Strokes after cardiac surgery and relationship to carotid stenosis

Treatment of carotid stenosis before coronary surgery

strokes after cardiac surgery and relationship to carotid stenosis

revascularization decreases the risk of post-CABG neurologic events. Although carotid artery stenosis is a known risk factor for perioperative stroke in patients undergoing .. Strokes after · cardiac surgery and relationship to carotid stenosis. Combined Cardiac and Carotid Artery Stenosis will be consulted more frequently than in the past to assess the risk of stroke related to surgical .. Stroke after CABG surgery is associated with advanced age, probably related to increased. Among patients undergoing cardiac surgery, post-operative stroke Strokes After Cardiac Surgery and Relationship to Carotid Stenosis.

A staged surgical approach is recommended. Stenting of carotid arteries represents a less invasive alternative for high-risk surgical patients. Background Atherosclerosis is a systemic disease and typically affects multiple arterial beds within the same patient.

These individuals may be at an increased risk for stroke [1]. Conversely, significant coronary artery disease occurs in nearly one third of patients with high-grade carotid stenosis who are being considered for carotid endarterectomy [2].

The incidence of perioperative stroke in patients with carotid atherosclerosis ranges from 2. The stroke risk is highest among patients with previous stroke or ischemic attack. The risk also correlates with the severity of the underlying carotid atherosclerosis. Naylor and co-workers showed that the odds ratio of occurrence of stroke after cardiac surgery is at 4. Therefore, the coexistence of severe carotid artery stenosis and symptomatic coronary artery disease represent a serious treatment dilemma.

strokes after cardiac surgery and relationship to carotid stenosis

Namely, the operative repair of one arterial bed is related to a substantial risk for complication from the other. In patients with a coexistence of severe carotid and coronary artery disease, the sequence for the treatment of coronary and carotid revascularisation procedures also remains controversial. Stroke during cardiac surgery has several mechanisms and carotid stenosis is only one of them. There is evidence that the stroke risk during CABG related to carotid atherosclerosis may have been over-estimated.

Even in individuals with carotid atherosclerosis, stroke during CABG is more likely to result from other sources than from carotid stenosis such as cardiac emboli or significant atheroma in the ascending aortic arch [6]. Furthermore, two-thirds of strokes occurred after an uneventful initial recovery from surgery, suggesting that hemodynamic failure during the operation is of minimal causal role [7].

A study of Wolman and co-workers has identified that all major predictors of perioperative stroke are related to the presence of intracardiac thrombus or aortic atheromatous plaque [9]. This finding is important, as nearly half of all patients with carotid atherosclerosis have severe aortic disease as well. These data indicate that in surgical patients with asymptomatic carotid atherosclerosis other risk factors are often responsible for perioperative stroke and not carotid stenosis.

The risk for stoke in CABG patients is also related to operative duration and postoperative atrial fibrillation [7]. Therefore, revascularisation of asymptomatic carotid stenosis is unlikely to completely abolish the risk for perioperative stroke, particularly in patients with advanced cardiac and aortic atherosclerotic disease. One of the options is also combined carotid endarterectomy and CABG; however this type of treatment is related to high stroke and death rates of 7.

Patients who have undergone carotid endarterectomy before CABG are also at higher risk for complications. The carotid endarterectomy guidelines report that the incidence of stroke, myocardial infarction and death is In spite of that, recent meta-analysis concluded that there is no significant difference in outcome for staged or synchronous procedures [13].

The European Society of Vascular Surgery ESVS Guidelines recommend as appropriate management of patients with concomitant severe coronary and carotid artery disease an individualised surgical approach [14]. Therefore, because of high operative complication rate, benefit from carotid surgery separate or in combination with CABG is expected only in high risk groups and these high complication rates would clearly offset the long-term benefit from secondary stroke prevention.

A few small studies have shown that the complication rate in patients who have undergone carotid angioplasty and stenting followed by CABG is significantly lower than in patients who have undergone combined carotid endarterectomy and open heat surgery [15].

Similarly, a meta-analysis of day outcome following staged carotid artery stenting before coronary bypass surgery showed that carotid artery stenting plus CABG is an attractive and less invasive alternative to carotid endarterectomy plus CABG [16].

Although the number of reported studies and included patients are so far small, the data support validity of stenting particularly in high-risk surgical patients. Patients with carotid occlusive disease who undergo CABG are at high risk for perioperative stroke. Patients and Methods One hundred consecutive patients 70 male and 30 female underwent simultaneous open-heart surgery and carotid endarterectomy CEA in our institution during 5-year period to At the same time, isolated carotid artery surgeries were performed.

