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Strategy for the reduction of stroke incidence in cardiac surgical patients
T H Wareing1, V G Davila-Roman, B B Daily
1Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
Insights
Screening for ascending aortic atherosclerosis (AAA) and carotid artery disease in cardiac surgery patients can reduce stroke risk. Aggressive surgical treatment for moderate to severe AAA and carotid disease is associated with lower stroke rates.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Medicine
Background:
- Ascending aortic atherosclerosis (AAA) and severe carotid artery disease are significant stroke risk factors in cardiac surgical patients.
- Coronary artery disease is highly prevalent in this patient population.
Purpose of the Study:
- To evaluate the impact of screening for AAA and carotid artery disease on stroke rates in patients undergoing cardiac surgery.
- To assess the effectiveness of aggressive surgical management for these conditions.
Main Methods:
- Intraoperative ultrasonography for AAA screening and carotid duplex scanning for carotid artery disease.
- Analysis of stroke and mortality rates in relation to the severity of AAA and carotid disease and treatment strategies.
- Comparison of stroke rates between patients with and without intervention for AAA and carotid disease.
Main Results:
- The overall 30-day stroke rate was 1.6% in 1,200 patients.
- Patients with no or mild AAA had a lower stroke rate (1.1%).
- Zero stroke rate was observed in patients undergoing ascending aortic replacement for moderate/severe AAA or combined carotid endarterectomy and cardiac surgery.
- Higher stroke rates were noted in patients with moderate/severe AAA who had minor interventions (6.3%) and those with severe carotid disease who did not undergo endarterectomy (18.7%).
Conclusions:
- Screening for AAA and carotid artery disease is crucial in cardiac surgical candidates.
- Aggressive surgical treatment of moderate to severe AAA and severe or symptomatic carotid artery disease significantly reduces stroke frequency.
- Proactive management of vascular disease in cardiac surgery patients improves neurological outcomes.
Abstract:
Atherosclerosis of the ascending aorta (AAA) and severe carotid artery disease are risk factors for stroke in cardiac surgical patients. Twelve hundred of a consecutive series of 1,334 patients 50 years of age or older having a cardiac operation were screened for the presence of AAA by intraoperative ultrasonographic scanning and for the presence of carotid artery occlusive disease (791 of 798 patients > or = 65 years of age and younger symptomatic patients) by carotid duplex scanning. Coronary artery disease was present in 88% of the patients. Patients with moderate or severe AAA (n = 231; 19.3% of the total) were treated by ascending aortic replacement (n = 27) or by modified, less extensive techniques (n = 168) to avoid the atherosclerotic areas. Thirty-three patients had combined carotid endarterectomy and cardiac operation. Thirty-day mortality and stroke rates for the 1,200 patients were 4.0% and 1.6%, respectively. The stroke rate was low (1.1%) among the 969 patients with no or mild AAA. It was zero among 27 patients with moderate or severe AAA who had ascending aortic replacement and among the 33 patients who had carotid endarterectomy. The stroke rates were higher for 111 patients with moderate or severe ascending aortic disease who had only minor interventions (6.3%) and for 16 patients with severe carotid artery disease who did not have carotid endarterectomy (18.7%). Screening for AAA and carotid artery disease and aggressive surgical treatment of moderate or severe AAA and severe or symptomatic carotid artery disease appears to reduce the frequency of stroke in older cardiac surgical patients.