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J Thorac Cardiovasc Surg 2002;124:210-211
© 2002 The American Association for Thoracic Surgery
Letters to the Editor |
IRCCS Ospedale Maggiore Policlinico, Univerità degli Studi, Milan, Italy
To the Editor:
We read with interest the recently published experience of Kihara and colleagues
1 about the treatment of concomitant coronary artery disease and intracranial vascular disease. They suggest that intracranial vascular stenosis be treated with percutaneous transluminal angioplasty (PTA) and that on-pump coronary artery bypass grafting (CABG) be performed within 5 days after the procedure. In the case of diffuse stenosis of intracranial vessels, they do not treat the intracranial vessels and proceed to off-pump CABG plus coronary PTA (ie, hybrid revascularization).
The authors do not quote specific publications regarding intracranial cerebral artery disease as a risk factor for central nervous system complications after CABG. Yoon and colleagues 2 support the authors' approach with a prospective study suggesting that intracranial carotid artery disease alone may be an independent risk factor.
Neurologic damage after cardiac surgery remains a major problem, and its impact on survival and quality of life after surgery has become an increasingly important issue. We think that patients with clinical predictors for cerebral injury (eg, advanced age, prior stroke or transient ischemic attack, diabetes) 3 and disclosed carotid stenosis of more than 70% have to undergo nonsurgical and surgical strategies to maximize their neurologic outcome.
The management of symptomatic and asymptomatic carotid disease in candidates for CABG is still controversial: simultaneous carotid endarterectomy, staged endarterectomy, no endarterectomy.
PTA and stenting can be a new useful option to treat intracranial and extracranial lesions. Endovascular therapy is effective for prevention of stroke 4 and, from our limited experience in extracranial carotid disease, it is safe for patients with complex disease who are awaiting cardiac surgery.
In past years our group has gained experience and confidence with simultaneous carotid endarterectomy and CABG, but recently, demonstrating carotid PTA effectiveness, we offered our patients with comorbidities another option: carotid PTA and stenting before CABG. This modality, reducing operative time, is expected to diminish surgical trauma and facilitate the postoperative course.
Beyond long-term effectiveness, some questions arise: post-PTA antiplatelet drug dosage and surgical bleeding, the modality of staging, and stent patency during unplanned surgery with cardiopulmonary bypass or with protamine and other procoagulant drugs.
Furthermore neurologic outcome may be improved by using off-pump CABG and adopting individualized strategies (bilateral internal thoracic artery grafts, T grafts, sequential anastomoses, hybrid revascularization). These techniques, in patients at high neurologic risk, 3 help to avoid aortic manipulation (crossclamp, side-biting clamp, cannulation) and minimize embolic hazards of aortic atheromatous disease. Recent works also suggest that off-pump CABG permits reduction of another cause of neurologic events: postoperative arrhythmias. 5
Kihara and colleagues, when reporting their experience with the treatment of intracranial stenosis, explored another area in the field of neurologic injury prevention during CABG. This relevant issue after the advent of carotid PTA/stents and off-pump techniques has gained renewed interest and raised new subjects for debate.
12/8/123443
doi:10.1067/mtc.2002.123443
References
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