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J Thorac Cardiovasc Surg 2000;119:764-772
© 2000 The American Association for Thoracic Surgery

SURGERY FOR ACQUIRED CARDIOVASCULAR DISEASE

LONG-TERM RESULTS OF SIMULTANEOUS CAROTID ENDARTERECTOMY AND MYOCARDIAL REVASCULARIZATION WITH CARDIOPULMONARY BYPASS USED FOR BOTH PROCEDURES

Kazutomo Minami, MD, PhD, Kazuaki Fukahara, MD, Dietmar Boethig, MD, Andreas Bairaktaris, MD, Dirk Fritzsche, MD, PhD, Reiner Koerfer, MD, PhD

From the Department of Thoracic and Cardiovascular Surgery, Heart Center North-Rhine Westfalia, Bad Oeynhausen, Germany.

Address for reprints: Kazutomo Minami, MD, PhD, Department of Thoracic and Cardiovascular Surgery, Heart Center North-Rhine Westfalia, University of Bochum, Georgstrasse 11, D-32545 Bad Oeynhausen, Germany.


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Discussion
 Appendix
 References
 
Objective: Controversy continues about the treatment of patients with a concomitant occlusive disease of the coronary and carotid arteries. Our operative strategy in these patients is to do simultaneous carotid endarterectomy and myocardial revascularization in conjunction with cardiopulmonary bypass with mild hypothermia. We report our experience with this kind of one-stage procedure and its retrospective long-term results.
Methods: From February 1985 to September 1998, 340 patients underwent simultaneous carotid endarterectomy and myocardial revascularization. The average age of the patients was 65.3 years; 45.6% were neurologically symptomatic, and 44.4% had bilateral carotid stenosis. The indication for carotid endarterectomy was lumen diameter reduction of more than 75%, angiographic signs of thrombogenic endovascular morphology, or both. Carotid endarterectomy was performed in conjunction with cardiopulmonary bypass with mild hypothermia, hemodilution, systemic heparinization, and controlled hemodynamics under pulsatile perfusion for additional cerebral protection.
Results: There were 16 perioperative neurologic complications (4.7%), 11 permanent deficits (3.2%), and 9 cardiac complications (2.6%). Early mortality was 2.6% (SE 0.8%): 2 patients had a stroke and 2 had a myocardial infarction. The 5-year survival was 78.9% (SE 2.6%), and freedom from ipsilateral stroke and cardiac event were 93.2% (SE 1.5%) and 87.5% (SE 2.1%), respectively. The predictor for early death was age over 70 years, and predictors for late death were age over 70 years, previous myocardial infarction, previous stroke, and bilateral carotid stenosis of greater than 90%.
Conclusion: On the basis of our long-term results, we believe that simultaneous carotid endarterectomy and myocardial revascularization in conjunction with cardiopulmonary bypass is a method safe enough to prefer its routine use with acceptable low operative risk and satisfactory long-term morbidity.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Discussion
 Appendix
 References
 
Postoperative cerebral stroke remains one of the most serious complications in cardiac surgery. The reported frequency of neurologic complications after coronary artery bypass grafting (CABG) varies widely, even in the more recent literature, depending on the sensitivity used to state postoperative neurologic changes. The frequency of severe perioperative neurologic complications in unselected patients undergoing CABG has been reported to be between 0.5% and 7.0%.Go Go 1-3

Possible causes of neurologic complications after elective CABG include inadequate cerebral perfusion with hypotension or hypoperfusion, arterial macroembolization or microembolization, and intracranial or extracranial vascular disease. Because atherosclerosis is a generalized disease, a considerable number of patients have significant stenosis in both the coronary and carotid arteries. The incidence of significant stenosis of extracranial arteries in patients requiring CABG reported in the literature ranges from 2.4% to 14% and varies according to the diagnostic means used.Go Go 4-6

Preexisting extracranial arterial occlusive disease is one of the most frequent causes of perioperative cerebral ischemia. The treatment strategy of patients with concomitant occlusive disease of coronary and carotid arteries is still a matter of discussion. Our operative strategy in these patients is to do simultaneous carotid artery endarterectomy and myocardial revascularization, with cardiopulmonary bypass (CPB) being instituted before carotid endarterectomy for additional cerebral protection with mild hypothermia, hemodilution, systemic heparinization, and controlled hemodynamics under pulsatile perfusion.

