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Ann Thorac Surg 2004;78:2037-2042
© 2004 The Society of Thoracic Surgeons

Original Article: Cardiovascular

Concomitant Carotid Endarterectomy and Coronary Bypass Surgery: Outcome of On-Pump and Off-Pump Techniques

Yugal Mishra, PhDa,*, Harpreet Wasir, MCha, Vijay Kohli, MCha, Zile Singh Meharwal, MCha, Rajneesh Malhotra, MCha, Yatin Mehta, MDb, Naresh Trehan, MDa

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

Accepted for publication June 2, 2004.

* Address reprint requests to Dr Mishra, Escorts Heart Institute and Research Centre, New Delhi, India (E-mail: dryugal{at}yahoo.com).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
BACKGROUND: There continues to be a dilemma regarding the best means of surgical management of significant carotid artery disease in patients requiring coronary artery bypass surgery. A combined approach of coronary artery bypass and carotid endarterectomy has shown good results in patients with concomitant carotid and coronary artery disease. We reviewed our results of coronary artery surgery using conventional cardiopulmonary bypass or off-pump techniques and carotid endarterectomy done as a combined procedure.

METHODS: Between January 1996 and June 2002, 358 patients underwent concomitant coronary artery bypass and carotid endarterectomy. There were 140 males (84.3%) and 26 females (15.7%) in group I. Group II consisted of 158 males (82.3%) and 34 females (17.7%). One hundred sixty-six patients (group I) were done off pump whereas in 192 patients (group II), the procedure was done using conventional cardiopulmonary bypass. Carotid endarterectomy was performed before coronary artery bypass surgery in both groups.

RESULTS: The average number of grafts were 3.4 ± 0.8 with average operative time of 4.2 ± 0.4 hours in group I, and 3.3 ± 0.8 graft with operative time of 5.3 ± 1.2 hours in group II (p = 0.239 and p < 0.001, respectively). There were 2 deaths (1.2%) in group I and 3 deaths (1.6%) in group II (p = 0.870). No patient from group I and 1 patient (0.5%) from group II had postoperative stroke (p = 0.941). Mean hospital stay was 9.0 ± 1.2 days in group I and 11.2 ± 1.7days in group II (p < 0.001). At mean follow-up of 2.8 ± 0.9 years in group I, 2 patients (1.2%) had late death due to cardiac failure and contralateral carotid endarterectomy was done in 2 patients (1.2%). Group II had mean follow-up of 2.4 ± 0.6 years, during which 4 patients (2.1%) had late death and contralateral carotid endarterectomy was done in 3 patients (1.6%). Late stroke was seen in 1 patient (0.6%) from group I and 2 patients (1.0%) from group II.

CONCLUSIONS: Concomitant carotid endarterectomy and coronary artery bypass is a safe and effective procedure in patients with significant coronary and carotid artery disease. Equally good results can be reproduced using cardiopulmonary bypass or off-pump techniques for coronary artery surgery, with low morbidity, mortality, and good long-term results.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Patient with diffuse arteriosclerosis present a major management problem because attention tends to be focused on the symptomatic sub system to the detriment of the remaining vascular system. The association of concomitant carotid and coronary artery disease is well established more so due to the increased incidence of carotid artery disease with the aging population who undergo elective coronary artery bypass grafting (CABG). Incidentally, 8% to 14% of CABG patients have significant carotid stenosis [1, 2] and 40% to 50% of carotid endarterectomy (CEA) patients have coronary artery disease (CAD) [3, 4]. Carotid endarterectomy in the presence of untreated CAD carries a 17% risk of perioperative myocardial infarction and a 20% risk of perioperative death. Similarly, patients with untreated carotid artery stenosis also carry a risk of stroke after CABG [5].

The treatment options amid the ever-remaining controversy include combined CABG and CEA with single anesthesia or a staged approach with two separate anesthesia administrations. Those preferring the combined approach cite low incidence of stroke and myocardial infarction as well as cost benefits for the patients [6–9]. Although a large multicenter, randomized study is yet to clear this controversy, evolving technologies, including off-pump coronary bypass grafting (OPCABG) and carotid artery stenting, may have a significant impact as the further outcome on the results involving all these approaches. The recognition of complete revascularization by OPCABG has extended its use to the subset of patients considered to be at high risk for perioperative stroke. Included in this subset are patients with aortic arch arteriosclerosis, advanced age, severe ventricular dysfunction and carotid disease besides others.

