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[Simultaneous carotid endarterectomy and coronary artery bypass. when is it indicated?]
1Abteilung für Herz- und Gefässchirurgie am Universitätsklinikum Freiburg.
Insights
Simultaneous treatment of coronary heart disease (CHD) and carotid artery stenosis (CAST) carries risks. Neurologic deficits during surgery often stem from embolism, not severe carotid stenosis, suggesting limited benefit for combined procedures.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Surgery
Background:
- Concomitant coronary heart disease (CHD) and carotid artery stenosis (CAST) present a complex surgical challenge.
- Simultaneous correction of CHD and CAST is associated with increased perioperative risks.
- Neurologic deficits during cardiac surgery can arise from various sources, including extracorporeal circulation (ECC) and cardiac embolism.
Purpose of the Study:
- To evaluate the risk and necessity of simultaneous correction for patients with concurrent CHD and CAST.
- To investigate the role of carotid artery stenosis in causing neurologic deficits during open heart surgery.
- To define the specific indications for combined surgical intervention in patients with CHD and CAST.
Main Methods:
- Utilized Transcranial Doppler (TCD) to measure middle cerebral artery blood flow during open heart surgery.
- Compared flow measurements in patients with and without significant carotid artery lesions.
- Analyzed the incidence of new neurologic deficits in relation to surgical procedures and patient comorbidities.
Main Results:
- Transcranial Doppler measurements did not reveal significant flow reductions in the middle cerebral artery, even in patients with carotid lesions.
- The primary cause of new neurologic deficits during open heart surgery was identified as embolism, originating from ECC or the heart itself.
- High-grade carotid stenosis was not found to be a significant contributor to intraoperative neurologic events.
Conclusions:
- Simultaneous surgical correction of CHD and CAST is generally not indicated due to increased risk and lack of clear benefit.
- Neurologic complications during open heart surgery are more frequently attributed to embolic events than to pre-existing carotid stenosis.
- Combined surgical intervention for CHD and CAST should be reserved for highly selected cases, specifically those with severely unstable angina and symptomatic high-grade carotid stenosis.
Abstract:
In cases of concommitant coronary heart disease (CHD) and carotid artery stenosis (CAST) simultaneous correction has a higher risk. Transcranial Doppler flow measurements at the level of the arteria cerebri media did not detect any flow reduction during open heart surgery in patients with and without carotid lesions. New neurologic deficits during open heart procedures are mostly due to embolism from ECC or from the heart, rather than a high grade carotid stenosis. Simultaneous correction of CHD and CAST is only indicated in patients with severely unstable angina and symptomatic high grade stenosis of the carotid artery.