In a previous publication in 1988,Go 7 we reported the initial experience with 47 patients who underwent simultaneous carotid endarterectomy and myocardial revascularization by using CPB for both procedures. In the actual report we describe our further experience with this operative strategy of concomitant occlusive disease of the coronary and carotid arteries and present its early and long-term results.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Discussion
 Appendix
 References
 
From February 1985 until September 1998, 37,932 cardiac procedures with extracorporeal circulation were performed in our heart center. In 340 (1.3%) of 26,607 consecutive CABG candidates, simultaneous revascularization of the carotid artery was carried out because of a relevant stenosis of one or both carotid arteries. The patients included 260 men (76.9%) and 80 women (23.1%) aged from 42.7 to 82.3 years (average, 65.3 ± 7.3 years).

In all CABG candidates particular attention was directed to their history of neurologic and cerebrovascular symptoms, and Doppler ultrasonographic examination was carried out. If Doppler evaluation revealed a luminal reduction of more than 50% in the common or internal carotid artery, arterial digital subtraction angiography (alone or usually in combination with selective carotid cineangiography) was performed either simultaneously with cardiac catheterization or at a later date if the carotid stenosis initially had not been diagnosed. The initial indication for endarterectomy of the carotid artery was an angiographically diagnosed reduction in luminal diameter of more than 75%, a sign of thrombogenic endovascular morphology (transitoric ischemic attack, minor stroke, or intimal ulcerations), or both. Since 1989, in case of asymptomatic carotid stenosis, transcranial Doppler ultrasonography (Neuroguard, Neuroguard Inc) was applied to indicate hemodynamic deterioration.Go 8 A pathologic finding was defined as an increase of flow velocity in the mean cerebral artery of less than 20% after carbon dioxide stimulation induced by hypercapnia.Go Go 9-11 Patients with reduced perfusion reserve were operated on regardless of whether carotid artery stenosis was symptomatic or not (Fig 1). Patients with asymptomatic carotid artery stenosis and normal perfusion reserve without ulcerations were treated with individual anticoagulation or antithrombogenic drugs, and ultrasonographic short-time interval follow-up was recommended.



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  		Fig. 1. Our treatment strategy of patients with concominant occlusive disease of coronary and carotid arteries.

 
Operative technique
All patients had a unilateral carotid endarterectomy with autologous saphenous vein patch plasty and concomitant CABG. All patients were operated on by the same surgeons. At first, the carotid artery was exposed. Then median sternotomy and cannulation were performed, and CPB was initiated to provide additional organ protection (mild hypothermia with a blood temperature of 27°C, nasopharyngeal temperature of 30°C, and hemodilution with a hematocrit value of 20% to 25%). In addition, a systemic mean arterial pressure of 60 to 70 mm Hg with the unloaded beating heart was ensured by optimal manipulation of CPB, including synchronized pulsatile perfusion. Subsequently, endarterectomy and vein patch plasty of the carotid artery were done, and then CABG with intermittent myocardial ischemia was performed. The number of peripheral coronary anastomoses varied between 1 and 7, with an average of 2.9 ± 1.0. The neck incision was left open until the end of the cardiac procedure. Throughout the operation, the cerebral function was monitored by a continuous electroencephalogram (Drägerwerk AG).Go 12 An intraluminal shunt was used in only a few patients who had a sign of cerebral ischemia with the electroencephalogram monitor.