Strokes after cardiac surgery and relationship to carotid stenosis.

The clinical data and the outcome were retrospectively reviewed and analysed. The study was performed according to the regulations of the local ethics committee. The diagnosis of the carotid stenosis was confirmed by Doppler sonography, duplex, and angiography computed tomography, magnetic resonance, or rarely selective angiography. Cardiac diagnostics included echocardiography and coronary angiography. Indications for cardiac surgery depended on clinical symptoms and the severity of underlying diseases, e.

The criteria for concomitant carotid surgery were as follows: Carotid surgery was performed before cardiac procedure. At least one of the following techniques of neuromonitoring was applied: An oblique cervical incision was made and the carotid arteries were isolated.

Carotid Artery Disease

The surgical technique of carotid surgery was according to the decision of the surgeon. In case of patch plasty a longitudinal incision was performed in the common carotid artery and extended to the internal carotid artery beyond the distal extent of the plaque.

Treatment of carotid stenosis before coronary surgery

In case of eversion technique, transection of internal carotid artery was performed at the level of the bifurcation. In both cases, the atherosclerotic plaque was removed in a standard fashion. After carotid artery surgery, cardiac surgery started.

strokes after cardiac surgery and relationship to carotid stenosis

In case of coronary artery bypass grafting CABG and scheduled use of venous grafts, harvesting of the saphenous vein was performed simultaneously to the carotid surgery. Mostly, the distal venous graft anastomoses were first performed followed by the valvar procedure, then the anastomosis of left thoracic artery graft, and finally the proximal anastomoses. After completing the cardiac surgery, anticoagulation was reversed by protamine sulphate.

Then, drainages were placed and the wounds were closed. Postoperatively, patients received heparin 6 to 8 hours after surgery if there is no bleeding and aspirin from the first postoperative day onwards.

strokes after cardiac surgery and relationship to carotid stenosis

Early death or early neurologic deficit was defined as an event within 30 days postoperatively. Mean age was In most cases, severe coronary artery disease was the underlying cardiac pathology 73 patients; Table 1. Cardiac operations performed simultaneously with carotid surgery.

strokes after cardiac surgery and relationship to carotid stenosis

Unilateral carotid stenosis was present in 49 cases, bilateral stenosis was found in 39, and the contralateral carotid artery was occluded in 12 cases Figure 1. Thirteen patients suffered a stroke preoperatively.

Risk and Outcome after Simultaneous Carotid Surgery and Cardiac Surgery: Single Centre Experience

Distribution of carotid stenosis. Most patients suffered from either bilateral stenosis of carotid arteries or stenosis with occlusion of the contralateral artery. There was one stroke-related death, however, caused by multiple cerebral emboli of the posterior region. During surgery, two of these patients needed mechanical circulatory support: Table 2 presents some of the important clinical data of the early deaths.

  • Strokes after cardiac surgery and relationship to carotid stenosis.
  • Strokes after cardiac surgery and relationship to carotid stenosis.
  • Strokes After Cardiac Surgery and Relationship to Carotid Stenosis

The mean logistic EURO-score of early deaths was The first patient had a postoperative transient cerebral ischemia but recovered soon after surgery without long-term complications.

The second patient had a stroke with permanent neurological deficit Table 3 but his condition improved after neurological rehabilitation retaining a mild residual deficit Rankin level 2. Clinical data of patients who died after combined surgery within 30 days. Clinical data of patients with neurological complications after combined carotid and cardiac surgery.

The cause of brain injury in conjunction with cardiac surgery is multifactorial [ 1 ]. Thromboembolic material, air bubbles, or ruptured calcifications are the main causes of stroke but prolonged intraoperative and postoperative hypotension may increase the risk of stroke as well, due to reduction of cerebral perfusion behind carotid artery stenosis during CPB. However, relief of carotid stenosis decreases neurologic complications after cardiac surgery [ 1314 ].

The prerequisite for this is, however, that no complication has occurred during carotid surgery. The margin between the benefit and the complication of carotid surgery is narrow.

And although the problem of concomitant carotid stenosis in patients undergoing open-heart surgery is well known, the best strategy remains controversial. Current guidelines recommend carotid revascularization in symptomatic patients undergoing coronary artery bypass grafting CABG [ 15 ]. There is still no consensus for optimal management of patients undergoing other cardiac procedures than CABG and for asymptomatic patients.