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Ann Thorac Surg 2004;78:2209-2210
© 2004 The Society of Thoracic Surgeons
Department of Cardiovascular Surgery, Escorts Heart Institute and Research Centre, Okhla Rd, New Delhi 110 025, India
meharwal{at}hotmail.com
To the Editor:
We read with interest the article by Goto and associates [1]. We agree with the authors that severe aortic atherosclerosis of the ascending aorta significantly increases the risk of postoperative neurological dysfunction and stroke after coronary artery bypass grafting (CABG). We routinely perform transesophageal echocardiography in patients undergoing CABG, as this imaging technique can evaluate the ascending aorta, aortic arch, and the descending thoracic aorta. In a study [2] from our institution, the highest incidence of atheroma was found in the distal aortic arch, followed by the proximal aortic arch, and finally the ascending aorta. We also found that the incidence of aortic atherosclerosis increased with age. In patients older than 70 years, 33.6% had aortic atheroma, of whom one third had grade III (plaques with a mobile element) atheromatous disease. Off-pump CABG using a no-touch technique and arterial grafts may be good practice in patients with severe arteriosclerosis. Also proximal aortic connectors can be useful in situations where there is a small area of normal aorta without atherosclerosis.
Femoral artery cannulation for cardiopulmonary bypass (CPB) in patients with major aortic atherosclerosis can cause cerebral embolism and stroke as a result of retrograde perfusion. If CABG cannot be performed without CPB in these patients, subclavian artery cannulation, which was used in 24% of the patients in the study by Goto and colleagues, can be a better method for CPB because it provides antegrade perfusion.
The incidence of carotid artery disease among the patients with severe arteriosclerosis in the study by Goto and co-workers was 21% (16/76) and 14% of them (11 patients) had severe carotid artery disease or total obstruction of the carotid artery. The authors do not mention how many of these patients were symptomatic. Major carotid artery stenosis has been shown to be one of the most powerful predictors of perioperative stroke in patients undergoing a cardiac operation [3]. Our strategy is to perform combined CABG and carotid endarterectomy (CEA) in neurologically symptomatic patients and asymptomatic patients with carotid artery stenosis of more than 70%. In a study by Hertzer and co-workers [4] in which patients were randomized prospectively to CABG followed by CEA or combined CABG and CEA, the results favored combined CABG and CEA.
Thorough and careful preoperative and intraoperative screening is required in elderly patients undergoing CABG. The surgical strategy needs to be individualized to minimize the incidence of stroke.
References
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