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Extracorporeal circulation as an additional method for cerebral protection in simultaneous carotid endarterectomy and
J P Guibaud1, X Roques, N Laborde
1Department of Cardiovascular and Pediatric Cardiac Surgery, Bordeaux Heart University Hospital, Bordeaux Pessac, France. jean.philippe.guibaud@chu-bordeaux.fr
Insights
Simultaneous carotid endarterectomy (CE) and coronary artery bypass grafting (CABG) is safe when CE is performed under extracorporeal circulation (ECC). This approach offers improved cerebral protection, especially for bilateral carotid stenosis.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Surgery
Background:
- Surgical management of patients with concurrent carotid and coronary artery stenosis is controversial.
- Simultaneous carotid endarterectomy (CE) and coronary artery bypass grafting (CABG) has been performed, with varying approaches regarding extracorporeal circulation (ECC).
Purpose of the Study:
- To compare the outcomes of simultaneous CE and CABG performed with CE prior to ECC versus CE performed under ECC.
- To evaluate the safety and efficacy of ECC in providing cerebral protection during combined CE and CABG procedures.
Main Methods:
- Retrospective review of 124 patients undergoing simultaneous CE and CABG between 1994 and 2001.
- Patients were divided into two groups: Group 1 (CE prior to ECC) and Group 2 (CE under ECC prior to CABG).
- Outcomes analyzed included hospital mortality, cardiac-related mortality, and neurologic events.
Main Results:
- Overall hospital mortality was 7.3%.
- Group 1 (CE prior to ECC) had higher mortality (9.2%) and neurologic event incidence (10.7%), with bilateral carotid stenosis being a significant risk factor for neurologic events.
- Group 2 (CE under ECC) showed lower mortality (5.1%) and significantly lower neurologic morbidity (1.7%), with no CE-related deaths.
Conclusions:
- Simultaneous CE and CABG is a necessary approach for significant carotid stenosis.
- Performing CE under ECC prior to CABG is a safe and effective strategy, offering enhanced cerebral protection, particularly in cases of bilateral carotid stenosis.
- Hypothermia (≤28°C) during carotid clamping under ECC is optimal for cerebral protection when cerebral blood supply is compromised.
Abstract:
Surgical management of patients with concomitant carotid and coronary artery stenosis remains controversial. Our policy was always to perform at the same time carotid endarterectomy (CE) and coronary artery bypass grafting (CABG), but it was also considered that extracorporeal circulation (ECC), because of full heparinization, hemodilution, pulsatile flow, and hypothermia could provide better cerebral protection during CE. Retrospective data of 124 patients undergoing simultaneous CE and CABGs between January 1994 and December 2001 were reviewed. CE was performed prior to ECC in 65 patients (Group 1-mean age: 70.4 years; sex ratio: 49 male/16 female) and under ECC, prior to CABGs in 59 patients (Group 2-mean age: 69.9 years; sex ratio: 46 male/13 female). Overall hospital mortality was 7.3% (9/124): cardiac-related in 5 patients, or due to septicemia (1 patient), or ARD syndrome (1 patient), or stroke in two others. Univariate analysis demonstrated overweight, unstable angina, and emergency to be significant risk factors. Bilateral carotid stenosis was a significant risk factor of neurologic event when CE was performed prior to ECC (p < 0.05). In Group 1, mortality was 9.2% (6/65), and the incidence of neurologic events was 10.7% (7/65), and was responsible for two of the early deaths in patients with bilateral carotid stenosis. In Group 2, mortality was 5.1% (3/59) but never related to CE, while the neurologic morbidity was 1.7% (1 transient ischemic attack). It is concluded that (1) hospital mortality in patients undergoing simultaneous CE and CABGs was mainly cardiac-related. (2) The combined approach of both localizations appears to be mandatory, when carotid stenosis, even asymptomatic, was hemodynamically significant, or with ulcerative lesions likely to be responsible for embolism. (3) CE, first performed under ECC, appears to be a safe procedure, combining, in terms of cerebral protection, the benefits previously called up. This approach is all the more interesting when carotid stenosis is bilateral; hypothermia < or = 28 degrees C during the carotid clamping time is obviously the optimal method for cerebral protection when ipsilateral or contralateral supply is reduced, or even absent.
