Cardiovascular Surgery Cardiology 1992:80:118-125
Clinic for Cardiovascular Surgery and Clinic for Neurology, University Hospital, Zürich, Switzerland
KeyWords Coronary artery disease Carotid disease Combined operation Early and late results
Combined Carotid and Coronary Artery Surgery: Early and Late Results Abstract Patients with coronary artery disease can exhibit substantial vascular involvement; and vascular patients have a high inci dence of coronary disease. Combined coronary artery bypass grafting (CABG) and treatment of extracranial cerebrovascu lar disease was performed in 52 patients, presenting strong indications for surgical treatment of coronary artery disease and symptomatic carotid disease and/or asymptomatic ca rotid bruit that reflected an ulcerative lesion or stenosis exceeding 75%. Overall hospital mortality was 3.8%. Clinical presentation determined the risk of the combined procedure: early mortality was much higher in urgent and emergency cases than in elective cases. Eight-year actuarial survival was 86%. This group of patients was compared with staged proce dures in 45 patients (including carotid endarterectomy fol lowed by CABG several weeks later) and with 42 patients who underwent coronary artery bypass in the presence of carotid bruits. Both early cardiac complications in the former group and neurologic complications in the latter were significantly more frequent than in combined procedures. Combined pro cedures can be performed with acceptable risk and with encouraging long-term results also in this special group of patients; they may improve the long-term prognosis of pa tients with diffuse atherosclerosis much more.
Atherosclerosis is a generalized disease af fecting not only coronary circulation, but other parts of the vascular system as well. Vas cular diseases most commonly encountered in patients with coronary atherosclerosis are ex-
Received: April 4, 1991 Accepted after revision: September 12, 1991
tracranial cerebrovascular disease, abdominal aortic aneurysm and obliterative atheroscle rosis in the aortoiliac and femoropopliteal segment [ 1].
T. Carrel, MD Clinic for Cardiovascular Surgery University Hospital Rämistrasse 100 CH-8091 Zurich (Switzerland)
©1992 S. Karger AG. Basel 0008-6312/92/ 0802-011852.75/0
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T. Carrela G. Stillhardb M. Turinaa
Fig. 1. Incidence of simultaneous surgery in com parison to the overall isolated CABG ( 1978-1990).
Comparisons with results of staged proce dures of isolated CABG or isolated CEA are made in order to clarify indications for com bined procedures.
Patients and Methods From January 1978 to December 1990. a total of 142 simultaneous CABG and vascular procedures were carried out at the Clinic for Cardiovascular Sur gery of the University Hospital of Zürich. During the same period, isolated CABG was performed in 4 .155 patients at the same institution. Simultaneous proce dures represented 3.4% of all coronary revascularizations and showed an increasing trend over the last 5 years (fig. I). Among the 142 combined operations. 52 were performed in patients with coronary artery dis ease and either symptomatic extracranial vascular dis ease or asymptomatic carotid disease in the presence of ulcerative or stenosing (>75% ) lesions, repre senting 11.6% (52/447) of all carotid procedures per formed during the same period. They were carried out in 44 men and 8 women with a mean age of 60.5 years (range 47-73 year). In 4 additional patients, triple pro cedures were performed, including CABG. CEA and repair of abdominal aortic aneurysm. Characteristics of these patients (anatomic findings in the extracranial carotid artery and in coronary arteries) are depicted in tables 1 and 2. All patients had symptoms of coronary
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The prevalence of marked carotid stenosis among patients undergoing myocardial revas cularization has been reported to be between 6 and 20% [2-6] and as many as 50% of patients with extracranial vascular disease will have symptomatic coronary artery disease [3, 7-9], Cerebral complications of coronary artery by pass grafting (CABG) are not infrequent, espe cially in the older population. A further di lemma occurs in the presence of asymptomatic ulcerative or stenosing carotid disease. Clini cal experience indicates that a carotid stenosis of 70% or greater, whether symptomatic or asymptomatic, is associated with a 20-30% stroke rate within 3 years [4, 6]. The important relationship between the two entities is best expressed by the known but highly variable incidence of myocardial infarction following carotid endarterectomy (CEA) and the devastating effects of neurolog ical injury occurring occasionally after rou tine CABG. These patients present a major manage ment problem because attention tends to be focused on the symptomatic disease to the detriment of the second involved, less symp tomatic vascular disease. In such a situation, the following options of surgical therapy are available: to treat the more significant, life-threatening manifesta tion first and postpone the other operation (staged approach) or to perform CABG and the other vascular procedure during one oper ation (simultaneous procedure) [10. 11], The advantages of this latter approach are ob vious: the patient has to undergo only one operation, there is no additional risk in the waiting period for the second operation, fi nally surgical treatment is greatly accelerated. The present study focuses on early and late results of patients presenting with critical cor onary ischemia and carotid disease in whom simultaneous surgical treatment was per formed.
