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

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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 Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Goto, T. Search for Related Content PubMed Articles by Goto, T. Related Collections Cerebral protection Related Article

Ann Thorac Surg 2004;78:2210
© 2004 The Society of Thoracic Surgeons

---

Correspondence

Reply

^a Department of Anesthesiology, Kumamoto Chuo Hospital, 1-5-1 Tainoshima, Kumamoto 862-0965, Japan

togoto{at}bronze.ocn.ne.jp

To the Editor:

My coauthors and I thank Drs Meharwal and Trehan for their valuable comments on our report [1] and Trehan and associates [2] for a description of other work in the field. Their no-touch approach to the diseased ascending aorta, such as proximal aortic connectors and antegrade perfusion, reduces stroke after coronary artery bypass grafting (CABG) in patients with aortic atherosclerosis. Recently, we have used proximal aortic connectors and off-pump CABG in such patients. In regard to the management of operation in patients with severe stenosis or obstruction of carotid arteries, we maintained a higher pressure (>70 mm Hg) during cardiopulmonary bypass in patients with severe carotid artery stenosis or multiple infarctions and rewarmed them slowly. Of 11 patients with severe aortic atherosclerosis accompanied by severe stenosis or obstruction of the carotid arteries, 6 were symptomatic (2 with transient ischemia and 4 with stroke). Intraoperative stroke occurred in 2 patients with symptomatic carotid artery stenosis: one stroke was due to shower emboli associated with disease of the ascending aorta and the other, due to intracranial arterial stenosis and hypoperfusion. A postoperative infarction, which was due to atherothrombosis, occurred in only 1 patient with asymptomatic carotid artery stenosis.

Finally, Meharwal and Trehan recommend combining CABG and carotid endarterectomy (CEA) in symptomatic and asymptomatic patients with carotid artery stenosis of more than 70%. However, in one study [3], about one third of patients with severe carotid artery stenosis also had stenosis or obstruction of intracranial arteries. Barnett and co-workers [4] demonstrated that in the territory of symptomatic and asymptomatic carotid arteries with 70% to 99% stenosis, about 20% and 45% of strokes respectively, were not associated with carotid artery stenosis. My colleagues and I did not perform combined CEA and CABG in our study, but we planned staged CEA after CABG in 1 patient with transient ischemia. Perioperative evaluation, management, and therapy should be tailored to high-risk patients to reduce the incidence of stroke after CABG.

References

1. Goto T, Baba T, Matsuyama K, Honma K, Ura M, Koshiji T. Aortic atherosclerosis and postoperative neurological dysfunction in elderly coronary surgical patients. Ann Thorac Surg. 2003;75:1912–1918[Abstract/Free Full Text]
2. Trehan N, Mishra M, Kasliwal RR, Mishra A. Surgical strategies in patients at high risk for stroke undergoing coronary artery bypass grafting. Ann Thorac Surg. 2000;70:1037–1045[Abstract/Free Full Text]
3. Kappelle LJ, Eliasziw M, Fox AJ, Sharpe BL, Barnett HJM. Importance of intracranial atherosclerotic disease in patients with symptomatic stenosis of the internal carotid artery. The North American Symptomatic Carotid Endarterectomy Trial. Stroke. 1999;30:282–286[Abstract/Free Full Text]
4. Barnett HJ, Gunton RW, Eliasziw M, et al. Causes and severity of ischemic stroke in patients with internal carotid artery stenosis. JAMA. 2000;283:1429–1436[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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 Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Goto, T. Search for Related Content PubMed Articles by Goto, T. Related Collections Cerebral protection Related Article