The preoperative clinical characteristics of the patients are shown in Table I, and the angiographic features of the patient population are listed in Table II. The criteria for stating a perioperative myocardial infarction are the occurrence of new Q waves and persistent ST-segment changes correlated with an elevated myocardial fraction of creatinine kinase (CK-MB > 50 U/L). In later years, cardiac troponin T was used to state perioperative myocardial infarction (troponin T > 0.5 µg/L).


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  		Table I. Demographic and clinical characteristics
 

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  		Table II. Angiographic data
 
Statistical analysis
Preoperative and perioperative data were obtained by reviewing the patient’s hospital records, and information on long-term survival or events was gained by questionnaires to the patient’s referring physician and cardiologist. Data are expressed as mean ± SD. Early death and early stroke (with persisting neurologic deficit) were defined as events within 30 days postoperatively. For time-independent risk factor analysis (early postoperative events), the 2-tailed Fisher exact test and t test were used. Time-dependent factors were analyzed by the Kaplan-Meier method, the log-rank test, the Pearson correlation, and Cox regression models. Freedom-from-event percentages are given with SEs. Calculations were made with SPSS Release 8.0.0 (SPSS Inc).


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Discussion
 Appendix
 References
 
Patients were traced for a mean follow-up of 5.28 ± 3.8 years; total follow-up time is 1759 patient-years. Follow-up is 98.8% complete.

Early mortality after simultaneous carotid endarterectomy and coronary revascularization was 2.6% (9 patients). There was a clear association between early death and age over 70 years (P = .02).

Perioperative neurologic complications were seen in 16 patients (4.7%), including 11 permanent deficits (3.2%).

Early cardiac complications were 2 lethal myocardial infarctions. In 5 patients we saw drug-responsive ventricular arrhythmias, and 2 patients had transient low-output syndrome (Table III). The significant univariate risk factors for early death and stroke are listed in Table IV.


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  		Table III. Early postoperative complications and events
 

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  		Table IV. Risk factors for early death and stroke
 
Late neurologic events occurred in 29 patients, including 10 lethal strokes. The ipsilateral side was dominant for early stroke (ipsilateral side, n = 7; contralateral side, n = 4), but late stroke occurred more often on the contralateral side (ipsilateral side, n = 12; contralateral side, n = 17). Ten-year incidences of stroke were 9.3% (SE 2.5%) on the ipsilateral side and 11.8% (SE 2.6%) on the contralateral side. Overall freedom from stroke (Fig 2) at 5 years and 10 years was 86.8% (SE 2.1%) and 78.9% (SE 3.2%), and freedom from ipsilateral stroke (Fig 3) was 93.2% (1.6%) and 89.3% (SE 2.5%).



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  		Fig. 2. Freedom from overall stroke.

 


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  		Fig. 3. Freedom from ipsilateral stroke.

 
Late cardiac events occurred in 62 patients, including 27 lethal cardiac failures and 16 sudden deaths. Freedom from cardiac event (Fig 4) was 87.5% (SE 2.1%) and 68.3% (SE 3.4%) at 5 and 10 years, respectively.



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  		Fig. 4. Freedom from cardiac events.

 
Actuarial survival (Fig 5) was 78.9% (SE 2.6%) and 56.1% (SE 3.7%) at 5 and 10 years, respectively. Causes of late death were cardiac events in 52 patients (9 patients with cardiac infarction, 27 patients with cardiac failure, and 16 patients with sudden death), stroke in 10 patients, carcinoma in 18 patients, unknown causes in 8 patients, and other causes in 26 patients. Univariate risk factors of late death were age over 70 years, previous myocardial infarction, previous stroke, and bilateral carotid stenosis over 90%. Risk factors for late death, stroke, and neurologic or cardiac events are listed in Table V. The results of multivariate analysis for time-dependent risk factors are listed in Table VI.



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  		Fig. 5. Overall actuarial survivals.

