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J Thorac Cardiovasc Surg 2002;124:211
© 2002 The American Association for Thoracic Surgery

Letters to the Editor

Reply to the Editor:

Fukuyama Cardiovascular Hospital, 1-26, Sumiyoshi-cho, Fukuyama-city, Hiroshima 720-0809, Japan

We appreciate the thoughtful comments by Villa, Moneta, and Donatelli on our article about the surgical strategy for candidates for coronary artery bypass grafting (CABG) who have intracranial vascular stenosis. ¹ The strategy for symptomatic and asymptomatic cerebrovascular disease is still controversial, and catheter intervention could be one of the alternatives to surgery, especially for lesions that require a difficult surgical approach.

In extracranial carotid artery disease, endovascular therapy and surgery have been compared in several studies. There was no difference in rates of major complications but lower rates in minor complications for endovascular therapy, which suggests less invasiveness of percutaneous transluminal angioplasty (PTA)/stenting. ² Therefore, Spence and Eliasziw ³ stated that these procedures could be justified for patients with severe comorbidity such as heart disease. However, there are two problems: First, as Villa, Moneta, and Donatelli stated, strict anticoagulation is needed after delivery of the stent, which might increase the incidence of bleeding complications. The second issue is whether the technique can be applied for small-caliber vessels like intracranial carotid or vertebral arteries to obtain the same results as those for larger vessels.

In relation to the first question, we basically use PTA to avoid stent implantation before CABG, eliminating the need for anticoagulation therapy by using antiplatelet agents. For this purpose, excessive dilatation should be avoided to diminish acute occlusion due to dissection. The patients were given heparin for at least 24 hours after the procedure, and some of them were given heparin until the day of CABG. Inadequate vascular dilatation without stenting may cause a higher restenosis rate over the long term; however, the fact that this procedure is for the prevention of intraoperative stroke and bleeding complications justifies the lack of poorer long-term results, because quality of life is mainly affected by the extent of stroke during CABG if it occurs. This is the reason we perform CABG within 5 days after PTA, before recoil or occlusion of the dilated portion occurs. A different strategy must be established for cerebrovascular PTA/stenting with or without the use of cardiopulmonary bypass. PTA must be regarded as a temporary escape method to avoid intraoperative stroke. Long-term patency should not be anticipated.

There is no sophisticated answer for the second question. The restenosis rate of PTA/stenting for small-caliber vessels may be higher than that for larger vessels, the same as the results of coronary catheter intervention. ⁴ PTA/stenting for intracranial vessels is not as commonly applied as for extracranial vessels, but the results have become acceptable due to recent technological improvements in view of the serious nature of this disease. ⁵

With on-pump CABG, there is some risk of embolic stroke caused by manipulating and crossclamping the aorta or making the proximal end of free grafts, some of which can be avoided. Our strategy can avoid "nonembolic stroke" but cannot avoid "embolic stroke," and if we performed off-pump CABG for all CABG candidates, most of these problems would be solved. In off-pump cases, we can implant stents in both small- and large-caliber vessels using antiplatelet agents, with better long-term results.

Fortunately, in our patients, there was no case of perioperative stroke or recurrence of ischemic symptoms up to 3 years, but careful attention should be paid to the long-term results of these patients because all of them received PTA for small-caliber vessels. We hope that our strategy for cerebrovascular disease, together with that of Villa and his associates, can contribute to this challenging field of perioperative stroke prevention in CABG candidates.

12/8/123442

References

1. Kihara S, Shimakura T, Tanaka SA, Hanayama N, Saito N, Hirasawa Y, et al. Staged coronary artery bypass grafting after percutaneous angioplasty for intracranial vascular stenosis. J Thorac Cardiovasc Surg. 2001;122:608-10.
   
2. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet. 2001;357:1729-37.
   
3. Spence D, Eliasziw M. Endarterectomy or angioplasty for treatment of carotid stenosis? Lancet. 2001;357:1722-3.
   
4. Hsieh IC, Chien CC, Chang HJ, Chern MS, Hung KC, Lin FC, et al. Acute and long-term outcomes of stenting in coronary vessel > 3.0 mm, 3.0-2.5 mm, and < 2.5 mm. Catheter Cardiovasc Interv. 2001;53:314-22.
   
5. Gomez CR, Orr SC. Angioplasty and stenting for primary treatment of intracranial arterial stenoses. Arch Neurol. 2001;58:1687-90.
   

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