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Ann Thorac Surg 2002;73:793-797
© 2002 The Society of Thoracic Surgeons

Original article: cardiovascular

Safety and efficacy of one stage off-pump coronary artery operation and carotid endarterectomy

Zile Singh Meharwal, MCh*a, Anil Mishra, MCha, Naresh Trehan, MDa

a Department of Cardiovascular Surgery, Escorts Heart Institute and Research Centre, New Delhi, India

Accepted for publication October 16, 2001.

* Address reprint requests to Dr Meharwal, Escorts Heart Institute and Research Centre, Okhla Rd, New Delhi 110 025, India
e-mail: meharwal{at}hotmail.com


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. Patients with concomitant occlusive disease of coronary and carotid arteries remain at high risk of perioperative stroke and myocardial infarction. Combined coronary artery bypass grafting on cardiopulmonary bypass and carotid endarterectomy has been shown to give good results for this category of patients. In the present study, we analyzed our results of off-pump coronary artery bypass grafting and carotid endarterectomy as a one-stage procedure.

Methods. Between January 1997 and December 2000, 82 patients underwent combined off-pump coronary artery bypass grafting and carotid endarterectomy. All patients were evaluated by preoperative carotid duplex scanning and carotid angiography. All patients had more than or equal to 70% carotid artery stenosis. There were 35 asymptomatic patients (42.7%) and 47 symptomatic patients (57.3%). Carotid endarterectomy was performed before coronary artery bypass grafting in all the patients.

Results. There were 66 males (80.5%) and 16 females (19.5%) with a mean age of 63 ± 8 years. The average number of grafts was 3.4 ± 0.8. There was no hospital mortality. One patient had perioperative myocardial infarction. None of the patients had stroke. One patient had transient neurologic deficit and 1 patient had temporary 12th nerve dysfunction; both recovered completely. There was no incidence of neck wound infection, although 1 patient developed neck hematoma that required reexploration. At a mean follow-up of 2.2 ± 0.7 years, 1 patient required contralateral carotid endarterectomy and 1 patient died because of cardiac failure.

Conclusions. Combined off-pump coronary artery bypass grafting and carotid endarterectomy is a safe and effective procedure in patients with significant concomitant carotid and coronary artery disease.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Currently, more and more high-risk and elderly patients are seen for coronary artery bypass grafting (CABG). These patients often have extensive atherosclerosis, involving more than one system, that contributes to morbidity and mortality. Coronary and carotid artery diseases frequently coexist. The inci-dence of more than 50% carotid artery stenosis in patients undergoing elective CABG has been reported as 22% [1]. In another study 8.5% of patients undergoing CABG had more than 80% carotid artery [2]. Even a higher incidence of carotid artery stenosis has been reported with left main coronary artery disease [3].

Significant carotid artery stenosis has been shown as the most powerful predictor of perioperative stroke in patients undergoing cardiac operation [4]. There is a 14% risk of perioperative stroke in patients with severe carotid artery disease undergoing CABG and the stroke rate remains 4% per year for the first 4 years after coronary revascularization [5, 6].

Controversy still continues about the management of carotid stenosis in patients requiring CABG [7]. The management strategy includes performing only carotid endarterectomy (CEA) or CABG, staged CEA and CABG, and simultaneous CEA and CABG. Combined coronary and carotid operations have been shown to be effective and safe procedures, and CEA was not a significant risk factor in a recent prospective study [8].

We have been performing combined on-pump CABG and CEA for patients having significant carotid and coronary artery disease. We started CEA with off-pump coronary artery bypass (OPCAB) in 1996, when we started routine off-pump coronary operations. In this study we report our experience of OPCAB and CEA over the last 4 years.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
The data was prospectively collected on all patients who underwent combined OPCAB and CEA between January 1997 and December 2000.

Preoperative screening
All patients undergoing CABG had carotid artery duplex scanning to screen carotid arteries and transesophageal echocardiography to screen the aorta as a part of preoperative evaluation. Extracranial carotid arteries were evaluated by color flow duplex scanning study. B-mode and color flow images of the common, external, and internal carotid arteries were obtained in longitudinal and transverse planes. The presence of plaques was noted and reduction in the cross-sectional area of the lumen was calculated. Doppler velocity spectra were recorded from each of these vessels, maintaining the angle of insonation as close to 60° as possible. The various parameters used for the evaluation of severity of stenosis were peak systolic velocity, peak diastolic velocity, velocity ratio of internal carotid artery with common carotid artery, and spectral broadening. The severity of internal carotid artery stenosis was graded as less than 70% when the peak systolic velocity was less than 120 cm per second and the ratio of peak systolic velocity in internal carotid artery and common carotid artery was less than 2 and more than or equal to 70% when peak systolic velocity was more than or equal to 120 and the ratio of peak systolic velocity in internal carotid artery and common carotid artery was more than or equal to 2. Patients who showed more than or equal to 70% narrowing of common or internal carotid artery underwent selective carotid angiography. Computed tomographic scan was done in all patients with carotid stenosis or neurologic symptoms. All patients with carotid disease or history of neurologic symptoms were evaluated by a neurologist. The same neurologist also followed the patients postoperatively. All patients with more than or equal to 70% carotid stenosis underwent combined procedure.