The aim of this study was to retrospectively analyze the safety and efficacy of performing combined CEA with CABG (on pump CABG versus OPCABG) in order to justify its performance based on immediate postoperative and late follow-up results.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
All patients who underwent combined CABG and CEA between January 1996 and June 2002 were studied retrospectively (n = 358). Group I consisted of 166 patients who underwent OPCABG and CEA. Group II consisted of 192 patients who underwent concomitant on-pump CABG and CEA.

Preoperative Screening and Indication for Surgery
A routine carotid artery duplex scanning to screen bilateral carotid artery and transesophageal echocardiography for aortic screening was done as part of the preoperative evaluation in all patients. Extracranial carotid arteries were evaluated by color flow duplex scanning; B-mode and color flow images of the common, external, and internal carotid arteries were obtained in both longitudinal and transverse planes and the cross-sectional area of the lumen was calculated. The Doppler velocity spectral curve was recorded from each vessel keeping the angle of insonation 60 degrees, as far as possible.

Severity of stenosis was assessed by studying the peak systolic velocity, peak diastolic velocity, velocity ratio between the internal carotid artery and 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 70% or more when peak systolic velocity was 120 or more and the ratio of peak systolic velocity in internal carotid artery and common carotid artery was 2 or more. Any patient showing 70% or greater narrowing of the common or internal carotid artery underwent selective carotid angiography. Computer tomography scan was done in all patients with significant carotid stenosis or any neurologic symptoms after been assessed by a neurologist. A combined procedure (CABG plus CEA) was done on all patients with 70% or greater carotid stenosis. The symptomatic patients were those who gave a history of transient ischemic attack, amaurosis fugax, or complete stroke.

There were 91 asymptomatic patients (54.8%) in group I and 106 in group II (55.2%, p = 0.974). Fifty-four patients (32.5%) in group I and 69 patients (35.9%) in group II (p = 0.571) had history of transient ischemic attack. Stroke was seen in 12 patients (72%) in group I and 17 patients (8.8%) in group II (p = 0.713).

Patient Population
Demographic and clinical data, neurologic and cardiac history, and results of cardiac catheterization and carotid angiography were recorded (Tables 1 and 2).


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  		Table 1. Preoperative Demographic Profile (CABG + CEA)
 
Operative Technique in Group I Patients
TECHNIQUE OF CAROTID ENDARTERCTOMY
The CEA was done after a median sternotomy and after harvesting the conduits; CABG followed thereafter. The electrocardiogram, arterial blood pressure, central venous pressure, and pulmonary arterial pressure were monitored. A transesophageal echocardiography was done in all patients as a hospital protocol. Carotid endarterectomy was performed by a vertical incision anterior to the sternocleidomastoid, thus exposing the common carotid artery, internal carotid artery, and the external carotid artery. The patient was heparinized by giving 2 mg/kg heparin. The artery was opened through a longitudinal incision followed by an endarterectomy. The arteriotomy was closed either directly or by a saphenous vein patch or polytetrafluoroethylene patch. Care was taken to keep the systolic blood pressure above 120 mm Hg and, if need be, inotropic agents were started to maintain adequate blood pressure and cerebral flow. The neck wound was closed with or without a drain, only after complete reversal of heparin by protamin after the CABG and after achieving good hemostasis.

TECHNIQUE OF OPCABG
The heart was exposed by a median sternotomy. The Octopus tissue stabilization systems (Medtronic, Minneapolis, MN) or the CTS (Cardiothoracic Systems, Cupertino, CA) were used for mechanical stabilization of the heart while performing all distal anastomosis). Intracoronary shunts (Baxter Anasta Flo intravascular shunt; Baxter, Irvine, CA) were used in most of the patients. A transesophageal echocardiography was performed in all patients to look for global or regional left ventricular functions before, during, and after the surgery.

Operative Technique in Group II Patients
Similar to group II, the conduits for CABG were harvested before starting the neck dissection for exposing to carotid arteries. Once exposed, a half-dose of heparin (2 mg/kg) was given and CEA performed. The neck incision was left open until the cardiac procedure was over and heparin reversal was done with protamine. Once done with the CEA patient was fully heparinized (4 mg/kg) to achieve a target activated clotting time (ACT) of more than 450 seconds. Cannulation was performed and cardiopulmonary bypass (CPB) was initiated. The core temperature was allowed to drift to 32°C. The aorta was cross-clamped, and the cardiac procedure was performed in a standard manner. Complete data concerning the extent of revascularization are summarized in Table 3.


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  		Table 3. Carotid Endarterectomy, Intraoperative Variables
 
POSTOPERATIVE DATA
The incidence of perioperative myocardial infarction, intensive care unit stay, complications, early deaths were determined (Table 4).


