Transcript Simultaneous Coronary Artery Bypass and Carotid Endarterectomy

Simultaneous Coronary
Artery Bypass and
Carotid Endarterectomy
Ye zhidong, Liu Peng
Department of Cardiovascular Surgery
China-Japan Friendship Hospital
Background
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Cardiovascular disease is No 1 which
threaten human
Multisystem atherosclerosis often seen
in clinic now
Patient suffer from combination of
ischemic heart disease and
cerebrovascular insufficiency increase
Incidence of MI ↑after CEA / incidence
of cerebral infarction ↑after CABG
Background
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Bernhard and colleagues first reported the
combined carotid and coronary artery
surgery in 1972
Since then about 100 article about this
combined operation reported
Byrne J and colleagues reported 758 cases
with low morbidity and mortality (3.1%)
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Combined carotid endarterectomy and coronary
artery bypass grafting in patients with
asymptomatic high-grade stenoses: an analysis
of 758 procedures. J Vasc Surg. 2006
Jul;44(1):67-72.
Background
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Though promising surgical results and
growing experience, CEA/CABG
remains controversial
– lack of consensus concerning
indications for combined procedures
 intraoperative techniques for brain protection
 sequence of operation
 outcome of the surgical treatment.
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Patients and Methods
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From January of 2001 to May of 2006, 18
patients underwent combined unilateral
carotid endarterectomy and CABG for severe
cerebrovascular and ischemic heart
Male 13, Female 5, Age ranged from 63-80
years old
Angiography were done for all cases to final
diagnose
Preoperative findings
New York Heart Association class
II
III
IV
Stable angina
Unstable angina
Previous myocardial infarction
Left main coronary artery disease
Double-vessel disease
Triple-vessel disease
No of patients
(%)
5(27.8)
12(66.7)
1(5.6)
12(66.7)
6(33.3)
2(11.1)
6(33.3)
2(11.1)
16(88.9)
Preoperative findings
No.of
patients(%)
Asymptomatic cervical bruit
3
Transient Ischemic Attacks (TIA)
12
Histories of stroke without neurologic symptoms
2
Residual neurologic symptomatology secondary to stroke.
1
Risk Factors Observed
Risk Factors
Hypertension
Hypercholesterolemia
Diabetes mellitus
Cigarette smoking
No. of Patients (%)
14 (77.8)
10 (55.6)
9 (50)
9 (50)
Severity of Extracranial
Cerebrovascular Disease
Carotid Stenosis
No. of Patients (%)
Occlusion with contralateral stenosis
>70%
2(11.1)
Unilateral stenosis >70%
with contralateral stenosis <50%
Unilateral stenosis>90%
Unilateral ulcerative plaque
with <50% stenosis
10(55.6)
5(27.8)
1(5.6)
Type of Operations
Type of procedure
No.of patients
CEA→CABG
CABG→CEA
Pump-on CABG
Off-Pump CABG
Using shunt
Using Patch
Femoral-Femoral bypass
17
1
5
13
18
18
1
Surgical technique
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General anesthesia
CEA completed first (except 1 case)
– 1mg/kg heparin
– Shunt implantation
– Patch closure running suture
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Pump on CABG for 5 cases
– CPB started with 28℃
– Cold blood cardioplegia
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Off-pump CABG for 13 cases
Results
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There was no death in our series
There were no cerebrovascular complications occur
in our series
One case developed reversible facial nerve injury
Others
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–
–
–
–
paroxysmal ventricular tachycardia,
supraventricular tachycardia
respiratory failure
renal insufficiency
hypertension
Follow up
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Follow-up period ranged from 3-36 months
By telephone or out-patient department
Questionnaire or ECG/Doppler
No cerebrovascular accident /TIA/angina
occur
One case performed femoral-femoral bypass
1 month after CEA/CABG
Discussion: indications
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CEA
– Asypmtomatic carotid stenosis >90%
– Sypmtomatic carotid stenosis >70%
– Ulcer plaque related to ITA
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CABG
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Left main trunk stenosis of coronary A
Triple vessel disease
Unstable angina pectoris
Impaired heart function due ischemic heart
Discussion
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Shunt and Patch
Off-pump or On-pump
Intimal flap fixation
IABP standby
Data restriction
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Fewer cases
Follow-up short, no angiography
Coclusions
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CEA/CABG can be done for high risk
patients who suffer both cerebrovascular
and ischemic heart disease
It is alter option for this kind of patients
Low mortality and morbidity can achieved if
restrict indication and careful follow the
right procedure
Further study needed