Definitions
Preoperative neurological status
Patients were categorized as symptomatic or asymptomatic. Symptomatic patients included those who gave history of transient ischemic attack, amaurosis fugax or complete stroke. Asymptomatic patients had no evidence of neurological findings.

Transient ischemic attack
Transient ischemic attack was defined as focal cerebral dysfunction of presumed vascular origin that resolved completely within 24 hours.

Stroke
Stroke was defined as focal or global cerebral dysfunction of presumed vascular origin lasting more than 24 hours.

Perioperative neurologic events
Perioperative neurologic events were evaluated by a neurologist and were defined as transient ischemic attack, reversible ischemic neurologic deficit, or complete stroke.

Perioperative myocardial infarction
Perioperative myocardial infarction was defined as either new Q waves, more than 10% elevation of myocardial band, fraction of creatinine phosphokinase, or new wall motion abnormality on echocardiogram.

Technique of carotid endarterectomy
Both CABG and CEA were performed by the same operating team. Carotid endarterectomy was performed before CABG, but after sternotomy, and after harvesting the conduits. Intraoperative monitoring included monitoring of electrocardiogram, arterial blood pressure, central venous pressure, pulmonary arterial pressures by Swan-Ganz catheter, and transesophageal echocardiography.

Carotid endarterectomy was performed by a vertical incision anterior to the sternocleidomastoid. The common carotid artery, internal carotid artery, and the external carotid artery were exposed, and then the patient was heparinized by 1.5 mg per kg of heparin. The decision to use the shunt or not was based on collateral circulation (backflow in the internal carotid artery). The arteriotomy was closed either directly or by a saphenous vein patch or polytetrafluoroethylene patch.

The neck wound was left open until the heparin was reversed with protamine after CABG. The wound was closed after CABG and after reversing the heparin, with or without drainage.

Technique of off-pump CABG
Coronary artery bypass grafting was performed through median sternotomy. The Octopus (Octopus 2, Octopus 2+, and Octopus 3; Octopus tissue stabilization system; Medtronic Inc, Minneapolis, MN) or the CTS (Cardiothoracic Systems, Cupertino, CA) were the mechanical stabilizers used. Intracoronary shunts (Baxter Anasta Flo Intravascular Shunt, Irvine, CA) were used in most of the patients. Transesophageal echocardiography was performed in all the patients to look for global and regional left ventricular functions before, during, and after the operation. During CABG, care was taken not to allow the blood pressure to fall below 100 mm Hg; systolic and pressure agents were used as necessary.

Follow-up
Patients were followed at 3-month, 6 month, and 1-year intervals, and their cardiac and neurological status were evaluated. Any patient with symptoms of neurologic dysfunction was referred to the neurologist for evaluation.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
A total of 2,556 patients underwent OPCAB between January 1997 and December 2000. Among these, 82 patients had significant carotid artery stenosis and underwent combined CEA and CABG. The demographic profile of the patients is shown in Table 1. Females constituted only 19.5% of all the patients.


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  		Table 1. Demographic Profile

 
Out of these 82 patients, 36 patients (43.9%) gave a history of transient ischemic attacks and 11 patients (13.4%) had a previous stroke. Thirty-five patients (42.7%) were asymptomatic. The findings of coronary and carotid angiography are shown in Table 2. Twelve patients (14.6%) had left main coronary artery stenosis and 15 patients (18.3%) had left ventricular ejection fraction of more than 30%.


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  		Table 2. Angiographic Findings

 
Right CEA was performed in 45 patients (54.9%) and left CEA was performed in 34 patients (41.5%). Only 3 patients (3.7%) underwent bilateral carotid endarterectomy (Table 3). The carotid arteriotomy was closed directly in 9 patients, whereas veins plasty was performed in 68 patients. In 5 patients, the arteriotomy was closed using a polytetrafluoroethylene patch. The intraoperative details of CABG are shown in Table 4. All but 1 patient received a left internal mammary artery, and 5 patients received a bilateral internal mammary artery. The average number of grafts was 3.4 ± 0.8.


