Simultaneous Operation of Carotid Endarterectomy and Coronary Artery Bypass Grafting Using Off-pump Method: New Strategy of Carotid Revascularization with Off-pump CABG

Abstract

The role of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) in patients with severe carotid artery stenosis and concurrent coronary artery stenosis is still controversial. However, patients with severe carotid stenosis experience a higher rate of perioperative cerebrovascular events, compared with those without serious stenosis. Simultaneous operations have been performed in our institute since 1999, and we report the efficacy of combined CEA and CABG especially without cardiopulmonary bypass (off-pump CABG=OPCABG).
Five combined oprations were performed between December 1999 and March 2001. All patients had multiple coronary lesions with more than 75% unilateral carotid stenosis. One patient had contralateral internal carotid occlusion and 1 had the tandem lesions at the distal internal carotid artery and middle cerebral artery concomitantly. Four were asymptomatic neurologically and 1 was symptomatic. Cerebral hemodynamics in all patients was examined with single photon emission CT (SPECT) and cerebral angiography, but none of them demonstrated hemodynamic compromise before operation. Three patients were treated with CEA and off-pump CABG, and 2 were CEA and CABG with cardiopulmonary bypass. CEA preceded CABG, but the saphenous veins were taken in the course of endarterectomy. After CEA, the operative field was turned over to the cardiovascular team with the cervical wound being opened. Subsequently the cardiovascular team performed CABG with off-pump or pump. Off-pump CABG brought less blood loss from the cervical wound for the minimum anticoagulant than CABG with cardiopulmonary bypass.
No cardiac event occurred perioperatively, but 1 patient with transient neurological ischemic attack with tandem lesions had a transient neurological ischemic attack during hemodialysis on the day after the operation. All the patients were discharged without neurological deterioration.
Preoperative screening to the supra-aortic artery is helpful for evaluating the presence of carotid or intracranial vessels in patients undergoing CABG, and cerebral blood flow studies to clarify the cerebral hemodynamics are important for patients with both carotid and coronary occlusive diseases. It is still not clear what patients are suitable for the combined operation, but all the patients with high grade carotid stenosis can undergo the combined operation with off-pump CABG with the benefits of low morbidity and patient convenience.