Simultaneous carotid endarterectomy and coronary artery bypass grafting in313 patients

The coincidence of coronary and carotid artery disease (uni- or bilateral, with or without involvement of the supra-aortic branch) is still a problem with regards to surgical strategy. Since the opening of the Heart Centre Du isburg in 1989 the authors have favoured a simultaneous approach to lesions in both arterial systems in order to avoid myocardial infarction or stroke , The aim of this retrospective study was to review the early and late resu lts of the combined procedures for the endpoints of death, myocardial infar ction and stroke. During a 7-year period (1990-1997) a total of 18,050 pati ents underwent cardiac surgery and extracorporeal circulation. Simultaneous intervention in both arterial systems was performed in 313 patients (1.73% ). All patients underwent preoperative ultrasonic diagnostics, digital subs traction angiography, neurological examination and cardiac catheterization, The principal indication was the need for myocardial revascularization, an d symptomatic or asymptomatic carotid stenosis of 80% diameter reduction or more (with or without contralateral disease). The mean age was 66.4 +/- 6. 9 years; 240 patients (76.7%) were male, 73 patients (23.3%) female; 243 pa tients (77.6%) had triple-vessel disease, 82 patients (26.2%) had left main stenosis and 94 patients (43.5%) had a reduced ejection fraction. A total of 171 patients (54.6%) had a previous myocardial infarction, 54 patients ( 17.3%) presented with unstable angina and nine patients (2.9%) had prior co ronary artery bypass grafts. Eighty-seven patients (27.8%) had an internal carotid artery stenosis on the right side, 75 patients (24%) on the left si de and 151 patients (48.2%) lesions in both carotid arteries. Prior carotid endarterectomy was performed in 14 patients (4.5%), and the contralateral carotid was occluded in 24 patients (7.7%), Fifty patients had a previous s troke (16%) and 185 patients (59.1%) were asymptomatic. During surgery, the the carotid artery was first exposed, followed by median sternotomy, syste mic heparinization, cannulation and cardiopulmonary bypass, After achieving mild hypothermia (30 degrees C), endarterectomy was performed with a venou s patch closure. An occluded contralateral carotid artery was always an ind ication for shunting. Coronary artery bypass grafting was carried out with intermittent cross-clamping under moderate hypothermia (22-27 degrees C), T en patients suffered a myocardial infarction (3.2%), seven patients (2.2%) had an apoplectic insult perioperatively (< 30 days) and one patient (0.3%) had an event during long-term follow-up. Early overall mortality was 28 (8 .9%), of which 13 were cardiac related (4.2%). Overall late mortality was e ight (2.6%), of which six were cardiac related (1.9%). Mean survival time w as 6.18 years, Simultaneous carotid endarterectomy and myocardial revascula rization can be justified as a routine surgical management of severe lesion s in both arterial systems. The risk of myocardial infarction, apoplectic s troke or mortality was not significantly different than isolated procedures . (C) 2000 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved.