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Ann Thorac Surg 1999;68:297
© 1999 The Society of Thoracic Surgeons
a Thoracic and Cardiovascular Surgery Department, University Hospital CHU Caen, 14033 Caen, France
To the Editor
I would like to congratulate Drs Lazar and Menzoian [1] for their article entitled: "Coronary bypass grafting in patients with cerebrovascular disease." The authors focused on the treatment of patients with coexistent carotid and coronary arteriosclerosis. Treatment of patients with simultaneous asymptomatic internal carotid artery, critical stenosis, and stable coronary artery disease varies widely among institutions. Our team has gained a rather wide experience of carotid stenting (CS) for asymptomatic carotid stenosis in patients scheduled for coronary artery bypass grafting (CABG). Since our published series [2] of 10 consecutive patients who had CS of the internal carotid artery before cardiac operations, we have enlarged our database with 26 more patients. Unstable angina and symptomatic carotid disease were excluded from the study. Mean age was 69 ± 4 years. Twelve patients showed a contralateral occlusion of the internal carotid artery, 5 had bilateral stenosis of more than 70%. Length of lesions varied from 0.7 cm to 4.3 cm. Ten cases were treated by balloon expandable Palmaz (Johnson and Johnson Interventional Systems, Warren, NJ) or Strecker (Medi-Tech, Watertown, MA) stents and 26 were dilated with the self-expanding Wall Stent (Schneider, USA) under cerebral protection. All patients received active platelet antiaggregating agents for 8 days before CS. The CABG was done a mean of 24.3 days after CS. Antiplatelet treatment was given 17 days preoperatively by heparin. Twelve patients had exclusive arterial grafts, 5 had exclusive saphenous vein grafts, and 19 had both arterial and venous grafts. Quantitative angiography and noninvasive color flow Doppler imaging were done at 1 day, and 3 and 6 months follow-up. Procedural success (< 25% diameter stenosis without embolization or death) was achieved in 35 of 36 patients (97%). Complications included one transient hemianopsia and two restenoses on follow-up (23 ± 2 months). These two recurrent stent deformations were treated with repeat angioplasties. Patients should have careful preoperative and postoperative neurologic examinations. Techniques such as transcranial Doppler should be used before and during the carotid stenting. The efficacy of surgical carotid endarterectomy (CEA) for extracranial carotid stenosis has been unequivocally demonstrated [3, 4]. The benefits of CEA are dependent on the number of perioperative complications. Patients in whom CEA has proved beneficial were carefully selected: they had disease at the carotid bifurcation, which is easily approached surgically. In combined CEA and CABG, changes in hemodynamics can cause embolization from ulcerated plaques or from air removal during extracorporeal circulation aggravated by perioperative heparinization. Operation time is prolonged and the need for a preprocedural and postprocedural systemic heparinization associated with CS can be a disturbing aspect in complex CABG procedures. Data are available on combined CABG and CEA. Stroke rates of 4.5% to 7.1% and mortality rates of 5.4% to 5.7% have been reported [2]. Some authors have advocated that, because of the size of extracranial vessels, they are well suited to stenting. With good deployment and use of high-pressure inflations, anticoagulation might not be necessary. The potential advantages of CS include lower perioperative risk, cost, and patient discomfort. Furthermore, some series suggest that restenosis occures in 7% to 16% of individuals after carotid angioplasty [5]. This rate should be lower with stenting [3] because optimal initial results are based on excellent angiographic results with no residual stenosis. Carotid stenting was done with the patient under local anesthesia. Communication with the patient and neurologic assessment during the procedure enabled the operator to detect any initial disturbance of consciousness resulting from insufficient collateral arteries. This treatment offers a safe and effective approach to asymptomatic stenoses of the internal carotid artery found during preoperative screening of patients scheduled for CABG, because it is less invasive than conventional CEA associated with median sternotomy and CBP. It offers excellent early and midterm results. This procedure can be used to treat elderly patients with a high risk of thoracotomy. The procedural minor stroke rate per artery in the present study was 3.6%. We were able to reduce balloon inflation times and minimize interruption of cerebral blood flow to 20 to 30 seconds. This was well-tolerated by all patients, even those with contralateral carotid occlusions. Our experience is indeed encouraging because all 36 patients were high risk. Recently, in 2 patients minimally invasive coronary artery bypass grafting with the left internal thoracic artery was done through minithoracotomy 2 weeks after CS. This study should serve as a stimulus to develop teams of stroke neurologists, interventional cardiologists, cardiovascular surgeons, and endovascular neuroradiologists with the expertise to carry out such works.
References
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  M. Guerra, J. C. Mota, M. Veloso, V. Gama, and L. Vouga Combined carotid stenting and urgent coronary artery surgery in unstable angina patients with severe carotid stenosis Interactive CardioVascular and Thoracic Surgery, August 1, 2009; 9(2): 278 - 281. [Abstract] [Full Text] [PDF]
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 M. A. Albert and E. M. Antman Preoperative Evaluation for Cardiac Surgery Card. Surg. Adult, January 1, 2003; 2(2003): 235 - 248. [Full Text]
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