported in studies using grafts in this position [20].

The management of patients with asymptomatic great vessel lesions is controversial. Zelenock and associates [21][22] have reported that many patients with asymptomatic, mild to moderate occlusive disease of the innominate artery, documented by angiography, do not require operative intervention. In contrast, some patients in our experience have required revascularization for the progression of initially asymptomatic disease [11]. The median sternotomy used to perform coronary revascularization provides optimum exposure of the aorta and proximal great vessels. With this exposure, inflow from the aorta can be reestablished, maximizing the potential for long-term patency. Although all patients in this study were symptomatic, it is our policy to revascularize asymptomatic, preocclusive anatomic lesions (ie, >80% stenosis) or severely ulcerated plaque (ie, >50%) in patients with acceptable medical risk.

We currently are following up 5 patients from our series in whom a left internal mammary artery was used to revascularize an anterior coronary artery. In 3 of these patients, proximal subclavian artery lesions required revascularization of the subclavian artery. In each case, the potential benefit of using the internal mammary artery as an optimal conduit for coronary artery revascularization [23] was balanced against the potential for vessel compromise because of progressive subclavian disease or limited patency of the subclavian bypass graft. In a patient with concomitant CAD and GVOD, the optimal use of the internal mammary artery remains to be established. However, the primary patency rate in the few patients in our series in whom the internal mammary artery was used is 100% at this time (mean follow-up, 4.48 years). In contrast to our experience, FitzGibbon and Keon [24] reported the late recurrence of a coronary–subclavian steal syndrome in 1 patient after the thrombosis of a carotid–subclavian bypass.

The existence of a coronary–subclavian steal syndrome has been documented by others [24][25][26][27][28]. Successful correction with relief of symptoms has been accomplished by carotid–subclavian bypass [24], angioplasty [27], or atherectomy [28] of the subclavian artery. In the 1 patient in this report who presented with a symptomatic coronary–subclavian steal syndrome, direct transthoracic revascularization provided immediate and long-term symptom-free relief.

The severe vasculopathy present in this group of patients and the frequency of late events as documented by the 10-year actuarial event-free statistics mandates close, ongoing follow-up. The low 10-year actuarial survival rate for patients who present at a relatively young age portends a poor long-term prognosis despite excellent long-term graft patency.

In summary, we conclude that an integrated approach to great vessel reconstruction incorporating transthoracic and extrathoracic approaches and techniques of endarterectomy and bypass can produce excellent long-term patency. Simultaneous revascularization of the great vessels and coronary arteries can produce immediate and long-term symptom-free outcome with acceptably low operative risk.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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