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Ann Thorac Surg 1998;66:1230-1235
© 1998 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Rapid-staged strategy for concomitant critical carotid and left main coronary disease with left ventricular dysfunction: IABP use

^a Cardiovascular Institute of the South, Columbia Medical Center of Southwest Louisiana, Lafayette, Louisiana, USA

Address reprint requests to Dr Allie, Cardiovascular Institute of the South, PO Box 61160, Lafayette, LA 70596-1160
e-mail: (paulr{at}globalreach.net)

Presented at the Forty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Naples, FL, Nov 6–8, 1997.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Few reports address the high-risk patient population with concomitant critical carotid and left main coronary disease with left ventricular dysfunction. To decrease the risks involved with the simultaneous and traditional staged surgical approaches, we developed a rapid staging strategy using an intraaortic balloon pump.

Methods. Between 1992 and 1996, 20 patients presented with a high-risk "triad" defined by greater than 70% stenosis of the left main coronary artery, ejection fraction less than 0.30, and greater than 90% stenosis of the internal carotid artery. An intraaortic balloon pump was placed immediately before carotid endarterectomy under angiographic guidance. Less than 24 hours later (mean, 18 hours) coronary artery bypass grafting was performed, and the intraaortic balloon pump was removed the day of coronary artery bypass grafting in all cases (total IABP duration, <36 hours).

Results. Eighteen patients (18/20) were extubated on the day of coronary artery bypass grafting (mean, 12 hours). Sixteen patients (16/20) were transferred from the intensive care unit within 48 hours, with total hospital stay ranging from 6 to 12 days (mean, 8 days). There were no 30-day postoperative deaths, myocardial infarctions, or neurologic, vascular, bleeding, or other major complications. At a mean 29.4-month follow-up, there were two noncardiac deaths and no neurologic events. Six-month, 1-year, and 2-year follow-up ultrasounds showed all operative carotid arteries remained patent.

Conclusions. A rapid staged procedure with angiographically guided placement of the intraaortic balloon pump was safe and effective in this very high risk patient population. It may be an option to decrease the risks involved with simultaneous operations and increase the efficiency and safety of "traditional" staged carotid and coronary artery bypass grafting procedures.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Patients presenting with coexisting critical carotid artery disease and coronary artery disease remain at high risk and represent a still controversial management problem. The rate of cerebrovascular accidents during coronary artery bypass grafting (CABG) is reported to be from 2% to 12% [1]. Concomitant coronary and internal carotid artery disease coexist in 2.4% to 22% of cases [2–6]. Patients with severe (>80%) uncorrected internal carotid artery disease have up to a 14% risk of cerebrovascular accident during CABG, and carotid artery disease is the most powerful predictor of cerebrovascular accident during CABG [2–7]. Likewise, carotid endarterectomy (CEA) performed in the setting of severe uncorrected coronary disease has been associated with an up to 20% operative mortality, with myocardial infarction responsible for 50% to 75% of all late deaths in this group [1, 8].

In 1972, Bernhard and colleagues [9] reported 16 patients undergoing a combined CABG and CEA to decrease the operative risks associated with treating coexisting carotid and coronary disease. Since then, several reports have described various staged and simultaneous approaches. Earlier series favored a staged approach as excessive mortality and morbidity were reported with a simultaneous approach [10, 11]. More recent reports have cited lower mortality and morbidity, and current recommendations tend to favor a simultaneous surgical approach [5, 12–15].

A collective review of the literature reveals only 12 reported experiences of more than 100 patients undergoing the simultaneous approach and demonstrate a mean perioperative death and cerebrovascular accident rate of 8.2% (range, 4.19% to 14.6%) (Table 1). These reports, all nonrandomized and retrospective over many years, are characterized by disparate selection criteria, multiple clinical variables, a broad range of results, and ill-defined conclusions about the optimal treatment of coexisting carotid and coronary artery disease.

	Material and methods

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Patients
From January 1, 1992, to December 31, 1996, a total of 60 patients with coexisting coronary and carotid disease requiring surgical revascularization presented to the start-up cardiovascular program at our small to medium-sized community hospital. These patients represented 6% of the 997 patients who required CABG at our institution. Twenty (33%) of these 60 patients were considered very problematic, according to criteria set forth in the high-risk triad described below, and are the basis for this report.

