Preoperative carotid duplex scanning in patients undergoing coronary artery bypass grafting

Abstract Objective: The aim of this study was to determine the prevalence and risk factors of carotid artery stenosis (CAS) using carotid duplex ultrasound in patients undergoing coronary artery bypass grafting (CABG). Methods: This retrospective study was conducted between January 2017 and January 2018 and included 166 consecutive patients [130 males (78.31%), 36 females (21.69%); mean age: 64.25±9.78 years] who underwent elective and isolated CABG. Patients who had significant CAS (≥50% stenosis) were compared with patients who had non-significant CAS (<50% stenosis). Logistic regression analysis was applied across the selected parameters to identify risk factors for significant CAS. Results: Of all patients, 36 (21.68%) had CAS ≥50% and 8 (4.81%) had unilateral carotid stenosis ≥70%. Carotid endarterectomy/CABG was performed simultaneously in five (3.01%) patients. None of these patients had cardiac and neurological problems during the postoperative period. The overall incidence of cerebrovascular accident (CVA) after CABG was 1.20% (n=2). Age (P=0.011) and history of CVA (P=0.035) were significantly higher in the CAS ≥50 group than in the CAS <50 group. Significant CAS was identified as a risk factor for postoperative CVA (P=0.013). Conclusion: Age and history of CVA were identified as risk factors for significant CAS. Furthermore, significant CAS was identified as a risk factor for postoperative CVA. For this reason, carotid screening is recommended for patients undergoing CABG even in the absence of associated risk factors.

Comparison of early outcomes with three approaches for combined coronary revascularization and carotid endarterectomy

Abstract Objective: This study aims to compare three different surgical approaches for combined coronary and carotid artery stenosis as a single stage procedure and to assess effect of operative strategy on mortality and neurological complications. Methods: This retrospective study involves 136 patients who had synchronous coronary artery revascularization and carotid endarterectomy in our institution, between January 2002 and December 2012. Patients were divided into 3 groups according to the surgical technique used. Group I included 70 patients who had carotid endarterectomy, followed by coronary revascularization with on-pump technique, group II included 29 patients who had carotid endarterectomy, followed by coronary revascularization with off-pump technique, group III included 37 patients who had coronary revascularization with on-pump technique followed by carotid endarterectomy under aortic cross-clamp and systemic hypothermia (22-27ºC). Postoperative outcomes were evaluated. Results: Overall early mortality and stroke rate was 5.1% for both. There were 3 (4.3%) deaths in group I, 2 (6.9%) deaths in group II and 2 (5.4%) deaths in group III. Stroke was observed in 5 (7.1%) patients in group I and 2 (6.9%) in group II. Stroke was not observed in group III. No statistically significant difference was observed for mortality and stroke rates among the groups. Conclusion: We identified no significant difference in mortality or neurologic complications among three approaches for synchronous surgery for coronary and carotid disease. Therefore it is impossible to conclude that a single principle might be adapted into standard practice. Patient specific risk factors and clinical conditions might be important in determining the surgical tecnnique.

Morbi-mortalidad de la endarterectomía carotídea / Morbidity and mortality of carotid endarterectomy

La endarterectomía carotídea (EC) en adición al mejor tratamiento médico mostró reducción del riesgo de eventos cerebrovasculares en pacientes sintomáticos y asintomáticos con estenosis moderada-grave del vaso en ensayos clínicos en centros académicos con cirujanos altamente seleccionados. Las principales guías internacionales recomiendan que el procedimiento se realice en centros con morbi-mortalidad auditada menor al 6% para pacientes sintomáticos y 3% para asintomáticos. Evaluamos la morbi-mortalidad peri-procedimiento en nuestro centro. Esta fue definida como la presencia de accidente cerebrovascular, infarto de miocardio y/o muerte dentro de los 30 días de la cirugía. Se indicó el procedimiento en pacientes sintomáticos con estenosis > 50%. En pacientes asintomáticos o sintomáticos con estenosis ≤ 50% se decidió el tratamiento sobre una base caso por caso. Todos los pacientes fueron examinados por un neurólogo y un cardiólogo antes y después de la EC. Se utilizó en forma rutinaria monitoreo intraoperatorio con Doppler transcraneano en los pacientes con adecuada ventana ultrasónica. Se evaluaron 306 endarterectomías carotídeas. No se registraron muertes. La morbilidad perioperatoria fue de 2.6% tanto para individuos sintomáticos como asintomáticos. Estos índices se compararon favorablemente con informes de otros centros de Latinoamérica y Europa. En conclusión, este informe muestra que la EC puede realizarse en la práctica clínica cotidiana con morbi-mortalidad peri-procedimiento dentro de los niveles recomendados por las guías internacionales.

