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Ann Thorac Surg 1995;60:318
© 1995 The Society of Thoracic Surgeons
DR DAVID C. REYES (Bay City, MI): It is a well-known fact that in severe carotid artery disease, more than 70% stenosis in both internal carotid arteries, the media or the intracerebral vessels is diminished; in other words, it is fragile and has a tendency for bleeding. Under these circumstances, if you have a patient with an 85% stenosis bilaterally and know in advance that you have done 22% of the cases bilaterally, and this patient has global symptoms, not territorial symptoms, what would be the management of this patient with unstable angina?
DR AKINS: The key to your question is what to do with a patient who is unstable. We have had a couple of patients in this setting in whom we have put in an intraaortic balloon pump and performed bilateral carotid endarterectomies along with coronary artery bypass grafting. That, however, is distinctly rare. Very often one of the carotid arteries is worse than the other, and the symptoms are usually not global but are one-sided. We can, therefore, either perform the carotid endarterectomy a day or two ahead of time on the one side with a combined operation later, or, if there is a difference in the severity of the stenosis, do the combined operation first with a staged operation later.
DR CARLOS BLANCHE (Los Angeles, CA): I congratulate Dr Akins for a most interesting presentation. I notice that some of these patients had their carotid arteries evaluated by coronary angiograms. Do you have any experience with carotid duplex scan to evaluate these patients routinely, and would you rely on this information to make decisions regarding combined carotid and coronary artery operations?
DR AKINS: Doctor Willard H. Daggett, the other person in our group who has as an aggressive approach to this disease as I have, has been scanning patients, all of his coronary bypass patients, for the last 15 years. We are going back now to determine the exact incidence of carotid stenosis and try to relate that to whether there is an age at which it becomes cost effective to scan all patients and whether there are other features that would predict that a carotid stenosis exists.
In terms of cost containment, I might suggest that performing one operation to treat two diseases is cheaper than performing two operations.
DR DONALD B. DOTY (Salt Lake City, UT): Maybe I missed it, but did you tell us specifically what you used for cerebral protection during this period of time when you are doing both operations?
DR AKINS: For doing both carotid arteries?
DR DOTY: No, for one.
DR AKINS: We leave this to our vascular surgeons. Most of them will have continuous electroencephalographic monitoring during the time of the carotid operation. If there is a change in the electroencephalogram, then a shunt is used. About half of our vascular surgeons will use a shunt anyway.
DR DOTY: So the operation on the carotid is performed before the patient goes on cardiopulmonary bypass?
DR AKINS: That is correct.
DR DOTY: So the cerebral protection is just like you would use for a regular carotid operation?
DR AKINS: Correct.
Related Article
Ann. Thorac. Surg. 1995 60: 311-317.
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