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J Thorac Cardiovasc Surg 2001;122:608-610
© 2001 The American Association for Thoracic Surgery
Surgery for Acquired Cardiovascular Disease (ACD) |
From the Department of Cardiovascular Surgery, Fukuyama Cardiovascular Hospital, Hiroshima,a and the Department of Neurosurgery, Shin-Tokyo Hospital, Chiba,b Japan.
Received for publication Nov 28, 2000. Revisions requested Jan 17, 2001; revisions received Feb 6, 2001. Accepted for publication Feb 16, 2001. Address for reprints: Shin'ichiro Kihara, MD, McGowan Center for Artificial Organ Development, University of Pittsburgh, 300 Technology Dr, Pittsburgh, PA 15219 (E-mail: kiharas{at}msx.upmc.edu).
Abstract
Objective: Cerebrovascular disease is commonly associated with coronary artery disease and is a major risk factor for cardiac surgery. Concomitant coronary artery bypass grafting and carotid endarterectomy may reduce the risk of stroke; however, this staged operation is effective only for extracranial lesions. The strategy for on-pump coronary artery bypass grafting for patients with intracranial vascular stenosis is still controversial.
Methods: The subjects were 157 consecutive candidates for coronary artery bypass grafting who underwent computed tomography and digital subtraction cerebral angiography preoperatively to check for cerebrovascular disease. Additional single-photon emission computed tomography was performed to evaluate cerebral ischemia, according to the neurologist's request. Patients with diffuse intracranial vascular stenosis impossible to treat with percutaneous transluminal angioplasty underwent off-pump coronary artery bypass grafting. Patients with a circumflex coronary artery lesion first underwent percutaneous transluminal angioplasty for cerebral vascular stenosis followed by secondary on-pump coronary artery bypass grafting.
Results: Three patients were selected for staged operations. Percutaneous transluminal angioplasty was performed for 4 intracranial stenotic lesions. All lesions were dilated successfully, and no complications developed during or after the procedure. All patients tolerated staged coronary artery bypass grafting and were extubated within 1 day without any mental disturbance. No further neurologic complication occurred, and computed tomography performed postoperatively revealed no significant changes.
Conclusion: Staged on-pump coronary bypass after percutaneous transluminal angioplasty for cerebrovascular disease may reduce the risk of stroke during cardiopulmonary bypass, and it is useful especially in patients with intracranial cerebrovascular disease.
Cerebrovascular disease is commonly associated with coronary artery disease and is one of the major risk factors for coronary artery surgery. In the treatment of such patients, concomitant coronary artery bypass grafting (CABG) and carotid endarterectomy may reduce the risk of stroke. However, endarterectomy is effective only for extracranial lesions. There is almost no surgical intervention for intracranial stenosis.
1 We performed staged CABG after percutaneous transluminal angioplasty (PTA) for intracranial vascular stenosis in candidates for CABG with severe cerebrovascular disease.
Clinical summary
Preoperative evaluation
From June 1996 to December 1998, a total of 157 consecutive candidates for elective CABG underwent preoperative brain computed tomography and digital subtraction cerebral angiography. Additional single-photon emission computed tomography (SPECT) was performed to evaluate cerebral ischemia according to the neurologist's request. Cerebral ischemia was diagnosed in 7 (4.5%) of these patients, and 4 who had contraindications for PTA underwent off-pump CABG without cerebral artery intervention. Three other patients with multivessel disease including circumflex artery stenosis underwent staged CABG after PTA for cerebral vascular stenosis.
PTA for intracranial vascular stenosis
The indications for PTA include brain ischemia on SPECT with more than 60% angiographic stenosis. 2 PTA was performed in 4 vessels in 3 patients. All of the lesions were intracranial, and the locations of the lesions are described inTable 1. Diffuse stenosis was a contraindication for PTA because of the high risk of stroke during the procedure. Successful angioplasty was defined as a reduction of the stenosis to 50%. No complication occurred during or after the procedure, and angiographic follow-up 5 days later revealed no restenosis in any target vessels.
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Recent advances in off-pump CABG may reduce the risk of stroke during cardiac surgery, and the left anterior descending and right coronary arteries are easy to access. However, revascularization of the circumflex artery may cause hemodynamic instability, especially in patients with poor cardiac function. 3 The fact that completeness of coronary revascularization is an important predictor of the long-term results of CABG in patients with severe left ventricular dysfunction 4 indicates that CPB still plays a major role in CABG. Therefore, in patients requiring CPB, cerebral vascular stenosis is still a problem. Many reports of concomitant CABG and carotid endarterectomy have been published, 5 but strategy for candidates for on-pump CABG with intracranial vascular stenosis is still controversial. We selected PTA to treat intracranial vascular disease. There are many reports of intracranial PTA, and the results have been acceptable in view of the serious nature of the condition. 3 Some aggressive surgeons may consider that these patients should undergo off-pump CABG including the circumflex artery. However, off-pump CABG is not available at all institutions where CABG is performed, especially for the circumflex coronary artery. 3 On-pump CABG still plays a major role in complete revascularization for coronary artery disease. If the coronary disease is accompanied by intracranial vascular stenosis, PTA may reduce the risk of stroke during CPB. Although SPECT was performed by neurologists on highly selected patients and digital subtraction cerebral angiography of intracranial vessels can be performed easily during preoperative catheterization, we must be concerned about the cost-effectiveness of these diagnostic approaches. They may be unnecessary unless the physiology of CPB could cause problems for the cerebral circulation. However, the fact that the risk of stroke in this population is higher than in patients who do not have these problems 5 indicates that staged on-pump CABG after PTA is useful, especially in patients who require complete revascularization, including the circumflex artery, with intracranial cerebrovascular disease.
References
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 E. Villa, A. Moneta, and F. Donatelli Optimizing neurologic outcome in coronary bypass surgery J. Thorac. Cardiovasc. Surg., July 1, 2002; 124(1): 210 - 211. [Full Text] [PDF]
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