Clinical trials in academic centers with high selected surgeons have demonstrated the effectiveness of carotid endarterectomy (CE) in addition to best medical treatment in symptomatic and asymptomatic patients with moderate to severe stenosis. International guidelines recommend that the procedure should be done in centers with morbidity and mortality rates of less than 6% for symptomatic and 3% for asymptomatic patients. We evaluated the morbidity and mortality of CE in our institution. This was defined by the presence of stroke, myocardial infarction and/or death within 30 days of surgery. Surgery was indicated in symptomatic patients with stenosis greater than 50%. For asymptomatic or symptomatic patients with stenosis ≤ 50% treatment was decided on a case-by-case basis. All patients were examined by a neurologist with and a cardiologist before and after the procedure. Intraoperative monitoring with transcranial Doppler was routinely used in patients with adequate ultrasonic window. We evaluated 306 procedures. No deaths occurred. Perioperative morbidity was 2.6% for both, symptomatic and asymptomatic subjects. These numbers compared favorably with those reported by other centers in Latin America and Europe. In conclusion, CE can be performed in routine clinical practice with morbidity and mortality results within those recommended by international guidelines.

Carotid endarterectomy

Carotid endarterectomy should be considered for patients with symptoms of focal cerebral ischemia, when it can be performed with a combined morbidity and mortality below the annual risk of stroke (5 per cent). The experience with 815 carotid endarterectomies performed from 1979 to 1992 is presented. There were 530 (65 per cent) men and 285 (35 per cent) women of ages from 34 to 82 (median 65); risk factors included diabetes mellitus 196 (24 per cent), hypertension 554 (68 per cent), and smoking 570 (70 per cent). Clinical presentation consisted of transient ischemic attacks 464 (57 per cent), cerebral infarction with minimal neurological residual 228 (28 per cent), stroke in evolution 2 (0.2 per cent), and asymptomatic stenosis 121 (15 per cent). By Sundt's classification of medical risk the groups were: grade I, 106 (13 per cent); grade II, 350 (43 per cent); grade III, 357 (44 per cent); grade IV, 2 (0.2 per cent). All patients received endotracheal anesthesia. Thiopental (3-5 mg/kg) and lidocaine (1 mg/kg) were given for induction and at 15 minutes intervals during carotid cross-clamping. Intraluminal shunts were used in 14 (2 per cent). A conventional (open) endarterectomy was performed in 379 (46 per cent) and a limited endarterectomy (closed) in 436 (54 per cent). Complications included 8 (1 per cent) deaths, 24 (3 per cent) developed a major neurological deficit that persisted, 24 (3 per cent) had perioperative TIA's which resolved completely. Of the patients with preoperative neurological deficits, 32 (4 per cent) recovered. Therefore, at one month after surgery, 782 (96 per cent) were either as well or better than preoperatively.Of 483 (59 per cent) postoperative angiograms, 40 (5 per cent) showed an internal carotid artery occlusion. Six of these patients developed and immediate postoperative cerebral infarction and one died. Non-neurologic complications were: cardiac 40 (5 per cent), peripheral nerve 24 (3 per cent), and local wound problems 16 (2 per cent). A carotid endarterectomy can be performed safely when it is done with meticulous attention to detail and consistent surgical technique.