Contemporary management of concomitant carotid and coronary artery disease

The best approach to the management of concomitant severe carotid and coronary artery disease remains unanswered. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend carotid endarterectomy (CEA) in asymptomatic carotid stenosis of ≥ 80% either prior to or combined with coronary artery bypass surgery (CABG). Currently, there is no consensus as to which surgical approach is superior. More recently, carotid artery stenting (CAS) prior to CABG is emerging as an alternative option with promising results in asymptomatic patients considered 'high risk' for CEA. A <3% composite event rate has been set as a benchmark for isolated CAS or CEA in asymptomatic patients by the ACC/AHA; however, most CEA or CAS studies in patients requiring concomitant CABG have shown event rates ranging from 10-12%. This review examines the available data on carotid revascularisation in relation to CABG surgery to aid in the risk-benefit decision analysis in this controversial area.     

Surgical management of concomitant carotid and coronary artery occlusive disease

The management of concomitant coronary and carotid disease is controversial. We report our experience of simultaneous coronary artery bypass surgery and carotid artery endarterectomy on 70 consecutive patients (34 males and 36 females) with a mean age of 68 years. The oldest patient was 91 years old. The average percent of carotid artery stenosis was 86% (range 60%–99%). The average number of grafts per patient was 3.35 (range 1–6). Two patients experienced postoperative strokes (2.86%), 1 had a perioperative infarct (1.42%), and 4 died in the hospital (5.7%). The simultaneous approach offers the advantage of shorter hospital stays, decreased anesthesia exposure, and significant cost savings. The causes of death include stroke, renal failure, and bowel infarction. This review indicates the simultaneous approach has a higher incidence of adverse outcomes compared with elective carotid endarterectomy or elective coronary artery bypass surgery. These patients, however, are at significantly higher risk due to their poor medical conditions, extensive atheromatous disease, and often emergent medical condition.Presented in part at 41^st Annual World Congress, International College of Angiology, Sapporo, Japan, July 1999.     

Concurrent coronary and carotid artery surgery: an open debate.

We read with great interest the article by Kolh et al.¹dealing with the question about concurrent coronary artery bypassgrafting (CABG) and carotid endarterectomy (CEA) surgery. Nevertheless,their report raises some concerns. The article     

Combined carotid and coronary artery surgery: early and late results.

Patients with coronary artery disease can exhibit substantial vascular involvement; and vascular patients have a high incidence of coronary disease. Combined coronary artery bypass grafting (CABG) and treatment of extracranial cerebrovascular disease was performed in 52 patients, presenting strong indications for surgical treatment of coronary artery disease and symptomatic carotid disease and/or asymptomatic carotid bruit that reflected an ulcerative lesion or stenosis exceeding 75%. Overall hospital mortality was 3.8%. Clinical presentation determined the risk of the combined procedure: early mortality was much higher in urgent and emergency cases than in elective cases. Eight-year actuarial survival was 86%. This group of patients was compared with staged procedures in 45 patients (including carotid endarterectomy followed by CABG several weeks later) and with 42 patients who underwent coronary artery bypass in the presence of carotid bruits. Both early cardiac complications in the former group and neurologic complications in the latter were significantly more frequent than in combined procedures. Combined procedures can be performed with acceptable risk and with encouraging long-term results also in this special group of patients; they may improve the long-term prognosis of patients with diffuse atherosclerosis much more.     

Surgical treatment of a coronary artery fistula with concomitant saccular coronary artery aneurysm: a case report.

An extremely rare case of a coronary artery fistula with a concomitant saccular aneurysm is presented. A 65-year-old woman, who had a history of chest bruising 5 years earlier, suffered from chest pain, which was diagnosed as being due to left coronary artery-pulmonary artery fistulae concomitant with a giant saccular coronary artery aneurysm. Suture closure of the afferent coronary artery to the aneurysm, aneurysmorrhaphy, and transpulmonary closure of coronary artery-pulmonary artery fistulae were performed. The postoperative course was uneventful and the patient was well at 3 months after the operation. Because the risk of surgery appears to be less than the potential development of fatal complications, it is recommended for the treatment of coronary artery fistula with a concomitant saccular aneurysm.     