 

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  		Table V. Univariate analysis of risk factors for late events
 

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  		Table VI. Multivariate analysis of time-dependent risk factors
 

   Discussion
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
Appendix
 References
 
Perioperative stroke after myocardial revascularization is an issue of increasing importance to cardiac surgeons. Patients with neurologic symptomatic carotid artery stenosis and a history of stroke undergoing CABG are at a higher risk of perioperative stroke than CABG candidates with asymptomatic carotid artery stenosis. Jones and associatesGo 13 noted an 8.6% incidence of perioperative stroke in patients with prior neurologic symptoms undergoing CABG. In our institution between February 1985 and September 1998, CABG was performed in 26,607 patients, and the incidence of perioperative neurologic complications was 3.1%, including 1.2% neurologic deficit.Go 14

The reported incidence of significant carotid artery stenosis in candidates for CABG varies from 1.6% to 6.8%.Go Go 4-6 A retrospective study of our own dataGo 14 (5880 consecutive patients with CABG) showed significant coexistent occlusive disease of the carotid artery in 2.4%. The number of candidates for surgery of concomitant occlusive disease of coronary and carotid artery is increasing. Tuman and associatesGo 15 reported that patients younger than 65 years who underwent CABG had an incidence of stroke of 0.9%, whereas asymptomatic patients older than 75 years had an incidence of stroke of 8.9%, and the incidence of stroke rose with increasing age.

Because of the rising number of elderly patients requiring cardiac surgery, it became more important to evaluate latent stenoses of carotid arteries. However, sometimes there are relevant discrepancies between Doppler ultrasonographic and angiographic findings. Moreover, in our opinion, even if digital subtraction angiography seems to be a useful general screening method in providing information about the overall status of the extracranial arteries, it is not accurate enough to plan an operation. Therefore we insisted on a selective carotid angiography to evaluate the morphology of the carotid lesion before operation. Recently, we also used transcranial Doppler ultrasonography with carbon dioxide stimulation as an effective preoperative diagnostic method.Go 8 We decided to perform carotid endarterectomy in patients with neurologically asymptomatic carotid stenosis if the perfusion reserve measured by using transcranial Doppler ultrasonography is reduced more than 20% below the normal value.Go Go 9-11

There is a continuing controversy about the management of patients with concomitant occlusive disease of the coronary and carotid arteries. In previous studies some groups have preferred to perform an isolated CABG, even in patients with hemodynamically relevant carotid artery stenosis, whereas others perform carotid thromboendarterectomy before CABG (2-stage procedure). However, experience with CABG without surgical treatment of hemodynamically relevant carotid artery stenosis indicates that the rate of perioperative neurologic complications after this policy is between 7.4% and 20.3%, with a mortality between 6.9% and 13.8%.Go Go Go 13,16-19 On the other hand, when an isolated carotid artery endarterectomy is performed before necessary CABG, the morbidity is relatively high (around 7%-8%) and is caused mainly by myocardial infarction.Go 16 Therefore some authors advocate the 1-stage procedure (combined surgery, carotid thromboendarterectomy before insertion of CPB for CABG or simultaneous surgery, and carotid endarterectomy under CPB before CABG). They recommended this 1-stage procedure if unstable angina pectoris, left main stem coronary artery stenosis, or diffuse multivessel coronary artery disease coexisting with symptomatic carotid artery occlusive disease is present.Go Go Go Go 13,16,19,20 Mehigan and associatesGo 17 prefer the 2-stage procedure if the clinical situation allows it and the 1-stage operation in poor-risk candidates. A staged approach is reserved by some authors for patients with severe carotid artery stenosis, complicated carotid revascularization, or significant bilateral carotid disease with relatively less severe coronary artery disease.Go Go 13,16 In recent studies Akins and colleaguesGo 21 and Trachiotis and Pfister,Go 22 who performed combined carotid endarterectomy and CABG, recommended 1-stage operation as the most effective means of avoiding myocardial complications and reducing neurologic deficits. In a meta-analysis on reports for surgical treatment of concomitant carotid and coronary artery disease, Takach and coworkersGo 23 summarized the combined procedure to be as safe as the staged procedure despite the higher-risk population in the combined procedure.

