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Ann Thorac Surg 2006;82:1572
© 2006 The Society of Thoracic Surgeons

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Correspondence

Reply

Division of Vascular/Endovascular Surgery, Division of Cardiac Surgery, Massachusetts General Hospital, Cardiac Surgery—White 403 Boston, MA 02114

(Email: cakins{at}partners.org).

To the Editor:

We were pleased to read the comments of Dr Goksel [1] referring to our published article [2] on combined carotid and coronary surgery. Their strategy, which entails antecedent carotid endarterectomy using cervical regional plexus block prior to cardiac operation, is in fact one that we have applied selectively in accordance with the clinical urgency of the proposed cardiac surgery. From a practical standpoint, the majority of patients with severe combined disease are discovered to have asymptomatic, albeit anatomically severe, carotid stenosis in the clinical setting of often pressing or urgent indications for myocardial revascularization. In such circumstances it would be counterintuitive in our view to perform antecedent carotid endarterectomy irrespective of the anesthetic management. However, the theoretic implication of their approach (namely that cardiac-related complications will be diminished with use of a regional anesthetic technique) has only recently been substantiated in a report from our own vascular surgery group [3]. The problem, of course, with validating the potential favorable impact of a local and regional anesthetic technique is that few studies are sufficiently powered to delineate a difference when adverse outcome endpoints occur so infrequently. In our own report, using the National Surgical Quality Improvement Program (NSQIP) database and entailing over 15,000 patients, we were able to demonstrate that the use of a local anesthetic technique had a significantly favorable impact on a composite outcome of early postoperative stroke, death, and myocardial infarction after carotid endarterectomy.

Goksel's [1] rationale for their approach is to be able to more certainly ascertain the cause or anatomy of perioperative stroke, or both. It is well established and reflected in our material that at least half of the strokes coincidental with the combined operation occur contralateral to the carotid operation. We believe the assignment of "blame" is less important than minimizing stroke and cardiac ischemic risk.

Another issue raised by Goksel [1] is the longstanding debate about the optimal approach for patient monitoring and the use of shunting during carotid endarterectomy. The relatively high shunt usage in our report relates to our earlier practice during the study period, when we performed a majority of the combined operations with arbitrary shunting. We certainly agree that with a selective approach based on monitoring (whether it be response of the awake patient, intraoperative electroencephalogram (EEG) monitoring, or indeed a variety of other methods) will be accompanied by approximately a 10% incidence of shunting. In our contemporary practice we use EEG monitoring and selective shunting.

We believe the approach outlined by Goksel [1] is a valid one, dependent on the urgency of the cardiac operation. However, if the cardiac operation needs to proceed rapidly after the carotid endarterectomy, their approach could be problematic, because we would be loath to give the larger doses of heparin needed for cardiopulmonary bypass within a few days of an antecedent carotid operation.

We thank Goksel [1] for his kind comments and for emphasizing an approach, which we believe may be applicable to certain patients, although not the majority, with combined carotid and coronary disease.

	References

Top References

 

1. Goksel OS. Combined carotid and coronary surgery: early and late results (letter) Ann Thorac Surg 2006;82:1571-1572.[Free Full Text]
2. Akins CW, Hildenberg AD, Vlahakes GI, et al. Late results of combined carotid and coronary surgery using actuarial methodology Ann Thorac Surg 2005;80:2091-2097.[Abstract/Free Full Text]
3. Stoner MC, Abbott WM, Wong DR, et al. Defining the high-risk patient for carotid endarterectomy: an analysis of the prospective National Surgical Quality Improvement Program database J Vasc Surg 2006;43:285-296.[Medline]

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 Author home page(s): Cary W. Akins Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Cambria, R. P. Articles by Akins, C. W. Search for Related Content PubMed Articles by Cambria, R. P. Articles by Akins, C. W. Related Collections Related Article