心脏直视手术前颈动脉支架术的初步探讨

目的 评估心脏疾病合并严重颈动脉狭窄患者于心脏直视手术前行颈动脉支架术预防围手术期缺血性卒中的有效性和安全性.方法 前瞻性队列研究,对心脏疾病合并严重颈动脉狭窄患者于心脏直视手术前行颈动脉支架术,评估颈动脉支架术至心脏直视术后30 d的终点事件(卒中、心肌梗死和死亡).结果 自2005年1月至2007年12月,本研究共连续入选42例患者.颈动脉支架技术成功率100%.远端栓塞防护装置使用率为97.6%(41/42).心脏直视手术包括:冠状动脉旁路移植术36例(85.7%),冠状动脉旁路移植术加瓣膜置换术5例(11.9%),瓣膜置换术1例(2.4%).自颈动脉支架术至心脏直视术后30 d的卒中率为2.4%(1/42),心肌梗死率为0%,死亡率为0%.结论 这一小样本前瞻性队列研究表明,心脏直视手术前行颈动脉支架术预防围手术期缺血性卒中安全有效,优于文献报告的分期颈动脉内膜剥脱术的结果,但由于本研究样本量小,需进一步研究验证.     

Simultaneous carotid and coronary artery surgery: indications and perioperative outcome

BACKGROUND: A significant number of patients with coronary artery disease is diagnosed with additional carotid artery disease. This subset of patients has been identified as a high-risk group for cardiac and cerebral complications following surgical intervention. METHODS: In a retrospective analysis we investigated the perioperative outcome of combined single-stage carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) in 63 patients operated between January 1989 and August 1998. In all of these patients, CEA was performed prior to CABG and before initiation of cardiopulmonary bypass. RESULTS: Perioperative mortality rate was 7.9% (5/63) for simultaneous CEA and CABG and was due to cardiac complications in all patients. Postoperative unilateral neurological symptoms were diagnosed in 1 patient (1.7%) and were completely reversible. No neurologic events suggestive for permanent cerebral damage were observed during the 30 d postoperative period. CONCLUSIONS: In our study combined single-stage CEA and CABG was associated with low cerebral morbidity and patient outcome was mainly determined by cardiac complications. In this subset of patients, simultaneous CEA and CABG appears to be a safe method.     

同期行冠状动脉旁路移植术和颈动脉剥脱术治疗冠心病合并颈动脉狭窄临床分析

目的:评价冠心病合并颈动脉狭窄患者同期行非体外循环冠状动脉旁路移植术(OPCABG)和颈动脉内膜剥脱术(CEA)的临床安全性及有效性。方法:收集2002年8月至2015年8月,于我院同期行冠状动脉旁路移植术和颈动脉内膜剥脱术患者的资料,共计44例,男性36例,女性8例,年龄37~75岁,平均年龄(64±8)岁。42例不稳定性心绞痛,2例心肌梗死。32例合并高血压,16例合并糖尿病,4例并发陈旧性心肌梗死,1例合并陈旧性脑梗死病史。冠状动脉造影显示:4例2支病变,40例3支病变。颈动脉超声提示:27例双侧病变,17例单侧严重变,术中均先行CEA再行OPCABG。结果:手术患者术后住院期间死亡1例,为术后心肌梗死;1例患者术后住院期间发生短暂性脑缺血发作;1例于术后1年内死亡,死亡原因不明;2例术后1年内再次行CEA,均为双侧重度狭窄患者;2例术后随访1~2年内发生脑梗死。余39例术后随访时间6个月~6年,复查无神经系统事件及心肌梗死事件。结论:同期行OPCABG和CEA治疗冠心病合并颈动脉狭窄疾病安全、有效,近期及中期随访效果良好。     

Predictive value of asymptomatic cervical bruit for carotid artery disease in coronary artery surgery revisited

OBJECTIVE: To investigate the predictive value of asymptomatic cervical bruit for detecting internal carotid artery disease in consecutive patients undergoing coronary artery bypass grafting (CABG). DESIGN: A prospective cohort study. SETTING: Tertiary referral university hospitals. PATIENTS: 153 consecutive patients (mean age 57 years) undergoing CABG, without previous history of cerebrovascular events. INTERVENTIONS: Patients underwent detailed pre-operative work-up, including coronary angiography and carotid artery duplex scanning. Internal carotid artery diameter stenosis was graded as A: normal; B: < 15%; C: 15%-50%; D: 50-80%; D+: > 80-99% and E=complete occlusion. RESULTS: 72 patients (47.1%) (95% CI: 39%, 55%) had no evidence of internal carotid artery stenosis; 81 (52.9%) (95% CI: 44.9%, 60.9%) had varying grades of disease, unilateral or bilateral. Cervical bruit was detected in 12/153 patients (7.8%) (95% CI: 3.5%, 12.1%) of whom all but one (0.7%) had varying grades of internal carotid artery disease; of these, 4 patients had bilateral cervical bruit (2.6%) (95% CI: 0.06%, 5.2%). The sensitivity, specificity, positive and negative predictive values and overall accuracy of cervical bruit for detection of > or = 50% internal carotid artery stenosis were 23.5%, 95.8%, 25%, 95.5% and 91.8%, respectively. The relative risk of > or = 50% stenosis ipsilateral to cervical bruit in 306 sides was 5.58 (95% CI: 2.0, 15.0) and the odds ratio 7.1 (95% CI: 2.0, 25.0). CONCLUSIONS: Asymptomatic cervical bruit proved a highly specific clinical sign for detection of internal carotid artery stenosis, whether haemodynamically significant (> or = 50%) or otherwise, in patients undergoing myocardial revascularisation. This was matched by a high negative predictive value and overall accuracy for flow limiting atheroma (> or = 50% stenosis). Yet, steering carotid investigations on the basis of cervical bruit alone would result in > or = 80% internal carotid artery stenosis remaining undetected in 3% of overall patients, in whom cervical bruit is absent.     