High-risk triad
All patients underwent a screening carotid ultrasound to predict significant disease; those with significant disease underwent simultaneous carotid and coronary angiography in the catheterization laboratory. The triad of coexisting high-risk conditions included (1) critical asymptomatic internal carotid artery disease, defined by greater than 90% stenosis; (2) critical left main coronary artery disease, defined by the presence of greater than 70% stenosis; and (3) poor left ventricular function, defined as an ejection fraction of less than 0.30. Patients identified as high risk, according to these criteria, were referred for immediate surgical consultation in the catheterization laboratory, and we developed a rapid staged strategy of care tailored specifically for this group of patients.

Operative procedure
To minimize the risks involved in simultaneous CEA and CABG procedures previously recommended in our group of high-risk patients, a rapid staged approach was developed to combine CEA and CABG procedures with placement of an IABP. The same surgical team and surgeon performed all of the procedures in this series. Angiography of the abdominal and iliac arteries was performed in all patients identified to have high-risk carotid and coronary disease, and the femoral sheath was left in place. Vascular aneurysmal disease, atherosclerotic disease, thrombotic debris, and tortuosity were all identified, and an appropriate iliac artery that would allow subsequent safe angiographic guidance of the IABP was chosen.

The amount of total nonionic contrast used ranged from 10 to 20 mL (mean, 15 mL). This additional nonionic contrast load only added a maximum of 20 mL to the amount used in each procedure, and was not considered a clinical risk to the patient. A Swan-Ganz catheter was placed immediately through the jugular vein, contralateral to the critical internal carotid artery lesion, and the patient was then transferred to the intensive care unit (ICU) with the femoral sheath left in place.

Intensive medical therapy, including intravenous nitroglycerin, heparin, dobutamine, intravenous antibiotics, and a continuous furosemide (Lasix; Hoechst-Roussell, Somerville, NJ) volume drip and renal-dose dopamine, was then instituted. All patients responded to the medical therapy and did not require an IABP to be placed immediately for cardiac stabilization.

Carotid endarterectomy was scheduled as the last case of the next day after the patient was admitted to the ICU. An IABP was fluoroscopically placed immediately preoperatively in the catheterization laboratory through the predetermined safest ileofemoral route. It is thought that minimization of total IABP time is critical to decreasing risks involved with the IABP itself and maximizing its hemodynamic effects.

Heparin administration was stopped 1 hour before placement of the IABP, and administration of dextran 40 (20 mL/h) was started for antiplatelet effect. Patients were transferred immediately to the operating room, where the CEA was performed under general anesthesia using a balanced technique with moderate-dose barbiturate anesthesia. All patients were given 1 g of intravenous methylprednisolone sodium succinate (Solu-Medrol; Upjohn, Kalamazoo, MI) for cerebral protection. All procedures incorporated carotid shunting, a Dacron patch, continuous dextran 40 (20 mL/h) and 8,000 u heparin intravenous bolus, 50% protamine reversal, meticulous blood glucose monitoring to keep the level less than 250 mg/dL, and maintenance of high cerebral perfusion pressures with a mean of at least 80 mm Hg or 20% greater than the mean blood pressure the patient obtained the previous night in the ICU. Meticulous local hemostasis and liberal use of topical thrombin were used. A drain was not used. Intraoperative management included arterial line monitoring, Swan-Ganz catheter management, and liberal phenylephrine hydrochloride and nitroglycerin administration. All patients awoke within 30 minutes of the CEA without clinical sequelae and remained hemodynamically stable during the operation with the IABP in place. Overnight management in the ICU included IABP support, continuous infusion of dextran, and intravenous infusion of nitroglycerin and inotropic support as dictated by standard Swan-Ganz monitoring. Heparin administration was not restarted.

All patients underwent CABG as an early first case the next morning. Mild systemic hypothermia (34°C) was induced with high bypass flows maintained to achieve a cardiac index of 2.75 to 3.0 L/mm² to sustain a systemic mean pressure of 80 mm Hg while the patient was on bypass. All distal anastomoses were completed first. Proximal anastomoses were created under partial occlusion or total cross-clamp occlusion, depending on the calcification present in the ascending aorta. After full heparin reversal, all patients received intravenous desmopressin acetate (Stimate; Armour Pharmaceutical Company, Collegeville, PA), 0.3 g/kg of body weight, and 2 g of aminocaproic acid (Amicar; Immunex Corporation, Seattle, WA) for hemostatic assurance. All patients were weaned off of bypass on their first attempt with moderate inotropic support and IABP. The IABP was rapidly weaned and removed in all patients the day of CABG (mean, 6 hours), and 18 of 20 (90%) were extubated the same day. A fast-track recovery strategy, as described previously [23, 24], was used in all cases.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
The demographics, clinical characteristics, and outcomes of the 20 patients presenting with the high-risk triad and treated with a rapid staged approach using an IABP are summarized in Table 2.

