HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract 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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Francis P. Sutter Scott M. Goldman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Khaitan, L. Articles by Whitlark, J. D. Search for Related Content PubMed PubMed Citation Articles by Khaitan, L. Articles by Whitlark, J. D.

Ann Thorac Surg 2000;69:421-424
© 2000 The Society of Thoracic Surgeons

---

Original Articles

Simultaneous carotid endarterectomy and coronary revascularization

^a Main Line Cardiothoracic Surgeons, Lankenau Hospital, Wynnewood, Pennsylvania, USA

Address reprint requests to Dr Sutter, Main Line Cardiothoracic Surgeons, Lankenau Hospital, Medical Science Building, Suite 280, 100 Lancaster Ave, Wynnewood, PA 19066
e-mail: mlcts2220{at}aol.com

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Combined cardiac operation and carotid endarterectomy using our technique is an acceptable approach to simultaneous correction of both carotid and cardiac disease.

Methods. From August 1989 to March 1998, 121 consecutive patients underwent combined operations. Of these patients, 112 had coronary artery bypass grafting and carotid endarterectomy, and 9 had coronary artery bypass grafting, carotid endarterectomy, and valve repair or replacement. All patients had a critical stenosis of 85% or more of the carotid artery. Mean age of the patients was 69.2 years; 80 patients were 65 years old or older. There were 88 men and 33 women. Notable risk factors included chronic obstructive pulmonary disease (19.8%), congestive heart failure (28%), preoperative myocardial infarction and unstable angina (66.9%). Of the patients, 20.7% had a stenosis of greater than 50% of the left main coronary artery. The technique used was correction of both the carotid and coronary lesions during a single aortic cross-clamp period using retrograde continuous blood cardioplegia for myocardial protection. Systemic hypothermia to 25°C was used for cerebral protection.

Results. Mean cross-clamp time was 118 minutes. Seven patients (5.8%) sustained perioperative cerebrovascular accidents. Two patients had transient ischemic attacks. The procedure-related mortality rate was 5.8%.

Conclusions. The described technique is a good method for simultaneous repair of coronary and carotid lesions in a high-risk group of patients with concomitant disease. We will continue to use it.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
The approach to the treatment of patients with both coronary artery disease and major carotid disease is controversial. The association of the two disease processes is well accepted. With the aging population of patients undergoing coronary artery bypass grafting (CABG), a greater number of them have associated clinically significant carotid disease. A procedure with both low morbidity and low mortality has been sought since the first description of a combined carotid endarterectomy (CEA) and open heart surgery approach by Bernhard and colleagues [1] in 1972. The desired goal of all approaches is to minimize neurologic complications and mortality. Multiple procedures such as simultaneous repair, staged repair, and "reverse staged" repairs have been described.

We present a simultaneous technique of repairing the heart and carotid artery during one cross-clamp time. Hypothermia to 25°C is used to add increased cerebral protection during the procedure.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Data were collected from an ongoing Society of Thoracic Surgeons database and chart review from August 1989 to March 1998. All patients were followed preoperatively and postoperatively by a consulting neurologist. Patients were seen the morning after the operation and every day during hospitalization until discharge.

Patient population
Retrospective review of The Society of Thoracic Surgeons database identified 121 consecutive patients who underwent combined carotid and cardiac operations from August 1989 to March 1998 at Lankenau Medical Center. This represents 2% of all cardiac operations performed by this service at the institution during this period. One hundred twelve of these patients underwent CABG with CEA, and 9 underwent CABG, CEA, and valve repair or replacement. All patients had a thorough history and physical examination preoperatively during which symptoms or signs of carotid disease were sought. All patients, regardless of physical findings, were further evaluated by noninvasive carotid Doppler ultrasound. Of all patients undergoing a cardiac surgical procedure at our institution, 6% have carotid disease with a greater than 50% stenosis by Doppler study. Patients with stenosis of more than 80% by Doppler ultrasound were considered for a combined CABG and CEA procedure and subsequently underwent digital subtraction angiography. Critical stenosis was defined as luminal narrowing of greater than 85% by digital subtraction angiography. Twenty-one patients were noted to have symptomatic carotid disease with a preoperative history of cerebrovascular accident (CVA) or transient ischemic attack. Twenty-five patients had bilateral critical carotid stenosis ( 85%) by digital subtraction angiography at the time of operation. Patients with carotid stenosis of less than 85% were treated no differently from patients without stenosis.