Hybrid技术治疗冠心病合并严重颈动脉狭窄的临床疗效及安全性研究

目的回顾性分析颈动脉支架术(CAS)和冠状动脉旁路移植术(CABG)同期或分期Hybrid技术治疗冠心病合并严重颈动脉狭窄的临床疗效及安全性。方法入选2008年7月至2014年9月期间中国医学科学院阜外医院成人心脏外科收治的同期或分期实施CAS和CABG的冠心病合并严重颈动脉狭窄患者274例,依据两种手术是否同期实施分为两组:同期手术组(间隔≤7 d,n=35)和分期手术组(间隔7 d,n=239)。对两组患者的临床资料及预后进行比较分析。结果与同期手术组相比,分期手术组患者的搭桥数量、颈动脉支架植入个数以及肾动脉支架植入个数显著增加,而呼吸机辅助时间显著减少,差异均具有统计学意义(P0.05)。中位随访时间为45.6(28.1~65.4)个月,随访期间仅1例患者发生脑卒中而死亡。两组患者围手术期不良事件发生率间差异无统计学意义(P0.05)。截至随访终期,Cox模型分析结果显示,是否同期手术与患者复合终点事件发生率无明显相关性(OR=0.679,95%CI:0.12~3.72;P=0.66)。结论 CAS联合CABG是治疗冠心病合并严重颈动脉狭窄的一种安全、有效的微创策略。     

Concurrent coronary and carotid artery surgery: factors influencing perioperative outcome and long-term results.

AIMS: To assess risk factors for early and late outcome after concurrent carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG). METHODS AND RESULTS: Records of all 311 consecutive patients having concurrent CEA and CABG from 1989 to 2002 were reviewed, and follow-up obtained (100% complete). In the group (mean age 67 years; 74% males), 62% had triple-vessel disease, 57% unstable angina, 31% left main coronary stenosis, 19% congestive heart failure, and 35% either a history of vascular procedures or existing vasculopathies. Preoperative assessment revealed transient ischaemic attack in 16%, stroke in 7%, and bilateral carotid disease in 20%. There were 7% emergent and 19% urgent operations, and ascending aorta was described as atheromatous or calcified in 21%. Hospital death occurred in 19 patients, myocardial infarction in seven, and permanent stroke in 12. Significant multivariable predictors of hospital death were aortic calcifications, coexisting vasculopathy, and emergent procedure. Significant predictors of postoperative stroke were calcified or dilated aorta, and of prolonged hospital stay were advanced age, unstable angina, and coexisting vascular disease. For hospital survivors, 10-year actuarial late event-free rates were: death, 50%; myocardial infarction, 84%; stroke, 93%; percutaneous angioplasty, 95%; redo CABG, 98%; and all morbidity and mortality, 48%. Significant multivariable predictors of late deaths were coexisting vasculopathy, age, renal insufficiency, previous cardiac surgery, tobacco abuse, calcified or atheromatous aorta, and duration of intensive care unit stay. CONCLUSION: Concurrent CEA and CABG can be performed with acceptable operative mortality and morbidity, and good long-term freedom from coronary and neurologic events. Atheromatous aortic disease is a harbinger of poor operative and long-term outcome.     

Indications for carotid artery surgery and stent: The role of carotid ultrasound

Carotid artery disease is the most frequently identified cause of ischemic stroke and is mostly due to atherosclerotic disease. Landmark trials have demonstrated that surgical intervention in cases of high-grade carotid stenosis can reduce the risk of subsequent stroke. Endovascular approaches continue to be evaluated in ongoing trials. Careful patient selection is critical if the potential benefits of carotid revascularization are to be realized. Ultrasound is a safe, accurate, readily available method to evaluate carotid artery disease. The degree of stenosis is the parameter most frequently used to make decisions about therapeutic approaches. Plaque characteristics may also be useful for identifying high-risk patients. Microembolic signals detected by transcranial Doppler ultrasound can identify cerebral embolization before or after carotid intervention. This review discusses the current clinical role of carotid ultrasound in the selection of patients for the two most frequently used carotid interventions: carotid endarterectomy or carotid angioplasty and stenting.     