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  		Table 4. Immediate Postoperative Results
 
FOLLOW-UP
The follow-up ranged from 1 month to 5 years and was done at regular intervals in the out patient department. The results are summarized in Table 5. During the immediate postoperative period the patient was maintained by the surgical team, which checked the neck wound for any hemotoma or excessive drainage. In case of any neurologic suspicion once the patient was conscious, a neurology consultation was obtained to rule out any cerebral event. A neurologic event was defined as recognition of any new sensory or motor neurologic deficit and correlating symptoms with radiographic signs on computed tomography scan of the head. Once discharged from hospital, patients were followed up at 3 months and 6 months, and at 1-year intervals at which time their cardiac and neurologic status was evaluated.


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  		Table 5. Follow-Up Results (Period 1 Month to 5 Years)
 
Statistical Analysis
All values were expressed as mean ± standard deviation. The {chi}2 test or Fisher's exact test was applied for comparing categorical data between two groups, whichever was applicable. An unpaired Student's t test was used for comparing mean values. A p value less than 0.05 was considered as statistically significant.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
A total of 16,022 patients underwent CABG between January 1996 and June 2002. Four hundred and sixty patients underwent carotid artery surgery, which included 102 isolated CEAs. In 358 patients, who constitute this study group, combined CABG and CEA was done. One hundred and sixty-six patients underwent OPCABG plus CEA and 192 patients underwent CEA along with conventional CABG. The demographic profile of patient is shown in Table 1. Males constituted 84.3% and 82.3% in group I and group II, respectively. Patients were either asymptomatic, in whom significant carotid artery disease was picked up as routine examination, or presented with a history of transient ischemic attacks that resolved within 24 hours or stroke associated with focal or global cerebral dysfunction of presumed vascular origin that lasted more than 24 hours (Table 1). The findings of coronary and carotid angiography are shown in Table 2. Right CEA was performed in 81 patient (48.8%) and left CEA in 85 (51.2%) in group I. In group II, 94 patients (49.0%) underwent right CEA and 98 patients (51.0%) underwent left CEA. No patient underwent bilateral carotid endarterectomy during the same anesthesia (Table 3). The intraoperative variables of CABG are shown in Table 3. The average number of distal anastomosis was 3.4 ± 0.8 in group I and 3.3 ± 0.8 in group II (p = 0.239). The total operating time between the two groups was statistically significant (4.2 ± 0.4 hours in group I and 5.3 ± 1.0 hours in group II, p < 0.001).


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  		Table 2. Coronary Angiographic Findings
 
Table 4 shows the postoperative outcome of all patients. The total intubation time was statistically significant between both the groups (18 ± 4 hours in group I versus 21 ± 6 hours in group II, p < 0.001). The cardiac intensive care stay was 23 ± 3 hours in group I and 28 ± 4 hours in group II (p < 0.001). The hospital stay was significantly less in group I (9.0 ± 1.2 days versus 11.2 ± 1.7 days, p < 0.001). No patient from group I and only 1 patient (0.5%) from group II had a stroke. A transient weakness was seen on the contralateral side in 1 patient from each group, and they recovered within 72 hours.

Neck hematoma was detected in 1 patient (0.6%) in group I and in 4 patients (2.1%) in group II within 3 hours postoperatively. These patients required reexploration and evacuation of hematoma. No incidence of neck wound infection was seen. There were 2 deaths (1.2%) from group I. Both these patients had severe ventricular dysfunction (EF 25%) with unstable angina. One of these patients had preoperative IABP. In both patients CABG and CEA were done successfully. The patients went into low cardiac output from day 1 postoperatively and did not respond to inotropic agents; one died on the fifth and the other on the seventh postoperative day. In group II there were 3 deaths (1.6%). All these patients had ventricular dysfunction (EF <30%) with significant carotid artery disease. One patient had critical (99%) left main artery disease with peripheral vascular disease and bronchial asthma. Postoperatively, he did well until the third postoperative day when intractable ventricular arrhythmias developed that did not respond to antiarrhythmic treatment; this patient died on the fourth postoperative day. The other 2 patients had unstable angina and underwent emergency CABG and CEA. Both patients had a history of preoperative ventricular arrhythmias, which persisted in the postoperative period. Both went into low cardiac output in spite of intraaortic balloon pump and high inotropic supports. These patients died on the fifth and sixth postoperative day. The mortality rate between group I and group II was statistically significant (p = 0.870). Patient follow-up ranged from 1 month to 5 years with a mean follow-up of 2.8 ± 0.9 years in group I and 2.4 ± 0.6 years in group II. The follow-up data are shown in Table 5.