Patient characteristics
The mean age of this population was 69.2 years, and 61 patients were at least 70 years old. There were 88 men and 33 women. Notable risk factors included previous myocardial infarction (46%), congestive heart failure (28%), and chronic obstructive pulmonary disease (19.8%) (Table 1). Indications for CABG included unstable angina in 81 patients and triple-vessel disease in 93. Twenty-five patients had greater than 50% stenosis of the left main coronary artery. The 24 patients who had no angina were seen with severe congestive heart failure or shortness of breath (Table 2). Forty-three patients had a history of peripheral vascular disease, defined as previous peripheral vascular surgical procedure or presence of claudication. Nine patients were having a redo cardiac operation. The mean Cleveland Clinic Score of the patients in this series was 5.31. The mean score of all patients undergoing cardiac operation during this time at this institution was 3.98.

As the cardioplegia is cooled, the systemic perfusate temperature is dropped to 25°C. The operation continues as if a cardiac operation alone were being performed. The aorta is opened, and the valve is excised if aortic valve replacement is being done; distal anastomoses are begun if myocardial revascularization alone is being performed; or an atrial incision is made if the mitral valve is exposed for assessment for repair or replacement.

Approximately 20 minutes into the cross-clamp time, the perfusionist informs the surgeon when a bladder temperature of 25°C is reached. The anastomosis is completed, or a convenient stopping place is reached, and the cardiac portion of the operation is stopped. The aortic cross-clamp remains in place, and continuous cold retroplegia protects the heart while attention is diverted to the carotid artery. The carotid artery is clamped, opened, and endarterectomized without shunting. The principles of endarterectomy are strictly followed including extending the endarterectomy incision to normal internal carotid artery distally, endarterectomy of the internal and external carotid arteries, meticulous debridement of all flaps, and closure of the arteriotomy with a saphenous vein or Hemashield patch using a running 6-0 nonabsorbable suture. The artery is deaired, and the clamps are released to reestablish flow into the carotid artery.

The remaining coronary grafts are completed, or the valve replacement or repair is performed while slow rewarming is begun. Before the final graft anastomosis is initiated or the closure of the aorta or atrium is commenced, the patient is rewarmed to a systemic temperature of 37°C. The operation is completed in routine fashion with discontinuation of cardiopulmonary bypass. For blood conservation, a low-speed pump sucker is maintained in the heparinized neck incision until heparin is reversed and formal hemostasis can be established.

It is notable that 24 patients had severely atherosclerotic aortas on which a cross-clamp could not be used. These patients underwent vented hypothermic fibrillatory arrest without cross-clamping. Carotid endarterectomy was performed while the heart was defibrillating. Proximal anastomoses were performed with a small side-biting clamp applied to a minimally diseased portion of the aorta.

Operations performed
Of the 121 patients, 112 underwent CABG with CEA. Nine patients had CABG with CEA and valve replacement or repair. There were five aortic valve replacements, three mitral valve replacements, and one mitral valve repair. Ninety-one percent of patients having combined CABG and CEA received only arterial grafts. The mean number of distal graft anastomoses was 3.93 per patient (Table 3).

	Results

Top Abstract Introduction Material and methods Results Comment References

There were seven perioperative CVAs (5.8%) documented by a fixed infarct on head computed tomography. Three were considered operative, ie, the patients awakened from anesthesia with a neurologic deficit, and four were postoperative, ie, they occurred more than 24 hours postoperatively. Two of these patients died of a CVA–related cause. Two patients had transient ischemic attacks with complete resolution of symptoms. Of the seven CVAs, two were on the same side as the CEA, two were on the contralateral side, and three were bilateral with the side opposite the CEA being worse on head computed tomography. Only one of the CVAs occurred in a patient who had operation under hypothermic fibrillatory arrest. There were no other neurologic complications in those 24 patients. At this institution, the overall CVA rate for all cardiac procedures performed between August 1989 and March 1998 was 2.4%. For patients with 50% to 79% carotid stenosis by Doppler ultrasound, the CVA rate is 2.4%.