Staged carotid artery stenting and coronary artery bypass graft surgery: initial results from a single center.

The objective of this study was to assess the clinical course of patients undergoing planned percutaneous carotid stenting followed by staged coronary artery bypass grafting (CABG). Coexisting carotid and coronary atherosclerotic disease is relatively common. A combined or staged surgical approach has a composite stroke, myocardial infarction, or death rate of > 10%. We performed a retrospective search of our single-institution database to identify all patients scheduled to undergo staged carotid stenting followed by CABG. Twenty-three such patients (17 males, 6 females) were identified, with 3/23 (13%) requiring bilateral carotid stenting. Most carotid lesions were asymptomatic (18/26; 69.2%) and severe (mean stenosis, 82.9% 6+/- 8.6%). Stents were successfully placed in 26/26 carotid arteries (100%). One stent procedure (1/26; 3.8%) resulted in a minor stroke, but full recovery occurred within 1 week. There were no other peri-stenting complications. Three patents (3/23; 13%), none of whom suffered an adverse event at carotid stenting, elected not to undergo CABG. The mean interval from last carotid stent to CABG was 69.6 6 +/- 39.6 days (range, 8-157 days). Antiplatelet therapy was ceased > 3 days prior to CABG in 10/20 patients (50%), but continued until surgery in the remainder. There were no peri-CABG bleeding or neurological complications, but one myocardial infarction occurred (1/20; 5%). Therefore, of the 20 patients who underwent planned carotid stenting followed by CABG, our overall rate of death, stroke, or myocardial infarction was 10%. However, our rate of death, persistent stroke or myocardial infarction was 5%. Planned carotid stenting followed by staged CABG is a viable method of treatment for patients with coexistent carotid and coronary atherosclerosis.     

Scanner and carotid artery surgery

The utility of CT scan imaging in patients with hemispheric cerebrovascular accidents suspected of being of carotid artery origin was investigated by analysis of case reports of 57 patients treated recently. A low density image was found in 38.5% of cases, superficial and deep localizations being of equal number. A silent infarct was detected in 13.6% of the patients and a meningioma was able to be diagnosed by the scanner. CT scan imaging is indispensable for care of these patients: --dissuasive in case of cerebral tumor, severe infarction or extensive cerebral destruction; --persuasive in case of major carotid artery lesions and/or those threatening with normal scanner image. Carotid artery surgery can then protect cerebral capital; --directive in case of "watershed" infarct, of enhancement, of silent infarct or an occurring accident. In all such cases, it appears indispensable.     

Concurrent coronary and carotid artery surgery: an open debate: reply

We read with interest the letter from Barili et al. onour work ‘Concurrent coronary artery surgery: factorsinfluencing perioperative outcome and long-term results’.¹We thank Barili et al. for their comments that need ourreply. First, we share their doubts regarding the precise impact ofasymptomatic carotid artery stenosis     

Prophylactic digitalization for coronary artery bypass surgery.

One hundred and twenty patients undergoing aortocoronary bypass procedures were randomly placed into control and digitalized groups. All were initially in normal sinus rhythm and without evidence of congestive heart failure. Supraventricular arrhythmias occurred in 17 of 66 controls and in only three of 54 digitalized patients (P less than 0.01). There was no evidence of digitals toxicity. Based on this evidence we recommend prophylactic digitalization for patients having aortocoronary bypass operations.     

Asymptomatic coronary artery disease and coronary bypass surgery.

The actuarial survival curves of "medically treated" patients whose arteriographic studies demonstrated coronary arterial lesions of various degrees-- now used widt applicable to the asymptomatic patient. No information is available regarding the course or prognosis of the asymptomatic patient with demonstrated lesions in the coronary arteries. For the reasons explained one can propose a hypothesis that the overall prognosis of this type of patient is better than average, probably better than that shown in the best data collected on symptomatic patients. The prophylactic value of aortocoronary bypass operations in preventing myocardial infarction and death has not been established. One can therefore question the justification for the wide case-finding effort of subjecting asymptomatic persons to coronary arteriography, even in light of the low risk of this procedure, unless unusual findings suggest an especially poor prognosis (one example might be past myocardial infarction in a very young patient). Although there are exceptional instances when prophylactic surgery is indicated for asymptomatic patients, further investigation of this subject is needed before the procedure becomes generally accepted.