Concomitant subclavian and coronary artery disease

BACKGROUND: Proximal subclavian artery occlusive disease in the presence of a patent internal mammary artery used as a conduit for a coronary artery bypass graft procedure may cause reversal of internal mammary artery flow (coronary-subclavian steal) and produce myocardial ischemia. METHODS: We reviewed outcome to determine whether subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal. Between 1985 and 1997, 20 patients had either concomitant subclavian and coronary artery disease diagnosed before operation (group 1, 5 patients) or symptomatic coronary-subclavian steal occurring after a previous coronary artery bypass graft procedure (group 2, 15 patients). Patients in group 1 received direct subclavian artery bypass and a simultaneous coronary artery bypass graft procedure in which the ipsilateral internal mammary artery was used for at least one of the bypass conduits. Patients in group 2 received either extrathoracic subclavian-carotid bypass (5 patients, 33.3%) or percutaneous transluminal angioplasty and stenting (10 patients, 66.7%) as treatment for symptomatic coronary-subclavian steal. RESULTS: All patients were symptom-free after intervention. One patient treated with percutaneous transluminal angioplasty and stenting died of progressive renal failure. Follow-up totaled 58.5 patient-years (mean, 3.1 years/patient). In group 1, primary patency was 100% (mean follow-up, 3.7 years). In group 2, one late recurrence was treated by operative revision, yielding a secondary patency rate of 100% (mean follow-up, 2.9 years). CONCLUSIONS: Subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal with acceptably low operative risk. Midterm follow-up demonstrates good patency.     

Concomitant coronary and peripheral arterial disease: single-stage revascularization

Acute presentation of critical peripheral arterial ischemia in an unstable cardiac patient is a challenge to the surgeon. Coexistence of two entities is usually managed with a staged approach; however, decision to treat which entity first may be difficult clinically. We present a 49-year-old man with acute infrarenal aortic occlusion and cardiac ischemia who was treated with single-stage ascending aorta-bifemoral bypass following saphenous vein grafting to left anterior descending artery. Concomitant coronary and peripheral vascular revascularization is a practical method with a high flow inflow source as ascending aorta. We believe that a single-stage approach may be performed in the unstable patient as presented in this report.     

Concomitant severe carotid and coronary artery diseases: a separate management or concomitant approach

Objective: To systematically compare outcomes between patients with asymptomatic carotid artery diseases (>80% stenosis) that had undergone staged carotid endarterectomy (CEA) before coronary artery bypass grafting (CABG) vs simultaneous CEA and CABG. Methods: A comprehensive electronic search of MEDLINE, Scopus, EMBASE, and Ovid from their inception up till August 2018 was performed to identify all studies comparing staged CEA followed by CABG to simultaneous CEA and CABG. Primary outcome measure was postoperative stroke, and secondary measures were myocardial infarction (MI) and 30‐day mortality rates. Results: A total of 67 953 patients were analyzed from 11 articles. There was higher rate of previous stroke in the staged cohort (2.64% vs 2.32%; odds ratio [OR], 0.81; 95% confidence interval [CI; 0.66, 0.99]; P = .040). There was no difference in previous MI (P = .57) or unstable angina (P = .08) among both cohorts. Postoperatively, there were higher stroke rates (3.64% vs 2.83%; OR, 0.72; 95% CI [0.62‐0.89]; P < .0001), operative mortality (4.32% vs 3.58%; OR, 0.90; 95% CI [0.83‐0.98]; P = .02), and 30‐day mortality (4.40% vs 3.58%; OR, 0.86; 95% CI [0.78‐0.96]; P = .006) in the simultaneous cohort. However, length of stay was significantly shorter in the simultaneous cohort (11.9 days vs 12.6 days; weighted mean difference 3.14 [0.77‐5.51]; P = .009). There were no significant differences in 1‐year mortality (P = .33), MI rates (P = .08), and rates of transient neurological deficits (P = .06). Conclusion: The results from this study favors staged CEA with CABG with lower incidence of postoperative stroke, operative, and 30‐day mortality. A larger study, ideally a randomized controlled trial, is required to address the superiority of each technique.     

Concomitant coronary artery bypass and cholecystectomy: a case report

A case is reported in which simultaneous surgical correction of coronary atherosclerosis and cholelithiasis was performed. A 71-year-old man was admitted with severe stable angina and right hypochondrial dull pain. Coronary angiograms disclosed severe triple vessel disease, and abdominal echography demonstrated gallstone. He underwent bypass of left anterior descending, diagonal, obtuse marginal, and right coronary arteries with autogenous saphenous vein on cardiopulmonary bypass. The procedure was followed immediately by cholecystectomy. His postoperative course was uneventful.     

