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Rapid-staged strategy for concomitant critical carotid and left main coronary disease with left ventricular
D E Allie1, M Lirtzman, A P Malik
1Cardiovascular Institute of the South, Columbia Medical Center of Southwest Louisiana, Lafayette 70596-1160, USA. paulr@globalreach.net
Insights
A rapid staged procedure using an intraaortic balloon pump effectively treated high-risk patients with critical carotid and left main coronary disease. This approach reduced complications and hospital stay, offering a safer alternative to traditional staged surgeries.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Interventional Cardiology
Background:
- Concomitant critical carotid artery stenosis and left main coronary artery disease with left ventricular dysfunction presents a high-risk surgical challenge.
- Traditional simultaneous or staged surgical approaches carry significant risks for this patient group.
Purpose of the Study:
- To evaluate the safety and efficacy of a rapid staging strategy using an intraaortic balloon pump (IABP) for patients with critical carotid and left main coronary disease.
- To decrease risks associated with simultaneous or traditional staged surgical interventions.
Main Methods:
- A cohort of 20 high-risk patients with severe left main coronary artery stenosis (>70%), reduced ejection fraction (<0.30), and severe internal carotid artery stenosis (>90%) were studied.
- An intraaortic balloon pump was immediately placed before carotid endarterectomy under angiographic guidance.
- Coronary artery bypass grafting was performed within 24 hours, with IABP removal on the day of surgery (total IABP duration <36 hours).
Main Results:
- Excellent early outcomes were observed, with 18/20 patients extubated on the day of coronary artery bypass grafting (mean 12 hours).
- 16/20 patients were discharged from the ICU within 48 hours, with a mean hospital stay of 8 days.
- No 30-day postoperative deaths, myocardial infarctions, or major neurologic/vascular complications occurred. Long-term follow-up showed sustained patency of operated carotid arteries.
Conclusions:
- A rapid staged procedure involving angiographically guided IABP placement is safe and effective for high-risk patients with combined carotid and coronary disease.
- This strategy may reduce operative risks and improve the efficiency and safety of carotid and coronary artery bypass grafting procedures.
Background:
Few reports address the high-risk patient population with concomitant critical carotid and left main coronary disease with left ventricular dysfunction. To decrease the risks involved with the simultaneous and traditional staged surgical approaches, we developed a rapid staging strategy using an intraaortic balloon pump.
Methods:
Between 1992 and 1996, 20 patients presented with a high-risk "triad" defined by greater than 70% stenosis of the left main coronary artery, ejection fraction less than 0.30, and greater than 90% stenosis of the internal carotid artery. An intraaortic balloon pump was placed immediately before carotid endarterectomy under angiographic guidance. Less than 24 hours later (mean, 18 hours) coronary artery bypass grafting was performed, and the intraaortic balloon pump was removed the day of coronary artery bypass grafting in all cases (total IABP duration, <36 hours).
Results:
Eighteen patients (18/20) were extubated on the day of coronary artery bypass grafting (mean, 12 hours). Sixteen patients (16/20) were transferred from the intensive care unit within 48 hours, with total hospital stay ranging from 6 to 12 days (mean, 8 days). There were no 30-day postoperative deaths, myocardial infarctions, or neurologic, vascular, bleeding, or other major complications. At a mean 29.4-month follow-up, there were two noncardiac deaths and no neurologic events. Six-month, 1-year, and 2-year follow-up ultrasounds showed all operative carotid arteries remained patent.
Conclusions:
A rapid staged procedure with angiographically guided placement of the intraaortic balloon pump was safe and effective in this very high risk patient population. It may be an option to decrease the risks involved with simultaneous operations and increase the efficiency and safety of "traditional" staged carotid and coronary artery bypass grafting procedures.
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