Technique o f Simultaneous Operation A simple surgical team performed both operations. First, the carotid part of the combined procedure was performed to avoid potential dangerous pressure and flow gradients through the carotid circulation during cardiopulmonary bypass (CPB). CEA was always per formed under low systemic heparinization (5,000 1U heparin) and with the aid of an internal carotid shunt. Arteriotomy was closed primarily or with a venous patch according to the surgeon’s preference. CEA was performed while saphenous vein was being removed from the leg for the coronary bypass.
120
Table 1. Anatomic findings of coronary artery dis ease in our 52 patients
NYHA II NYHA III NYHA IV Instable angina
2-Vessel disease
3-Vessel disease
Left main stenosis
3 7 1 2
5 12 2 3
2 6 5 4
After meticulous hemostasis, the cervical skin inci sion was dosed in layers, and the CABG was per formed under standard technique, using CPB in mod erate hypothermia, blood cardioplegia and internal mammary artery routinely as conduit. In patients with triple procedure, the repair of abdominal aorta was performed after CABG and hep arin reversal, but with the chest still open: this greatly facilitated the access to the abdominal aorta and accel erated the procedure. All patients were monitored with Swan-Ganz catheters for measurement of right- and left-sided pressures and cardiac output. Platelet inhibi tors (500 mg acetylsalicylic acid) were started after completion of endarterectomy. In no instance cardiac decompensation occurred during carotid surgery necessitating rapid institution of cardiopulmonary bypass. Actuarial survival curves were calculated using the Cutler-Edcrer method. Quantitative data arc given as means ± SD. Student’s t test was used to compare mean values when appropriate. Univariate analysis of the operative risk factors was made with Basic Sta tistical Program package NCSS 5.0. Kaysvillc, Utah. USA.
Results The incidence of triple-vessel disease, im paired ejection fraction and instable angina was not significantly different for patients having the combined procedure compared to a group of patients undergoing CABG alone, but there was a high incidence of left main branch stenosis in our group of combined pro cedures.
Carrel/Stillhard/Turina
Simultaneous Coronary and Carotid Surgery
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disease with exercise-induced angina pectoris in 35 patients and resting angina or unstable angina in 17 patients. A history of previous neurologic symptoms was found in 40 of 52 patients (76.9%); the remaining 12 patients had cervical bruits and were found to have severe carotid artery disease (obstruction > 75% or severe ulcerative diseae) on cerebral angiography. As determined by left ventriculography and/or echocardiography. 35 patients had normal ventricular function (ejection fraction over 50%); 11 patients had segmental hypokinesia or akinesia in the distribution of a previous myocardial infarction (moderate impair ment of ejection fraction: 40-50%) and 6 patients had diffuse ventricular impairment. Concomitant noncar diac diseases observed in these 52 patients are summa rized in table 3. Early and late results of these 52 patients were com pared with those of 45 patients who underwent staged procedures (CEA followed by coronary revasculariza tion later) and with those of 42 patients who under went CABG alone in the presence of cervical bruits (30 asymptomatic carotid stenosis 50-90%. 8 with unclear symptomatology and 4 with symptomatic < 75% uni lateral stenosis of internal carotid artery). Further, we studied early and late mortality and morbidity of patients who underwent either isolated coronary revas cularization (n = 4.155) or CEA (n = 447) during the same period with special attention to cardiac and neu rologic events. Stroke following CABG was defined as any neuro logical deficit present immediately after the operation or at discharge which occurred during the time of hos pitalization for the surgical procedure. When specified, the percentage of stenosis of ca rotid and coronary obstruction refers to a reduction in diameter. Significant coronary artery disease means 75 % or greater reduction in the diameter of the arteries involved. Analysis of carotid vascular lesions was per formed in all cases by Doppler flow techniques and angiographic studies of the four main cerebral vessels.