Concomitant surgical procedures for coronary artery disease and intraperitoneal double cancers: Report of a case

Concomitant surgical procedures for coronary artery disease and double cancers are reported. A 61-year-old man with severe triple-vessel coronary disease was found to have early gastric cancer and advanced rectal cancer. We successfully performed a concomitant coronary artery bypass graft using an extracorporeal ultrafiltration membrane and curative surgery for both cancers. Concomitant surgery thus appears to be a benefical and safe approach for the treatment of critical coronary artery disease and intraperitoneal double cancers in carefully selected patients.     

Concomitant cholecystectomy and coronary artery bypass.

INTRODUCTION AND METHODS: Cholelithiasis is a common disorder which may be present with coronary artery disease. Concomitant cholecystectomy and coronary artery bypass grafting (CABG) was performed in selected patients and retrospective study was performed to verify the safety of the concomitant surgery. RESULTS: A total of 55 patients (41 males and 14 females, mean age 64.6 8.7 years) underwent concomitant cholecystectomy and CABG between 1992 and 2001 at the Shin-Tokyo Hospital Group. Exclusion from concomitant surgery was choledocholithiasis and/or acute cholecystitis. Cholecystectomy was performed via an upper abdominal incision extending the mid-sternal incision. In 48 patients (87.3%), the gastroepiploic artery (GEA) was used for coronary revascularization. The mean number of bypass grafts was 3.6 1.2. The mean operative time, intubation period, ICU stay, and postoperative hospital stay were 376 minutes, 15.6 hours, 3.9 days, and 23.0 days, respectively. Postoperative feeding was resumed 1 day after extubation. No intra-abdominal complications, delays in feeding, abdominal wound complications or postoperative bowel obstruction were observed. CONCLUSIONS: Concomitant surgery of cholecystectomy and CABG did not increase the postoperative complications, and it is a feasible procedure of choice.     

Concomitant traumatic coronary artery and tricuspid valve injury: a heterogeneous presentation

Blunt thoracic trauma resulting in both tricuspid valve rupture and coronary artery injury is uncommon, encompasses a large spectrum of presentations and, therefore, can be difficult to diagnose. This report illustrates the heterogeneous presentation and clinical course of two patients with such a combination of cardiac injuries. The patient with associated right coronary artery dissection developed progressive right ventricular failure over a 12-year period before successful surgical repair, whereas another patient with left anterior descending coronary artery thrombosis required urgent operation for acute right ventricular dysfunction and hemodynamic decompensation.     

Management of coexisting coronary artery and asymptomatic carotid artery disease: report of a series of patients treated with coronary bypass alone.

BACKGROUND: A retrospective chart review of 94 patients with asymptomatic high-grade carotid stenosis undergoing coronary bypass (and valve replacement in some cases) was performed to determine whether significant carotid lesions can be safely ignored in patients undergoing cardiac surgical procedures. These operations were performed during a 2-year period. PATIENTS AND METHODS: There were 55 men and 39 women, with an age range of 37-89 years. Seventy-one patients had unilateral high-grade carotid stenosis, 17 patients had bilateral high-grade lesions, and six patients had unilateral high-grade stenosis and contralateral occlusion. Associated medical problems were recorded and short-term follow-up was obtained. RESULTS: There was one perioperative stroke and no deaths in this group of patients. CONCLUSIONS: Although these data indicate that high-grade carotid stenoses may be safely ignored during cardiac surgical procedures, a multicentre prospective randomized trial is needed to determine the appropriate treatment of the patient with coexisting carotid and coronary artery disease.     

Operative strategy in combined coronary and carotid artery disease

In the period between the opening of our heart center in November 1984 and May 1986, 2001 cardiac operations were performed with the aid of cardiopulmonary bypass. Almost three quarters (73.5%, n = 1471) of the patients had coronary artery disease and 20% (n = 359) had acquired valvular heart disease. In 47 of 1471 patients who underwent coronary artery bypass grafting, a simultaneous carotid endarterectomy was performed. They included 36 men and 11 women, aged between 51 and 78 years (mean 64 years). Preoperatively, 12 patients had cerebrovascular symptoms and 35 were neurologically asymptomatic. Twenty-three had unilateral carotid stenosis and 24 had bilateral or multiple vessel disease of the extracranial arteries. All except four patients had triple-vessel coronary artery disease. In three patients with aortic valve disease, coronary bypass, carotid endarterectomy, and aortic valve replacement were performed simultaneously. Cardiopulmonary bypass was instituted before carotid endarterectomy was performed, with mild hypothermia and hemodilution for added protection. Electroencephalographic monitoring was used throughout the operation. Forty-six of the 47 patients survived the operation without neurologic or cardiac complications. One patient had a neurologic deficit with hemiplegia and coma, which was lethal. We conclude that simultaneous endarterectomy of significant extracranial artery stenosis in candidates for coronary bypass is a method safe enough to justify its routine use.     

Surgical management of coronary artery stenosis and peripheral artery occlusive disease of the lower extremity in a patient with neurofibromatosis: Report of a case

We herein report the case of a patient demonstrating both coronary artery and peripheral artery occlusive disease with neurofibromatosis, which were successfully treated during the same session with coronary artery bypass graft surgery and a femoropopliteal bypass graft surgery procedure. The recognition of a possible association between neurofibromatosis and coronary artery and other vascular structures will further facilitate the successful surgery and clinical management of this rare clinical entity.     

Toward a rational management of concomitant carotid and coronary artery disease

BACKGROUND: Patients with angina undergoing carotid endarterectomy have a high perioperative mortality. Our aim was to assess the outcome of carotid endarterectomy in patients with concomitant coronary artery disease, in particular, to examine the timing of carotid endarterectomy and CABG. METHODS: A retrospective study was performed at a tertiary and secondary referral centre for cardiovascular disease. Over a five-year period 71 carotid endarterectomies and 6,590 coronary artery bypasses were performed. Significant (>70%) internal carotid stenoses were found in 35 (0.5%) patients due for CABG. Of these, 23 patients underwent Combined procedures (Carotid and CABG), 9 Reverse staged (CABG then Carotid), and 3 Prior staged carotid endarterectomies (Carotid then CABG). 36 other carotid endarterectomies were in patients evaluated cardiologically, but did not require CABG (Isolated group). Risk factors, 30 day perioperative outcome including hospital inpatient stay and early follow-up are reported. RESULTS: The Combined group 30-day perioperative mortality rate was 4.3% and permanent stroke rate 8.6%. There were no major complications in Reverse or Prior staged cases. Isolated group mortality was 2.7% with no strokes. Risk factors were more prevalent in the combined group; 56% previous myocardial infarction, 39% hypertension, 35% a history of raised cholesterol and 46% intermittent claudication. All cases were followed up for a mean of 18.4 months, with no carotid stroke related events. Overall hospital stay for staged patients was a mean 19.3 days (SE=2.4) days compared to mean 9.8 days for combined patients (SE=0.97, p<0.001). CONCLUSIONS: Patients with combined cardiac and carotid disease benefit from assessment of both systems in order to stage CABG and carotid endarterectomy. Risk factors were more prevalent in the combined group; a combined procedure offered a median difference of 8 days less hospital inpatient stay compared to the staged cases. Our experience suggests that carefully planned management of concomitant coronary and carotid disease can achieve better results.     

Exercise-induced ST depression in an asymptomatic population without coronary artery disease

Objectives. Exercise electrocardiogram (ExECG) in low risk populations frequently generates false positive ST depression. We aimed to characterize factors that are associated with exercise-induced ST depression in asymptomatic men without coronary artery disease. Design. Cycle ergometer exercise tests from 509 male firefighters without imaging proof of significant coronary artery disease were analysed. Analysed test data included heart rate at rest before exercise, and workload, blood pressure, heart rate, ST depression and ST segment slope at peak exercise. ST depression of >0.1?mV was considered significant (ST_dep). With a mean follow-up of 6.1?±?1.7 years, medical records were reviewed for cardiovascular diagnoses, hyperlipidemia and diabetes. Logistic regression analysis was used for risk assessment. Results. In total, 22% had ST_dep in ≥1 lead. Subjects with ST_dep were older than those with normal ExECG (p?dep was more common in extremity leads (9%) than in precordial leads (2%). ST_dep was categorized according to location (precordial/extremity) and slope direction into eight categories. Larger age-adjusted heart rate increase predicted ST_dep in seven categories (p?dep in five categories, predominantly where the ST slope was positive. Peak blood pressure and exercise capacity were both associated with ST_dep in few categories. We found no association between ST_dep and hypertension, hyperlipidemia or diabetes (all p?>?.05). Conclusions. In asymptomatic men with a physically demanding occupation and no coronary artery disease, both age and heart rate response were associated with ST depression, whereas common cardiovascular risk factors, blood pressure response and exercise capacity were not.     

Concomitant traumatic aortic valve and coronary artery injury

A 79-year-old man, who had sustained nonpenetrating chest trauma 1 month previously, was admitted for dyspnea. Echocardiography demonstrated prolapse of the noncoronary aortic cusp with severe regurgitation. Aortography showed no intimal flap in the ascending aorta. Coronary arteriography showed dissection extending from the left main trunk to the proximal circumflex artery. At surgery, no abnormalities were found in the aortic wall or around the left coronary ostium. Avulsion of the commissure between the right coronary cusp and the noncoronary cusp from its aortic wall attachment was detected. Aortic valve replacement and coronary artery bypass grafting were performed.