Simultaneous Coronary Artery Bypass and Carotid Endarterectomy Ye zhidong, Liu Peng Department of Cardiovascular Surgery China-Japan Friendship Hospital

Background Cardiovascular disease is No 1 which threaten human Cardiovascular disease is No 1 which threaten human Multisystem atherosclerosis often seen in clinic now Multisystem atherosclerosis often seen in clinic now Patient suffer from combination of ischemic heart disease and cerebrovascular insufficiency increase Patient suffer from combination of ischemic heart disease and cerebrovascular insufficiency increase Incidence of MI ↑ after CEA / incidence of cerebral infarction ↑ after CABG Incidence of MI ↑ after CEA / incidence of cerebral infarction ↑ after CABG

Background Bernhard and colleagues first reported the combined carotid and coronary artery surgery in 1972 Bernhard and colleagues first reported the combined carotid and coronary artery surgery in 1972 Since then about 100 article about this combined operation reported Since then about 100 article about this combined operation reported Byrne J and colleagues reported 758 cases with low morbidity and mortality (3.1%) Byrne J and colleagues reported 758 cases with low morbidity and mortality (3.1%) Combined carotid endarterectomy and coronary artery bypass grafting in patients with asymptomatic high-grade stenoses: an analysis of 758 procedures. J Vasc Surg Jul;44(1): Combined carotid endarterectomy and coronary artery bypass grafting in patients with asymptomatic high-grade stenoses: an analysis of 758 procedures. J Vasc Surg Jul;44(1):67-72.

Background Though promising surgical results and growing experience, CEA/CABG remains controversial Though promising surgical results and growing experience, CEA/CABG remains controversial –lack of consensus concerning indications for combined procedures indications for combined procedures intraoperative techniques for brain protection intraoperative techniques for brain protection sequence of operation sequence of operation outcome of the surgical treatment. outcome of the surgical treatment.

Patients and Methods From January of 2001 to May of 2006, 18 patients underwent combined unilateral carotid endarterectomy and CABG for severe cerebrovascular and ischemic heart From January of 2001 to May of 2006, 18 patients underwent combined unilateral carotid endarterectomy and CABG for severe cerebrovascular and ischemic heart Male 13, Female 5, Age ranged from years old Male 13, Female 5, Age ranged from years old Angiography were done for all cases to final diagnose Angiography were done for all cases to final diagnose

Preoperative findings No of patients (%) New York Heart Association class IIIIIIV Stable angina Unstable angina Previous myocardial infarction Left main coronary artery disease Double-vessel disease Triple-vessel disease 5(27.8)12(66.7)1(5.6)12(66.7)6(33.3)2(11.1)6(33.3)2(11.1)16(88.9)

Preoperative findings No.of patients(%) Asymptomatic cervical bruit Transient Ischemic Attacks (TIA) Histories of stroke without neurologic symptoms Residual neurologic symptomatology secondary to stroke

Risk Factors Observed Risk Factors No. of Patients (%) HypertensionHypercholesterolemia Diabetes mellitus Cigarette smoking 14 (77.8) 10 (55.6) 9 (50)

Severity of Extracranial Cerebrovascular Disease Carotid Stenosis No. of Patients (%) Occlusion with contralateral stenosis >70% Unilateral stenosis >70% with contralateral stenosis <50% Unilateral stenosis>90% Unilateral ulcerative plaque with <50% stenosis 2(11.1)10(55.6)5(27.8)1(5.6)

Type of Operations Type of procedure No.of patients CEA → CABG CABG → CEA Pump-on CABG Off-Pump CABG Using shunt Using Patch Femoral-Femoral bypass

Surgical technique General anesthesia General anesthesia CEA completed first (except 1 case) CEA completed first (except 1 case) –1mg/kg heparin –Shunt implantation –Patch closure running suture Pump on CABG for 5 cases Pump on CABG for 5 cases –CPB started with 28 ℃ –Cold blood cardioplegia Off-pump CABG for 13 cases Off-pump CABG for 13 cases

Results There was no death in our series There was no death in our series There were no cerebrovascular complications occur in our series There were no cerebrovascular complications occur in our series One case developed reversible facial nerve injury One case developed reversible facial nerve injury Others – –paroxysmal ventricular tachycardia, – –supraventricular tachycardia – – respiratory failure – –renal insufficiency – –hypertension

Follow up Follow-up period ranged from 3-36 months Follow-up period ranged from 3-36 months By telephone or out-patient department By telephone or out-patient department Questionnaire or ECG/Doppler Questionnaire or ECG/Doppler No cerebrovascular accident /TIA/angina occur No cerebrovascular accident /TIA/angina occur One case performed femoral-femoral bypass 1 month after CEA/CABG One case performed femoral-femoral bypass 1 month after CEA/CABG

Discussion: indications CEA CEA –Asypmtomatic carotid stenosis >90% –Sypmtomatic carotid stenosis >70% –Ulcer plaque related to ITA CABG CABG –Left main trunk stenosis of coronary A –Triple vessel disease –Unstable angina pectoris –Impaired heart function due ischemic heart

Discussion Shunt and Patch Shunt and Patch Off-pump or On-pump Off-pump or On-pump Intimal flap fixation Intimal flap fixation IABP standby IABP standby

Data restriction Fewer cases Fewer cases Follow-up short, no angiography Follow-up short, no angiography

Coclusions CEA/CABG can be done for high risk patients who suffer both cerebrovascular and ischemic heart disease CEA/CABG can be done for high risk patients who suffer both cerebrovascular and ischemic heart disease It is alter option for this kind of patients It is alter option for this kind of patients Low mortality and morbidity can achieved if restrict indication and careful follow the right procedure Low mortality and morbidity can achieved if restrict indication and careful follow the right procedure Further study needed Further study needed