In the 1-stage procedure most authors repair the carotid artery stenosis before full establishment of CPB. In contrast, we prefer to use the advantages of CPB, such as hemodilution, hypothermia, heparinization, and hemodynamic control, for cerebral protection during carotid endarterectomy. Hypothermia induced by moderate systemic blood cooling around 27°C during CPB can be expected to protect the brain by decreasing cerebral oxygen consumption and to decrease the accumulation of anoxic metabolites in brain tissue. We keep the nasopharyngeal temperature at around 30°C, maintaining a beating heart for pulsatile body perfusion. Although there is a lack of consensus concerning the optimal mean arterial pressure for cerebral protection during CPB, higher perfusion pressures of 70 to 90 mm Hg are considered to be safer in patients with occlusive disease of the carotid artery. Tufo and coworkersGo 24 found that lowering of systemic arterial blood pressure below 50 mm Hg for longer than 10 minutes resulted in a 4-fold increase in risk compared with that observed when higher blood pressure was present. In a recent review of concomitant disease of the carotid and coronary arteries, Lazar and MenzoianGo 25 concluded that neurologic complications of CPB appear to be more related to arteriosclerotic aortic disease than to low flow caused by carotid artery stenosis.

In this context, however, disadvantages of performing carotid endarterectomy under CPB, such as excessive operative bleeding, prolonged operation time, and possible blood contamination of the drapes around the carotid incision, might lead to a higher incidence of mediastinal infection. Although there are 2 lethal infections (0.6%) in our series, the incidence of mediastinal infection was not higher than that of elective isolated CABG in our institution. On the other hand, there are some advantages in the 1-stage approach, including shorter hospital stay, decreased exposure to anesthesia, and cost savings.Go 26

Hypothermia was expected to make the analysis of electroencephalography more difficult than in isolated carotid endarterectomy under normothermia. In our series minor electroencephalographic changes were fairly common during carotid endarterectomy, but they were generally not followed by cerebral sequelae. In contrast, most of the electroencephalographic changes that occurred after carotid endarterectomy were associated with perioperative neurologic complications.Go 7 This suggests that cerebral embolism might be a frequent cause of postoperative cerebral deficits.

Our early and long-term results suggest that elderly patients have an elevated risk for early and late death. Strategy of treatment and strategy of operative management of such elderly patients must be considered thoughtfully. The results in this series, particularly the excellent freedom from neurologic events in the early and long-term course, support the efficiency of our simultaneous operative strategy. The operative mortality and the incidence of neurologic complications and myocardial infarction in this report compare favorably with literature data for patients with concomitant severe occlusive disease of the coronary and carotid arteries managed by using a combined operative approach (Table VII).Go Go Go 23,27-31


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  		Table VII. Review of the results after combined operative approach
 
On the basis of our long-term results, we believe that simultaneous carotid endarterectomy and myocardial revascularization both in conjunction with CPB is a method safe enough to prefer its routine use with acceptable low operative risk and satisfactory long-term morbidity.


   Appendix
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Appendix
References
 

Analyzed potential risk factors
Age
Diabetes
Obesity
Hyperlipidemia
Hypertension
Smoking
Previous lung disease
Symptomatic carotid stenosis
Previous stroke
Previous transient ischemic attack
Previous peripheral atherosclerotic occlusive disease
Previous carotid operation
Bilateral carotid stenosis
Severity of ipsilateral-contralateral carotid stenosis
Previous myocardial infarction
Previous cardiac decompensation
Previous cardiac operation
Number of diseased coronary vessels
Number of CABGs
Concomitant valve operation


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Appendix
 References
 

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Received for publication March 29, 1999. Revisions requested May 27, 1999; revisions received Nov 12, 1999. Accepted for publication Dec 7, 1999.


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