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Combined carotid and cardiac procedures: improved results and surgical approach
F Donatelli1, S Pelenghi, M Pocar
1Istituto di Malattie dell'apparato cardiovascolare e respiratorio, Universitá degli Studi di Milano, Ospedale Maggiore Policlinico, Milan, Italy.
Insights
Combined carotid endarterectomy and cardiac surgery is safe, preventing perioperative strokes in patients with significant carotid atherosclerosis and coronary artery disease. This approach offers economic advantages.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Surgery
Background:
- Cerebrovascular complications are a major concern after cardiac surgery, especially with carotid atherosclerosis.
- Perioperative stroke occurs in 14% of patients with significant carotid involvement.
- Carotid operations in patients with coronary artery disease (CAD) have high mortality rates.
Purpose of the Study:
- To evaluate the safety and efficacy of combined carotid endarterectomy and cardiac surgery.
- To assess the impact on perioperative stroke and mortality.
- To determine the economic viability of this combined approach.
Main Methods:
- Seventy patients with severe carotid stenosis underwent combined procedures.
- Procedures included coronary artery bypass grafts, valve replacements, and aneurysmectomies.
- Carotid endarterectomy was performed immediately before cardiopulmonary bypass.
Main Results:
- Seven perioperative deaths occurred, all cardiac-related.
- No perioperative strokes were observed in the study cohort.
- The combined approach was deemed safe and expeditious.
Conclusions:
- Carotid endarterectomy before cardiopulmonary bypass is a safe strategy for patients with combined cardiac and carotid disease.
- Meticulous monitoring and minimizing cerebral ischemia are critical for vasculopathic patients.
- This combined surgical approach may offer economic benefits over alternative treatments.
Abstract:
Severe cerebrovascular complications following cardiac surgical procedures remain a major concern, particularly in patients with significant carotid atherosclerotic involvement (14% of perioperative stroke). Operative mortality for carotid operations in patients with documented Coronary Artery Disease (CAD) may be as high as 20%. Seventy patients underwent combined operations (unilateral carotid stenosis > 70%, unilateral stenosis > 50% with ulcerated plaque or bilateral stenoses > 50%; and this also included patients with unilateral occlusion). Cardiac procedures were 69 coronary artery bypass grafts, four left ventricular aneurysmectomies, three aortic valve replacements and surgery on two mitral valves. Seven perioperative deaths occurred, which were all caused by cardiac events. There were no perioperative strokes. Carotid endarterectomy immediately before cardiopulmonary bypass is a safe and expeditious approach to coexisting significant cardiac and carotid disease. In our experience, technical details in monitoring and minimizing cerebral ischemia are possibly more crucial in these severe vasculopathic patients. Moreover, it is probably advantageous from an economic standpoint compared with other therapeutic treatments.