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Ann Thorac Surg 1999;68:297
© 1999 The Society of Thoracic Surgeons

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Correspondence

Coexistent coronary and cerebrovascular disease: a place for carotid stenting

^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

1. Lazar H.L., Menzoian J.O. Coronary artery bypass grafting in patients with cerebrovascular disease. Ann Thorac Surg 1998;66:968-974.[Abstract/Free Full Text]
2. Babatasi G., Massetti M., Theron J., Khayat A. Asymptomatic carotid stenosis in patients undergoing major cardiac surgery. Eur J Cardiothorac Surg 1997;11:547-553.[Abstract]
3. Yadav J.S., Roubin G.S., Iyer S., et al. Elective stenting of the extracranial carotid arteries. Circulation 1997;95:376-381.[Abstract/Free Full Text]
4. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid stenosis. JAMA 1995;273:1421-1428.[Abstract/Free Full Text]
5. Crawley F., Clifton A., Taylor R.S., Brown M.M. Symptomatic restenosis after carotid percutaneous transluminal angioplasty. Lancet 1998;352:708-709.[Medline]

This article has been cited by other articles:

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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]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Massimo Massetti Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Babatasi, G. Articles by Theron, J. Search for Related Content PubMed Articles by Babatasi, G. Articles by Theron, J.