Table 2. Carotid artery diseases in our 52 patients
Ulcerative asymptomatic unilateral carotid lesion Asymptomatic unilateral carotid stenosis Ulcerative symptomatic unilateral carotid lesion Symptomatic unilateral carotid stenosis Bilateral carotid stenosis Unilateral stenosis and contralateral carotid obstruction Unilateral stenosis and contralateral wall irregularities
2 12 15 8 5 3
Lesion: Reduction in diameter < 75%; stenosis: significant reduction in diameter > 7 5 %.
Table 3. Concomitant noncardiac and noncerebrovascular diseases in our collective Nicotin abuse Adiposity Arterial hypertension Chronic obstructive pulmonary disease Diabetes mellitus Peripheral vascular disease Chronic renal failure
67.2% 57.8% 51.8% 42.2% 15.4% 15.4% 5.7%
failure (p < 0.02) as categorical variables as well as age (p < 0.002) and ejection fraction (p < 0.018) as continuous variables were sta tistically significant risk factors for operative mortality and morbidity (table 4). Neither intubation time and stay at the intensive care unit nor total hospitalization time were significantly longer in patients with combined procedures than in patients with isolated CABG. Actuarial survival at 8 years was 88 ± 4.5%. Late mortality was not significantly dif ferent between elective and nonelective pro cedures. Late results could be obtained for all survivors at a mean follow-up of 42 months: long-term follow-up showed that 3 patients experienced late neurologic events, but none of these events involved the hemisphere on the side of the previous CEA. Results of com parative groups are summarized in table 5.
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Early mortality of combined carotid and coronary operation was 3.8%: it was not sig nificantly different from early mortality of isolated CABG in patients with comparable severity (symptoms and pathologic anatomy) of coronary artery disease over the same pe riod (2.9%), urgent and emergency operations all included. No postoperative death occurred in the small group of patients with triple pro cedure. Operative risk and complication rate were higher in nonelective procedures than in elective cases. One patient died a few hours after operation from low cardiac output due to perioperative myocardial infarction. Severe peri- or early postoperative compli cations associated with the combined proce dures were encountered in 4 patients (7.5%): 1 patient suffered a postoperative neurologi cal complication 24 h after the combined pro cedure with triple CABG and left internal CEA: he had a sudden attack of dizziness and aphasia. The deficit disappeared quickly, and he had no residual deficit at discharge: 1 patient demonstrated malignant cardiac ar rhythmia early after operation while 2 pa tients had postoperative recovery compli cated by pneumonia in 1 and renal failure in the other. There were no deaths or major complications after the triple procedure. Univariate analysis demonstrated that in complete revascularization (p < 0.016), emergency operation (p < 0.011) and renal
Table 4. Univariate analysis of predictive risk fac tors for operative mortality and morbidity Variables
p value
Catégorial variables 0.94 0.68 0.54 0.76 0.89 0.09 0.70 0.016 0.011 0.02
Sex Hypertension Actual smoking Angina pattern Previous infarction Left main stenosis Number of grafts Incomplete revascularisation Emergency CABG Renal failure
postoperative course (30 days) after CABG from sequelae of neurologic complication: 3 of them demonstrated asymptomatic unilat eral 90% stenosis of the internal carotid ar tery, and the last had bilateral stenosis with out any previous neurologic history. In 9 ad ditional patients, a neurological deficit (not further specified) occurred postoperatively or during the 1st year after CABG. 20 patients could be operated in a second session (6 months to 2 years after CABG) without mor tality and morbidity.
