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Combined Coronary Amp Carotid Disease

Combined Carotid & Coronary Disease

1. Coronary Surgery

 Carotid Stenosis > 50%
CABG5-8%
CABG > 6517%
CABG + Left main50%

2. Risk Factors for Stroke Following CABG

A. Overall stroke risk 1-3.5%
B. Mural thrombi in the left ventricle
C. Atheromatous lesions in the ascending aorta
D. Air embolism
E. History of previous stroke

3. Carotid Artery Stenosis and CABG

A. Carotid stenoses are less of a risk factor for stroke with CABG because with CPB:
1) Cerebral vascular resistance lowered
2) Hypothermia reduces brain metabolism and oxygen requirement
3) Hemodilution
4) Auto-regulation of cerebral blood flow is related more to flow than MAP
B. Indications for combined coronary and carotid procedures are limited
C. Indications for combined coronary and carotid artery procedures
1) Severe CAD: unstable angina, left main stenosis or 3 vessel CAD with poor LV function and
2) An actively symptomatic carotid artery stenosis

4. Indications for Staged Operations for Coronary and Carotid Artery Disease

A. Significant 1, 2 or 3 vessel CAD requiring CABG in a patient with asymptomatic high grade CAS with medically controlled symptoms
B. Patient with actively symptomatic carotid artery stenosis with stable angina and adequate LV function

5. Combined Coronary and Carotid Artery Disease

A. Controversial Areas
1) Stable angina requiring CABG and coexistent asymptomatic high grade (> 80%) bilateral carotid stenosis
2) Redo CEA or CABG with coexistent lesions in the other vascular system

6. Operative Strategies for Combined Procedures

A. Ensure adequate exposure of neck in addition to chest and legs
B. Pre - bypass vs. on bypass CEA
C. After CEA, wound left open until systemic heparinization reversed

7. Results of Combined Procedures

A. Morbidity and mortality for patients requiring combined procedures is higher than for either procedure alone
1) Mortality 4%
2) Post-operative stroke 9%
3) Peri-operative MI 6%
B. Therefore: Only 1-3% of patients requiring CABG or CEA will be candidates for combined procedures