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  		Table 3. Carotid Endarterectomy (Intraoperative Variables)

 

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  		Table 4. Coronary Artery Bypass Grafting (Intraoperative Variables)

 
Table 5 shows the postoperative outcome of all patients. No patient had stroke. One patient had transient weakness on the contralateral side, which recovered within 72 hours. No patient had infection at the CEA site develop. One patient had neck hematoma develop, which required re-exploration and evacuation of hematoma. There was no hospital mortality. Eighty-one patients were followed from 6 months to 4 years with a mean follow-up of 2.2 ± 0.7 years. One patient was lost to follow-up. Follow-up data is shown in Table 6. One patient died during follow-up due to a cardiac cause; this patient had a preoperative ejection fraction of 25% and died of cardiac failure 2 years after operation. None of the patients had stroke during follow-up, although CEA was required in 1 patient on the contralateral side. Three patients had cardiac symptoms and had angiograms. One of these patients was found to have stenosis in the vein graft to the posterior descending artery and underwent angioplasty. One of the other patients required angioplasty of the obtuse marginal artery.


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  		Table 5. Postoperative Outcome

 

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  		Table 6. Follow-up Results

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Patients presenting with coexisting significant carotid artery disease and coronary artery disease are high-risk surgical candidates and represent a controversial management problem. Patients with severe (> 80%) uncorrected internal carotid artery disease have as much as a 14% risk of cerebrovascular accident during CABG, and carotid artery disease is the most powerful predictor of cerebrovascular accident during CABG [1, 4, 9–10]. Also, CEA performed in the setting of severe uncorrected coronary artery disease has been associated with as much as a 20% mortality, with myocardial infarction being responsible for 50% to 75% of all late deaths in this group [11]. The asymptomatic carotid atherosclerosis study has shown statistically significant surgical benefit over medical therapy in the asymptomatic internal carotid lesions in terms of stroke prevention.

We had been performing carotid endarterectomy in all patients undergoing CABG and were having significant carotid artery stenosis. The CEA was performed before CABG and before going on bypass. Some authors recommended the one-stage procedure (CEA before initiation of CPB for CABG or CEA under CPB before CABG) for patients with unstable angina, left main coronary artery stenosis, or diffuse multivessel coronary artery disease coexisting with symptomatic carotid artery occlusive disease [12]. We started CABG without CPB as a routine procedure in 1996. We then started CEA along with off-pump CABG.

Combined one-stage CABG and CEA has advantages over the two-stage procedure, including shorter hospital stay, decreased exposure to anesthesia, and decreased costs [13]. Earlier studies by Hertzer and coworkers [6] and Dunn [14] reported elevated stroke and mortality rates after the combined approach. In contrast, many other large series [10, 15–17] have not reported the higher strokes and mortality rates found in earlier studies. Many studies have evaluated risk factors for stroke during coronary artery operation, including hypertension, increasing age, diabetes, carotid bruit, previous transient ischemic attack, and prior stroke [18–19]. In addition, prolonged CPB time also has been reported to be associated with a higher risk of stroke [18, 20]. Off-pump coronary artery bypass avoids CPB as one of the contributing factors for stroke. The OPCAB gives additional benefits of decreased morbidity in terms of blood loss, use of blood and blood products, intensive care unit stay, and hospital stay [21–22].

We perform CEA before CABG. This has the advantage of avoiding the negative effects of hemodynamic disturbances during OPCAB on carotid circulation. Maintenance of perioperative hemodynamic stability and effective operative management is important during the procedure. We maintain the systolic pressure above 100 mm Hg during CABG, using inotropes whenever necessary. The conduits are harvested before CEA. This avoids the total heparinization time and avoids excessive operative bleeding.

We do not use the intravascular shunt routinely. If the backbleed from the carotid artery is not good, we use the shunt. We tend to use the patch to close the carotid artery. This was used in 73 (89%) of our patients. In a report by Takach and coworkers [10], neither an intraoperative carotid shunt nor the patch closure of the carotid vessels was an independent predictor of stroke. We did not have any incidence of permanent stroke, though one patient had a temporary neurologic deficit from which the patient recovered completely. One patient developed signs of 12th nerve involvement after 48 hours of operation. Computed tomographic scan of the brain did not reveal any abnormality. The patient was started on antiinflammatory drugs and recovered completely within 10 days. This may have occurred because of the edema around the nerve.

Fifteen (18.3%) of our patients had ejection fraction less than or equal to 30% and 12 patients (14.6%) had left main coronary stenosis. Allie and coworkers [23] have recommended preoperative intraaortic balloon pump insertion immediately before CEA, followed by CABG the next day in patients that presented with high-risk triad defined by more than 70% stenosis of left main coronary artery, ejection fraction of less than 0.30, and more than 90% stenosis of internal carotid artery. Two of our patients required intraaortic balloon pump intraoperatively for hemodynamic instability. At a mean follow-up of 2.2 ± 0.7 years, all patients were free of stroke, although 1 patient required CEA on the opposite side, and 1 patient died because of cardiac failure.

In summary, off pump coronary artery operation combined with carotid endarterectomy as a one-stage procedure is safe and effective for patients presenting with significant carotid and coronary artery disease. This avoids the risks of CPB, and the one-stage operation avoids two anesthesia procedures and decreases costs.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

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  10. Takach T.J., Reul G.H., 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]
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