Age Ejection fraction Left ventricular end-diastolic pressure
0.002 0.018 0.4
Renal failure: Preoperative creatinine value > 150 (imol/1: age > 70 years: ejection fraction
Clinic for Cardiovascular Surgery and Clinic for Neurology, University Hospital, Zürich, Switzerland
KeyWords Coronary artery disease Carotid disease Combined operation Early and late results
Combined Carotid and Coronary Artery Surgery: Early and Late Results Abstract Patients with coronary artery disease can exhibit substantial vascular involvement; and vascular patients have a high inci dence of coronary disease. Combined coronary artery bypass grafting (CABG) and treatment of extracranial cerebrovascu lar disease was performed in 52 patients, presenting strong indications for surgical treatment of coronary artery disease and symptomatic carotid disease and/or asymptomatic ca rotid bruit that reflected an ulcerative lesion or stenosis exceeding 75%. Overall hospital mortality was 3.8%. Clinical presentation determined the risk of the combined procedure: early mortality was much higher in urgent and emergency cases than in elective cases. Eight-year actuarial survival was 86%. This group of patients was compared with staged proce dures in 45 patients (including carotid endarterectomy fol lowed by CABG several weeks later) and with 42 patients who underwent coronary artery bypass in the presence of carotid bruits. Both early cardiac complications in the former group and neurologic complications in the latter were significantly more frequent than in combined procedures. Combined pro cedures can be performed with acceptable risk and with encouraging long-term results also in this special group of patients; they may improve the long-term prognosis of pa tients with diffuse atherosclerosis much more.
Atherosclerosis is a generalized disease af fecting not only coronary circulation, but other parts of the vascular system as well. Vas cular diseases most commonly encountered in patients with coronary atherosclerosis are ex-
Received: April 4, 1991 Accepted after revision: September 12, 1991
tracranial cerebrovascular disease, abdominal aortic aneurysm and obliterative atheroscle rosis in the aortoiliac and femoropopliteal segment [ 1].
T. Carrel, MD Clinic for Cardiovascular Surgery University Hospital Rämistrasse 100 CH-8091 Zurich (Switzerland)
©1992 S. Karger AG. Basel 0008-6312/92/ 0802-011852.75/0
Downloaded by: Thomas Jefferson University Scott Library 147.140.20.32 - 1/18/2018 12:55:25 PM
T. Carrela G. Stillhardb M. Turinaa
Fig. 1. Incidence of simultaneous surgery in com parison to the overall isolated CABG ( 1978-1990).
Comparisons with results of staged proce dures of isolated CABG or isolated CEA are made in order to clarify indications for com bined procedures.
Patients and Methods From January 1978 to December 1990. a total of 142 simultaneous CABG and vascular procedures were carried out at the Clinic for Cardiovascular Sur gery of the University Hospital of Zürich. During the same period, isolated CABG was performed in 4 .155 patients at the same institution. Simultaneous proce dures represented 3.4% of all coronary revascularizations and showed an increasing trend over the last 5 years (fig. I). Among the 142 combined operations. 52 were performed in patients with coronary artery dis ease and either symptomatic extracranial vascular dis ease or asymptomatic carotid disease in the presence of ulcerative or stenosing (>75% ) lesions, repre senting 11.6% (52/447) of all carotid procedures per formed during the same period. They were carried out in 44 men and 8 women with a mean age of 60.5 years (range 47-73 year). In 4 additional patients, triple pro cedures were performed, including CABG. CEA and repair of abdominal aortic aneurysm. Characteristics of these patients (anatomic findings in the extracranial carotid artery and in coronary arteries) are depicted in tables 1 and 2. All patients had symptoms of coronary
Downloaded by: Thomas Jefferson University Scott Library 147.140.20.32 - 1/18/2018 12:55:25 PM
The prevalence of marked carotid stenosis among patients undergoing myocardial revas cularization has been reported to be between 6 and 20% [2-6] and as many as 50% of patients with extracranial vascular disease will have symptomatic coronary artery disease [3, 7-9], Cerebral complications of coronary artery by pass grafting (CABG) are not infrequent, espe cially in the older population. A further di lemma occurs in the presence of asymptomatic ulcerative or stenosing carotid disease. Clini cal experience indicates that a carotid stenosis of 70% or greater, whether symptomatic or asymptomatic, is associated with a 20-30% stroke rate within 3 years [4, 6]. The important relationship between the two entities is best expressed by the known but highly variable incidence of myocardial infarction following carotid endarterectomy (CEA) and the devastating effects of neurolog ical injury occurring occasionally after rou tine CABG. These patients present a major manage ment problem because attention tends to be focused on the symptomatic disease to the detriment of the second involved, less symp tomatic vascular disease. In such a situation, the following options of surgical therapy are available: to treat the more significant, life-threatening manifesta tion first and postpone the other operation (staged approach) or to perform CABG and the other vascular procedure during one oper ation (simultaneous procedure) [10. 11], The advantages of this latter approach are ob vious: the patient has to undergo only one operation, there is no additional risk in the waiting period for the second operation, fi nally surgical treatment is greatly accelerated. The present study focuses on early and late results of patients presenting with critical cor onary ischemia and carotid disease in whom simultaneous surgical treatment was per formed.
