HYPOTHERMIC CIRCULATORY ARREST FOR CEREBRAL PROTECTION DURING COMBINED CAROTID AND CARDIAC-SURGERY IN PATIENTS WITH BILATERAL CAROTID-ARTERY DISEASE

Objective The authors evaluated the protective effect of hypothermic c irculatory arrest for patients with bilateral carotid artery disease w ho underwent cardiac surgical procedures. Summary Background Data Seve re bilateral carotid artery disease coexisting with cardiac disease th at requires surgical treatment is associated with a substantial incide nce of stroke after operations that require cardiopulmonary bypass. Th e optimal method of management of patients with these coexisting condi tions is not established clearly. Because hypothermia has a protective effect on neural and myocardial tissue during cardiac operations, a p rotocol employing profound hypothermia and a period of circulatory arr est was evaluated in a group ct patients who underwent combined caroti d and cardiac surgery who were considered to be at increased risk for the development of stroke. Methods Fifty patients with bilateral carot id artery disease, including 24 patients with high-grade unilateral st enosis and contralateral occlusion and 6 patients with 80% to 99% bila teral stenosis, underwent combined carotid endarterectomy and cardiac surgery (coronary artery bypass grafting in all 50 patients and additi onal procedures in 8 patients). Profound systemic hypothermia (15 C) w as instituted, and the carotid endarterectomy was performed during a p eriod of circulatory arrest that averaged 30 minutes. The cardiac proc edure was performed during the periods of cooling and rewarming. Resul ts The 30-day mortality rate was 6% (3 patients). There were no early postoperative strokes or reversible ischemic neurologic deficits. Ther e have been seven late deaths in the postoperative period, which exten ds to 54 months. None of these deaths were caused by stroke. There has been one late stroke, which occurred in the distribution of the unope rated carotid artery. Conclusions This technique provides adequate pro tection of the brain and myocardium during combined carotid and cardia c surgical procedures and appears to reduce the frequency of stroke in the high-risk subgroup oi patients with bilateral carotid artery dise ase.