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Bilateral Common Carotid Artery Occlusion as an Adequate Preconditioning Stimulus to Induce Early Ischemic Tolerance to Focal Cerebral Ischemia
Published on: May 9, 2013
Is an integrated approach warranted for concomitant carotid and coronary artery disease?
T J Takach1, G J Reul, D A Cooley
1Department of Cardiovascular Surgery, Texas Heart Institute, Houston 77225-0345, USA.
Insights
Simultaneous treatment of coronary and carotid artery disease shows similar outcomes to staged approaches, especially since 1986. Advances in cardiac care have improved safety for both methods in managing these complex vascular conditions.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Interventional Cardiology
Background:
- Management of severe, combined coronary and carotid artery occlusive disease presents a clinical challenge.
- Controversy exists regarding the optimal surgical strategy for these patients.
Purpose of the Study:
- To compare outcomes of simultaneous versus staged surgical treatment for patients with concomitant coronary and carotid artery occlusive disease.
- To identify predictors of adverse outcomes in this patient population.
Main Methods:
- A retrospective analysis of 512 patients undergoing coronary revascularization between 1975 and 1996.
- Patients were divided into two groups: simultaneous coronary revascularization and carotid endarterectomy (Group 1) or staged approach (Group 2).
- Outcomes including stroke, death, and myocardial infarction were compared between groups, with analysis stratified by year (before and after 1986).
Main Results:
- Before 1986, Group 1 had significantly higher rates of stroke and death compared to Group 2.
- Since 1986, outcomes for stroke, death, and myocardial infarction were similar between the simultaneous (Group 1) and staged (Group 2) treatment approaches.
- Heart-related factors such as reoperation, intra-aortic balloon use, low ejection fraction, and severe angina were predictors of death; older age and heart failure predicted stroke.
Conclusions:
- Contemporary surgical results suggest that a staged treatment approach offers no advantage over simultaneous treatment for severe, concomitant coronary and carotid artery occlusive disease.
- Improvements in myocardial protection and perioperative hemodynamic management likely contribute to the reduced incidences of stroke and death observed in recent years.
Background:
The management of patients with severe, concomitant coronary and carotid artery occlusive disease is controversial.
Methods:
Between 1975 and 1996, 512 patients (mean age, 64.9 years; 70% male) were admitted for coronary revascularization; 316 (61.7%) had asymptomatic, severe carotid disease (stenosis > 70%) and 196 (38.3%) had symptomatic carotid disease (159 [31.1%] with transient ischemia and 37 [7.2%] with completed stroke). In group 1, coronary revascularization and carotid endarterectomy were simultaneously performed in 255 patients (49.8%) with unstable angina. In group 2 (staged approach), carotid endarterectomy was performed before coronary revascularization in 257 patients (50.2%) without unstable angina.
Results:
Before 1986, the incidence of stroke and death was greater in group 1 (n = 149) than in group 2 (n = 156) (14 [9.4%] versus 4 [2.6%]; p < 0.01). Since 1986, outcomes in group 1 (n = 106) and group 2 (n = 101) have been similar for stroke (2 [1.9%] versus 2 [2.0%]), death (4 [3.8%] versus 3 [3.0%]), and myocardial infarction (4 [3.8%] versus 5 [5.0%]). Significant univariate and multivariate predictors of adverse outcome were primarily heart-related (reoperation, intraaortic balloon use, ejection fraction < 0.50, and angina grade 4 for death; age > 70 years and congestive heart failure for stroke).
Conclusions:
Despite highly selected populations, contemporary surgical results do not indicate that staged treatment of severe, concomitant coronary and carotid artery occlusive disease has an advantage over simultaneous treatment. Advances in myocardial protection and perioperative hemodynamic management may account for the low incidences of stroke and death in these operations.
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