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Evaluation and treatment of carotid stenosis in open-heart surgery patients
L Pillai1, I Z Gutierrez, G R Curl
1VA Medical Center, Buffalo, New York 14215.
Abstract:
Indications for identification and treatment of extracranial carotid artery disease in candidates for open-heart surgery (OHS) remain unsettled. We evaluated the efficacy of OPG-GEE screening and our nonrandomized use of carotid endarterectomy in 2312 OHS patients from 1975 to 1989. Data was analyzed using the chi 2 squared and Fisher's exact tests. OPG was performed in 1602/2312 (69%) of the patients. OPG was positive in 122/1602 patients (7.6%) and negative in 1480/1602 (92.4%) patients. Of the patients with positive OPG, 31 patients had insignificant carotid bifurcation disease, 32 patients had total internal carotid artery occlusion, and 59 patients had operable carotid bifurcation lesions. Selective use of angiography identified an additional 8 patients with operable carotid bifurcation lesions (total 67, 33 symptomatic and 34 asymptomatic). Overall stroke rate for 2312 patients was 40/2312 (1.7%) [30 day mortality rate 60/2312 (3.2%)]. Stroke incidence was significantly increased (P < 0.01) in patients with a positive OPG, 8/122 (6.60%) vs those with negative OPG (23/1480, 1.6%). However, it was most marked in patients with operable bifurcation lesions (6/67, 9.0%). Stroke was not increased in patients with carotid occlusion or positive OPG without significant carotid bifurcation disease (2/63, 3.20%). Carotid endarterectomy in patients with operable bifurcation lesions was associated with a decreased (P < 0.05) stroke rate after OHS (1/44, 2.30% vs 5/23, 21.7%). Our data suggests identification of significant carotid disease and carotid endarterectomy will decrease stroke after OHS.
Insights
Screening for extracranial carotid artery disease and performing carotid endarterectomy in open-heart surgery candidates significantly reduces stroke risk. This intervention is particularly beneficial for patients with operable carotid bifurcation lesions.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Surgery
Background:
- Indications for screening and treating extracranial carotid artery disease in open-heart surgery (OHS) candidates are not well-established.
- Extracranial carotid artery disease poses a risk for stroke during OHS.
Purpose of the Study:
- To evaluate the effectiveness of OPG-GEE screening and carotid endarterectomy in reducing stroke incidence in OHS patients.
- To determine the impact of carotid artery disease severity on stroke risk after OHS.
Main Methods:
- Retrospective analysis of 2312 OHS patients from 1975 to 1989.
- Utilized OPG-GEE for screening, followed by selective angiography.
- Carotid endarterectomy was performed selectively for operable lesions.
Main Results:
- Stroke incidence was significantly higher in patients with positive OPG-GEE screening (6.60%) compared to those with negative screening (1.6%).
- Patients with operable carotid bifurcation lesions had the highest stroke incidence (9.0%).
- Carotid endarterectomy in patients with operable lesions was associated with a significantly decreased stroke rate after OHS (2.30% vs 21.7%).
Conclusions:
- Identification of significant carotid artery disease via OPG-GEE screening is crucial for OHS candidates.
- Carotid endarterectomy in selected patients with operable carotid bifurcation lesions effectively reduces the risk of stroke following OHS.