Two patients (1.2%) from group I and 4 patients (2.1%) from group II died of cardiac causes during follow-up. All these patients had ejection fractions less than 30% and died of cardiac failure 2 years after operation. Late stroke was seen in 1 patient (0.6%) from group I and 2 patients (1.0%) from group II. In 8 patients, angina developed and coronary angiograms revealed graft stenosis. Six patients underwent vein graft angioplasty, and 2 patients were medically managed with cardiac medicines.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
A continuing controversy exists about the best management regimen for patients with coronary artery disease requiring surgery who also have significant carotid artery disease. Approaches vary from totally ignoring carotid stenosis at the time of myocardial revascularization, to performing staged operations, or even continuing the two operations during a single anesthesia. One can not ignore the fact that if addressing only one lesion at the time of surgery, the other poses a high risk in terms of morbidity and mortality perioperatively and postoperatively. Reports of perioperative neurologic complications ranging from 7.4% to 20.3% are reported for patients who had undergone CABG without surgical treatment of significant carotid artery disease. The mortality rate for such patients also varies from 6.9% to 13.8% [10]. Different authors have suggested a combined approach as the procedure of choice in combined arterial disease to avoid myocardial infarction and reduce neurologic deficits [11–15].

The role of medical management for symptomatic patients with significant carotid artery disease is quite limited. As also supported by the North American Symptomatic Carotid Endarterectomy Trial [16] and the European Carotid Surgery Trial [17], Brener and colleagues [13] report there is an increased risk of myocardial infarction and death among patients undergoing staged procedures, with no difference in stroke rates.

In our series of 358 patients, we report a mortality rate of less than 2%, which is quite acceptable as compared with other authors' reported mortality rates [18–20].

In our center, we started CABG without CPB as a routine procedure in 1996, after which CEA with OPCABG was done routinely. We employ two different approaches for treating concomitant disease of carotid and coronary arteries. The first involves CEA followed by OPCABG, while the second involves CEA followed by conventional CABG using CPB. Other authors have described various approaches to tackle these concomitant procedures [21–24]. Weiss and associates [24] performed CEA with aorta cross-clamping and core cooling of patient to 20°C. Similarly, Khaitan and associates [19] performed CEA with aortic cross-clamping and patient cooling to 25°C; they reported a 5.8% hospital mortality rate and a 5.8% rate of perioperative neurologic complications. We believe that these approaches significantly prolong the cardiopulmonary bypass and aortic cross-clamp time, even though these reports demonstrates acceptable hospital mortality and perioperative neurologic complications. A combined one-stage procedure of CABG and CEA has a shorter hospital stay, reduces exposure to anesthesia, and reduces hospital costs [6]. Although factors like hypertension, advanced age, diabetes, carotid bruit, transient ischemic attack, prior stroke, and CPB [25–27] itself pose threats for stroke, the technique of OPCABG circumvents these to reduce its incidence while at the same time provides additional benefits to reduce morbidity in terms of blood loss, less need for blood products, and reduced intensive care and hospital stay, as also seen in our study [28]. Hertzer and associates [9] showed a 2.8% risk of stroke for a combined approach and 14.4% (6.9% at the time of coronary grafting and 7.5% at the time of delayed CEA) for the staged procedure, thus stressing the importance of a timely performance of the combined procedure.

Thirty-four patients (17.7%) from group II had an ejection fraction or 30% or less and 12 patients (6.3%) had critical left main coronary artery stenosis. Five patients (2.6%) had preoperative or intraoperative balloon pump for reasons such as high pulmonary artery pressure, severe ventricular dysfunction, unstable angina, or critical coronary artery disease. For such patients of relatively high risk, while some authors advocate a staged procedure, we advocate a one-stage combined procedure.

Although our results show almost comparable results in both the groups, we still prefer to do a one-stage procedure using OPCABG to circumvent the deleterious effects of organ hypoperfusion and dysfunction with prolonged CPB time. Although in our series the incidence of renal dysfunction (3.0% in group I versus 3.6% in group II) and prolonged ventilation (3.6% in group I versus 5.7% in group II) was higher in patients in whom CPB was used, it was not statistically significant as compared with that reported by Bonoceni and colleagues [21]. Our approach using OPCABG had a shorter intubation time, intensive care unit stay, and hospital stay (Table 4).

In this series of patients, we found acceptable overall freedom from stroke at follow-up, which compares favorably with data from the literature for patients who have undergone combined surgery for concomitant severe coronary and carotid artery disease [29–31].

Based on our outcomes, we thus conclude that, with our experience, concomitant one-stage CEA and CABG is a safe and effective technique of choice for patients with significant coronary and carotid artery disease. Coronary artery bypass graft surgery performed using both CPB and off-pump techniques combined with CEA show equally good results with low morbidity and mortality and encouraging postoperative follow-up results.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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