The procedure-related mortality rate was 5.8% (7 patients). Two patients died of a cardiac-related cause in the early postoperative period. Three patients died of a pulmonary-related cause. One (the patient having operation under fibrillatory arrest and sustaining a CVA) died on postoperative day 63 of aspiration pneumonia. One had development of pneumonia in the postoperative period and died on postoperative day 16, and 1 had diffuse miliary lung cancer, which was initially confused with congestive heart failure on the chest roentgenogram. Two of the deaths were CVA related as previously mentioned and occurred on postoperative days 8 and 14.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Patients who have both coronary artery disease and carotid disease present a challenge. We recognize that the two disease processes must be addressed. However, there is no ideal method to treat this group of patients. The surgeon can be compelled to approach both disease processes simultaneously. It is well known that cardiac events are one of the major causes of postoperative complications after CEA. Similarly, neurologic events complicate many cardiac procedures postoperatively in patients with asymptomatic and symptomatic critical carotid stenosis. Here we present an operative technique performed in a large group of patients with good results.

Staged, synchronous, and "reverse staged" procedures are among the approaches used in this group of patients. A review by Gugulakis and coauthors [3] published in 1991 examined the results in 1,444 patients who underwent various combined procedures. The incidence of permanent neurologic deficit was 2.4%, and the hospital mortality rate was 4.2%. Five years later, a follow-up study by Daily and associates [4] reviewed six additional reports. The rate of permanent neurologic deficit was 4.5% and the hospital mortality rate, 4.9%. Table 4 shows a comparison of five more studies [5–9]. Their permanent neurologic deficit (PND) rate was 4.7% and the mortality rate, 3.8%. Our CVS morbidity rate was 5.8%, which is comparable, and our mortality rate was also 5.8%, slightly higher than that for these other studies. The obvious questions concern the increased mortality in our study.

Our cross-clamp and pump times were increased compared with the standard times at this institution. This increase must contribute to the morbidity and mortality associated with our technique. The prolonged stay in the intensive care unit observed in our patient population can be attributable to the extra time spent on the pump secondary to the CEA. This would be obviated only if CEA were performed prior to placing the patient on pump. Another interesting observation is that the time from clamp removal to off-pump time is equal in the CEA + CABG and CABG only populations at this institution. This reinforces our confidence in retrograde cardioplegia, which is the basis of the technique presented [10].

All patients who received combined CEA and CABG at this institution had carotid stenosis greater than 85%. This represents less than 2% of our patient population undergoing cardiac procedures. Six percent of all patients undergoing cardiac procedures at this institution have carotid disease of greater than 50% stenosis. Patients with carotid stenosis of 50% to 85% are treated as routine CABG patients, and the stroke rate is 2.5%. In contrast, the 121 patients in this review had a CVA rate of 5.8%. The exact etiology of CABG–related strokes is not well established [11, 12]. It might be expected that in patients who undergo simultaneous CEA + CABG, strokes would be related to the carotid disease. However, only two of the seven CVAs occurred on the side of the CEA. The other five were bilateral and contralateral. Therefore, five of the strokes may have been related to the CABG procedure. An interesting group of 24 patients had operation without aortic cross-clamping. The aortas were not clamped because by intraoperative epiaortic ultrasound (performed only since 1994) [13], they were severely diseased. There was only one neurologic event in this subgroup of patients. Perhaps if all patients with severe coronary and carotid disease underwent operation without cross-clamping of the aorta or with epiaortic ultrasound, neurologic morbidity would decrease. This requires a controlled study and is worthy of further investigation.