Technique o f Simultaneous Operation A simple surgical team performed both operations. First, the carotid part of the combined procedure was performed to avoid potential dangerous pressure and flow gradients through the carotid circulation during cardiopulmonary bypass (CPB). CEA was always per formed under low systemic heparinization (5,000 1U heparin) and with the aid of an internal carotid shunt. Arteriotomy was closed primarily or with a venous patch according to the surgeon’s preference. CEA was performed while saphenous vein was being removed from the leg for the coronary bypass.
120
Table 1. Anatomic findings of coronary artery dis ease in our 52 patients
NYHA II NYHA III NYHA IV Instable angina
2-Vessel disease
3-Vessel disease
Left main stenosis
3 7 1 2
5 12 2 3
2 6 5 4
After meticulous hemostasis, the cervical skin inci sion was dosed in layers, and the CABG was per formed under standard technique, using CPB in mod erate hypothermia, blood cardioplegia and internal mammary artery routinely as conduit. In patients with triple procedure, the repair of abdominal aorta was performed after CABG and hep arin reversal, but with the chest still open: this greatly facilitated the access to the abdominal aorta and accel erated the procedure. All patients were monitored with Swan-Ganz catheters for measurement of right- and left-sided pressures and cardiac output. Platelet inhibi tors (500 mg acetylsalicylic acid) were started after completion of endarterectomy. In no instance cardiac decompensation occurred during carotid surgery necessitating rapid institution of cardiopulmonary bypass. Actuarial survival curves were calculated using the Cutler-Edcrer method. Quantitative data arc given as means ± SD. Student’s t test was used to compare mean values when appropriate. Univariate analysis of the operative risk factors was made with Basic Sta tistical Program package NCSS 5.0. Kaysvillc, Utah. USA.
Results The incidence of triple-vessel disease, im paired ejection fraction and instable angina was not significantly different for patients having the combined procedure compared to a group of patients undergoing CABG alone, but there was a high incidence of left main branch stenosis in our group of combined pro cedures.
Carrel/Stillhard/Turina
Simultaneous Coronary and Carotid Surgery
Downloaded by: Thomas Jefferson University Scott Library 147.140.20.32 - 1/18/2018 12:55:25 PM
disease with exercise-induced angina pectoris in 35 patients and resting angina or unstable angina in 17 patients. A history of previous neurologic symptoms was found in 40 of 52 patients (76.9%); the remaining 12 patients had cervical bruits and were found to have severe carotid artery disease (obstruction > 75% or severe ulcerative diseae) on cerebral angiography. As determined by left ventriculography and/or echocardiography. 35 patients had normal ventricular function (ejection fraction over 50%); 11 patients had segmental hypokinesia or akinesia in the distribution of a previous myocardial infarction (moderate impair ment of ejection fraction: 40-50%) and 6 patients had diffuse ventricular impairment. Concomitant noncar diac diseases observed in these 52 patients are summa rized in table 3. Early and late results of these 52 patients were com pared with those of 45 patients who underwent staged procedures (CEA followed by coronary revasculariza tion later) and with those of 42 patients who under went CABG alone in the presence of cervical bruits (30 asymptomatic carotid stenosis 50-90%. 8 with unclear symptomatology and 4 with symptomatic < 75% uni lateral stenosis of internal carotid artery). Further, we studied early and late mortality and morbidity of patients who underwent either isolated coronary revas cularization (n = 4.155) or CEA (n = 447) during the same period with special attention to cardiac and neu rologic events. Stroke following CABG was defined as any neuro logical deficit present immediately after the operation or at discharge which occurred during the time of hos pitalization for the surgical procedure. When specified, the percentage of stenosis of ca rotid and coronary obstruction refers to a reduction in diameter. Significant coronary artery disease means 75 % or greater reduction in the diameter of the arteries involved. Analysis of carotid vascular lesions was per formed in all cases by Doppler flow techniques and angiographic studies of the four main cerebral vessels.