Table 3 reviews the operative characteristics and ICU profiles of the 20 patients in this report.

	Comment

Top Abstract Introduction Material and methods Results Comment References

Surgical treatment options for patients with coexisting carotid and coronary artery disease include a traditional staged or reversed staged surgical approach and a simultaneously surgical approach, with recent trends toward the simultaneous approach being recommended.

The emergence of a simultaneous operative approach for treating coexisting carotid and coronary artery disease has the assumed advantage of lower cost, less exposure to anesthetic, shorter ICU and hospital stays, and decreasing risks of coronary and cerebral events. Proponents of the simultaneous approach report that it is as safe as the staged approach yet the mortality and morbidity remain substantial. The morbidity and mortality in the six series reporting more than 100 patients since 1992 was 7.1%, despite the fact that myocardial infarction was not reported in two of the six series (see Table 1). Unfortunately, there are no large-scale, prospective, randomized trials comparing outcomes of these approaches.

Only 12 studies reporting more than 100 patients treated with the simultaneous approach exist in the literature (see Table 1). These studies demonstrate a mean mortality and cerebrovascular accident incidence of 8.2%. Few patients with clinical triad described in this report are even identified in those larger series, leaving little clinical guidance. In 1992, Myers and colleagues [26] first reported their experience in 5 patients with simultaneous symptomatic three-vessel coronary artery disease and symptomatic carotid artery disease. The investigators placed an IABP before performing CEA, which was followed by CABG 24 hours later. All 5 patients did well and were discharged between 7 and 13 days after the procedures. One patient required a femoral embolectomy, and another patient required a femoral artery pseudoaneurysm repair several weeks later. There are no other reported series using an IABP during a staged-repair strategy for combined carotid and coronary artery disease.

Cambria and colleagues [27] and Akins and colleagues [12] placed an IABP in 20% of their separately reported series of patients undergoing simultaneous repair. However, the investigators did not include specific data regarding this subgroup of patients.

An IABP has been reported for cardiac support during noncardiac operations, and its physiology has been well-described [28]. Most recently, the IABP has been used favorably in patients with an ejection fraction less than 0.25 and in rapid recovery protocols in elderly high-risk patients [24, 29]. Recent reports have documented decreasing overall IABP complication rates to be less than 2% [30, 31].

With this as background, a low threshold for IABP use has been adapted since 1992 and a rapid staged repair strategy that includes the IABP has been used in all patients presenting with the clinical triad described in this report.

In our present series, all 20 patients represent what was considered the highest risk population among patients with coexisting coronary and carotid artery disease. Our rapid staged strategy for treating each of these patients resulted in no major cardiac or cerebral complications. Integral to this strategy are (1) an integrated close working relationship with the cardiologist, (2) routine preoperative carotid artery ultrasound screening, (3) angiographically guided IABP placement immediately before CEA, (4) rapid staging of CABG the next morning with IABP in place, (5) rapid IABP removal the same day of CABG, and (6) standard "fast-track" recovery protocol.

We recognize the potential criticism of this series to be its retrospective, nonrandomized nature and small overall number of patients. Cost issues also are not addressed in this report. Still, we believe this subset of 20 high-risk patients allows the conclusion that the rapid staged repair strategy for simultaneous critical carotid disease and severe left main coronary artery disease with poor left ventricular function with use of an IABP is both safe and effective.

In summary, we believe the rapid staged approach using an IABP may be an option to decrease the risks involved with simultaneous operations and increase the efficiency and safety of the "traditional" staged carotid and CABG procedures, and we recommend its expanded use. Until a well-designed, multicenter, multiarm, prospective, randomized trial is conducted, controversy will still abound in the management recommendations for the high-risk patient population presenting with concomitant carotid and coronary artery disease. An appropriate trial is needed.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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