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Management of patients with carotid bruit undergoing cardiopulmonary bypass
Insights
Patients with asymptomatic carotid bruit undergoing cardiac procedures can safely skip carotid endarterectomy. Ultrasonic screening is sufficient, avoiding unnecessary arteriography and reducing risks associated with cardiac surgery.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Surgery
Background:
- Carotid bruit can indicate internal carotid artery stenosis.
- Patients undergoing cardiac procedures may have coexisting carotid artery disease.
- The risk of neurological events during cardiopulmonary bypass in patients with carotid bruit is a concern.
Purpose of the Study:
- To evaluate the safety of cardiopulmonary bypass in patients with asymptomatic carotid bruit.
- To determine the necessity of carotid endarterectomy or arteriography prior to cardiac procedures in patients with carotid bruit.
Main Methods:
- Screening of 1,433 cardiac patients for carotid bruit over 31 months.
- Ultrasonic carotid duplex scans for 94 patients with bruit to assess internal carotid artery stenosis.
- Analysis of neurological events in relation to carotid bruit, stenosis severity, and interventions.
Main Results:
- No focal neurological events occurred in 82 patients with asymptomatic carotid bruit, regardless of stenosis severity.
- One neurological death occurred in a subset of 9 patients with symptomatic bruit, significant stenosis, and prior endarterectomy.
- Nine (0.7%) focal neurological events occurred in 1,339 patients without carotid bruit.
Conclusions:
- Asymptomatic patients with or without hemodynamically significant carotid stenosis can safely undergo cardiopulmonary bypass without prior carotid endarterectomy.
- Ultrasonic carotid duplex scanning is adequate for screening asymptomatic patients with carotid bruit before cardiac procedures.
- Arteriography is not required for asymptomatic patients with carotid bruit prior to cardiopulmonary bypass.
Abstract:
During a 31 month period, 1,433 consecutive patients undergoing cardiac procedures were screened for carotid bruit. A total of 94 patients with carotid bruit were identified who had ultrasonic carotid duplex scans. Nine patients had a history of transient ischemic attack, carotid bruit, and reduction in internal carotid artery diameter by greater than or equal to 50% according to ultrasonic carotid duplex scanning. All nine patients underwent carotid angiography followed by thromboendarterectomy prior to or simultaneous with cardiopulmonary bypass. There was one neurological complication leading to death in this subset. Sixteen patients with asymptomatic carotid bruit had ultrasonic carotid duplex scanning revealing an internal carotid artery lesion of greater than or equal to 50% but did not undergo arteriography or thromboendarterectomy prior to the cardiac procedure. Perfusion pressure was maintained at greater than or equal to 70 mm Hg during bypass. There were no focal neurological events in this subset. Sixty-six patients with internal carotid artery stenosis of less than 50% diameter reduction and asymptomatic bruits had no further work-up or modification in perfusion technique, and there were no focal neurological events in this group. Thus there were no focal neurological events in any of the 82 patients with asymptomatic carotid bruit. An additional group of three patients with a previous stroke and internal carotid artery occlusion by ultrasonic carotid duplex scanning had transient exacerbation of neurological symptoms after cardiopulmonary bypass. The remaining 1,339 patients without carotid bruit had nine (0.7%) focal neurological events postoperatively. We believe that asymptomatic patients with or without hemodynamically significant stenosis can safely undergo cardiopulmonary bypass procedures without carotid thromboendarterectomy. Patients with asymptomatic bruits can be safely screened with ultrasonic carotid duplex scanning and do not require arteriography prior to cardiopulmonary bypass.