Table 2. Carotid artery diseases in our 52 patients
Ulcerative asymptomatic unilateral carotid lesion Asymptomatic unilateral carotid stenosis Ulcerative symptomatic unilateral carotid lesion Symptomatic unilateral carotid stenosis Bilateral carotid stenosis Unilateral stenosis and contralateral carotid obstruction Unilateral stenosis and contralateral wall irregularities
2 12 15 8 5 3
Lesion: Reduction in diameter < 75%; stenosis: significant reduction in diameter > 7 5 %.
Table 3. Concomitant noncardiac and noncerebrovascular diseases in our collective Nicotin abuse Adiposity Arterial hypertension Chronic obstructive pulmonary disease Diabetes mellitus Peripheral vascular disease Chronic renal failure
67.2% 57.8% 51.8% 42.2% 15.4% 15.4% 5.7%
failure (p < 0.02) as categorical variables as well as age (p < 0.002) and ejection fraction (p < 0.018) as continuous variables were sta tistically significant risk factors for operative mortality and morbidity (table 4). Neither intubation time and stay at the intensive care unit nor total hospitalization time were significantly longer in patients with combined procedures than in patients with isolated CABG. Actuarial survival at 8 years was 88 ± 4.5%. Late mortality was not significantly dif ferent between elective and nonelective pro cedures. Late results could be obtained for all survivors at a mean follow-up of 42 months: long-term follow-up showed that 3 patients experienced late neurologic events, but none of these events involved the hemisphere on the side of the previous CEA. Results of com parative groups are summarized in table 5.
121
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Early mortality of combined carotid and coronary operation was 3.8%: it was not sig nificantly different from early mortality of isolated CABG in patients with comparable severity (symptoms and pathologic anatomy) of coronary artery disease over the same pe riod (2.9%), urgent and emergency operations all included. No postoperative death occurred in the small group of patients with triple pro cedure. Operative risk and complication rate were higher in nonelective procedures than in elective cases. One patient died a few hours after operation from low cardiac output due to perioperative myocardial infarction. Severe peri- or early postoperative compli cations associated with the combined proce dures were encountered in 4 patients (7.5%): 1 patient suffered a postoperative neurologi cal complication 24 h after the combined pro cedure with triple CABG and left internal CEA: he had a sudden attack of dizziness and aphasia. The deficit disappeared quickly, and he had no residual deficit at discharge: 1 patient demonstrated malignant cardiac ar rhythmia early after operation while 2 pa tients had postoperative recovery compli cated by pneumonia in 1 and renal failure in the other. There were no deaths or major complications after the triple procedure. Univariate analysis demonstrated that in complete revascularization (p < 0.016), emergency operation (p < 0.011) and renal
Table 4. Univariate analysis of predictive risk fac tors for operative mortality and morbidity Variables
p value
Catégorial variables 0.94 0.68 0.54 0.76 0.89 0.09 0.70 0.016 0.011 0.02
Sex Hypertension Actual smoking Angina pattern Previous infarction Left main stenosis Number of grafts Incomplete revascularisation Emergency CABG Renal failure
postoperative course (30 days) after CABG from sequelae of neurologic complication: 3 of them demonstrated asymptomatic unilat eral 90% stenosis of the internal carotid ar tery, and the last had bilateral stenosis with out any previous neurologic history. In 9 ad ditional patients, a neurological deficit (not further specified) occurred postoperatively or during the 1st year after CABG. 20 patients could be operated in a second session (6 months to 2 years after CABG) without mor tality and morbidity.
Age Ejection fraction Left ventricular end-diastolic pressure
0.002 0.018 0.4
Renal failure: Preoperative creatinine value > 150 (imol/1: age > 70 years: ejection fraction