In conclusion, although the approach to combined CABG and CEA remains controversial, the operative technique we describe is a good one for treating this challenging group of patients. It entails a single period of anesthesia and hypothermia for cerebral protection. We have used this method with acceptable morbidity and mortality and recommend its use. Further consideration should be given to performing all of the cardiac procedures in such patients without an aortic cross-clamp in place. This and the use of epiaortic ultrasound may further reduce neurologic morbidity in this patient population.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Bernhard V.M., Johnson W.D., Peterson J.J. Carotid artery stenosis. Arch Surg 1972;105:837-840.[Abstract/Free Full Text]
2. Sutter F.P., Goldman S.M., Clancy M., et al. Continuous retrograde blood cardioplegia. Ann Thorac Surg 1991;51:136-137.[Abstract]
3. Gugulakis A., Kalodiki E., Nicolaides A.N. Combined carotid endarterectomy and coronary artery bypass grafting. Int Angiol 1991;10:167-172.[Medline]
4. Daily P.O., Freeman R.K., Dembitsky W.P., et al. Cost reduction by combined carotid endarterectomy and coronary artery bypass grafting. J Thorac Cardiovasc Surg 1996;111:1185-1193.[Abstract/Free Full Text]
5. Jahangiri M., Rees G.M., Edmonson S.J., et al. A surgical approach to coexistent coronary and carotid artery disease. Heart 1997;77:164-167.[Abstract/Free Full Text]
6. Mackey W.C., Khabbaz K., Bojar R., et al. Simultaneous carotid endarterectomy and coronary bypass. J Vasc Surg 1996;24:58-64.[Medline]
7. Trachiotis G.D., Pfister A.J. Management strategy for simultaneous carotid endarterectomy and coronary revascularization. Ann Thorac Surg 1997;64:1013-1018.[Abstract/Free Full Text]
8. Gutschi S., Machler H. Indications and outcome of simultaneous operation of carotid stenoses and stenosing coronary arteriosclerosis. Zentralbl Chir 1996;121:1054-1057.[Medline]
9. Takach T.J., Reul G.J., Jr, Cooley D.A., et al. Is an integrated approach warranted for concomitant carotid and coronary artery disease?. Ann Thorac Surg 1997;64:16-22.[Abstract/Free Full Text]
10. Moshkovitz Y., David T.E., Caleb M., Feindel C.M., de Sa M.P.L. Circulatory arrest under moderate systemic hypothermia and cold retrograde cerebral perfusion. Ann Thorac Surg 1998;66:1179-1184.[Abstract/Free Full Text]
11. Ricotta J.J., Faggioli G.L., Castilone A., Hassett J.M. Risk factors for stroke after cardiac surgery. J Vasc Surg 1995;21:359-364.[Medline]
12. Wijdicks E.F., Jack C.R. Coronary artery bypass grafting–associated ischemic strode. A clinical and neuroradiological study. J Neuroimaging 1996;6:20-22.[Medline]
13. Duda A.M., Letwin L.B., Sutter F.P., et al. Does use of aortic ultrasound decrease stroke rate in coronary artery bypass grafting?. J Vasc Surg 1995;21:98-109.[Medline]

This article has been cited by other articles:

				C. W. Akins and R. P. Cambria Myocardial Revascularization with Carotid Artery Disease Card. Surg. Adult, January 1, 2008; 3(2008): 655 - 668. [Full Text]

				L. Nwakanma, H. K. Poonyagariyagorn, R. Bello, A. Khoynezhad, D. Smego, and K. A. Plestis Early and late results of combined carotid endarterectomy and coronary artery bypass versus isolated coronary artery bypass Interactive CardioVascular and Thoracic Surgery, April 1, 2006; 5(2): 159 - 165. [Abstract] [Full Text] [PDF]

				C. W. Akins, A. D. Hilgenberg, G. J. Vlahakes, J. C. Madsen, T. E. MacGillivray, G. M. LaMuraglia, and R. P. Cambria Late Results of Combined Carotid and Coronary Surgery Using Actual Versus Actuarial Methodology Ann. Thorac. Surg., December 1, 2005; 80(6): 2091 - 2097. [Abstract] [Full Text] [PDF]

				C. W. Akins and A. C. Moncure Myocardial Revascularization with Carotid Artery Disease Card. Surg. Adult, January 1, 2003; 2(2003): 627 - 637. [Full Text]

				A. Zacharias, T. A. Schwann, C. J. Riordan, P. M. Clark, B. Martinez, S. J. Durham, M. Engoren, and R. H. Habib Operative and 5-year outcomes of combined carotid and coronary revascularization: review of a large contemporary experience Ann. Thorac. Surg., February 1, 2002; 73(2): 491 - 497. [Abstract] [Full Text] [PDF]

				P. E. Antunes, G. Anacleto, J.M. Ferrao de Oliveira, L. Eugenio, and M. J. Antunes Staged carotid and coronary surgery for concomitant carotid and coronary artery disease Eur. J. Cardiothorac. Surg., February 1, 2002; 21(2): 181 - 186. [Abstract] [Full Text] [PDF]

This Article Abstract 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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Francis P. Sutter Scott M. Goldman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Khaitan, L. Articles by Whitlark, J. D. Search for Related Content PubMed PubMed Citation Articles by Khaitan, L. Articles by Whitlark, J. D.