- Email: [email protected]
Complications of Combined Brachiocephalic and Coronary Revascularization
CORRESPONDENCE
occlusion of grafts or endarterectomies and more likely to suffer embolism from unoperated plaques. In addition, the hematological changes introduced by the use of the pump oxygenator system may influence A number of recent reports have dealt with the per- the potential patency of smaller artificial grafts or of formance of combined carotid endarterectomy and endarterectomy sites inasmuch as they represent myocardial revascularization, including the paper by more thrombogenic surfaces. Perhaps it is worth reOkies and associates (Ann Thorac Surg 23:560, 1977). membering that direct coronary surgery was not sucIn each study, neurological complications have oc- cessful until the coronary vein bypass graft was used curred. Okies and associates report a combined mor- and we stopped directly attacking the coronary artality and neurological morbidity of nearly 20% (3 of teries. 16 patients) but conclude that these complications We currently prefer to operate the carotid arteries "seemed unrelated to the fact that these procedures first and take our chances with myocardial infarction, were done at one operation." which we find easier to treat than stroke. We will We have recently had experience with 4 patients in probably continue to combine innominate and corowhom combined brachiocephalic and coronary revas- nary artery surgery since they require the same incicularization was performed. Significant complica- sion. tions occurred in each patient: Joseph S. Carey, M . D . 1. An innominate artery bypass (8 mm Dacron) and Ramon A. Cukingnan, M.D. triple coronary artery bypass were performed; the 2001 Santa Monica Blvd, Suite 560 graft clotted ten days later, requiring reoperation to Santa Monica, C A 90404 perform an endarterectomy 2. Innominate endarterectomy, single coronary vein graft, and left aorta-subclavian vein bypass were performed; the patient sustained a right hemiplegia three days later (from which he completely Avoiding Gas Microemboli recovered), presumably related to a nonobstructive To The Editor: ulcerated plaque in the left carotid artery. 3. Left carotid endarterectomy and triple coronary With reference to the letter to the editor entitled "Exvein grafting were performed; three months later tracorporeal Pump Filter" (Ann Thorac Surg 24:197, the patient's carotid symptoms recurred, and an- 1977), I wish to give my experienced answer to the giography revealed restenosis of the endarterec- question of what to do to avoid introducing large tomized carotid artery which required reopera- numbers of gas microemboli into the patient at the onset of perfusion when using bloodless prime withtion. 4. A right carotid endarterectomy and triple coronary out an arterial filter. First of all, the basic rule should be not to produce vein graft were performed in a patient with bilatany gas bubbles in the arterial reservoir of the eral carotid stenosis; right hemiparesis occurred on the third postoperative day, but recovery was oxygenator or in the arterial perfusion line. These complete. Angiography three weeks later showed bubbles are released from the solution itself. This can occlusion of the right internal carotid artery at the be avoided by lowering and maintaining the temperasite of endarterectomy. A left carotid endarterec- ture of the prime between30" and 32°C during recirculation before bypass. Gas bubbles are released from tomy was subsequently performed. priming solution at 25°C (room temperature) when Thus of 4 patients 2 developed occlusion of the they come in contact with the heat exchanger, which carotid endarterectomy, and in a third a Dacron is probably set at 36" to 37°C. Acceleration of bubbling bypass occluded during the early postoperative even occurs when the priming solution is not recircuperiod; 2 strokes occurred, both related to disease of lated and when it is hyperoxygenated. The oxygen flow rate during recirculation should be the nonoperated carotid artery. Incidentally, the carotid endarterectomies were performed by highly reduced to 1 to 2 liters per minute. Any uncontrolled release of oxygen microbubbles experienced staff vascular surgeons who have an excannot be detrimental to the patient-the bubble will cellent track record. Although all 4 of these patients are currently doing be instantly absorbed by tissues. well, this series of complications has led us to conclude that the combination of vascular and coronary Frank C . Cieslak, B . S . , C.C.P. surgery may indeed influence the success of the indi- Cardiovascular Surgery Division vidual procedures. Patients with combined coronary Columbus-Cuneo-Cabrini Medical Center and vascular disease may have a more advanced type 2520 N Lakeuiew A u e of atherosclerosis. They may be more likely to develop Chicago, I L 60614
Complications of Combined Brachiocephalic and Coronary Revascularization To the Editor:
385
occlusion of grafts or endarterectomies and more likely to suffer embolism from unoperated plaques. In addition, the hematological changes introduced by the use of the pump oxygenator system may influence A number of recent reports have dealt with the per- the potential patency of smaller artificial grafts or of formance of combined carotid endarterectomy and endarterectomy sites inasmuch as they represent myocardial revascularization, including the paper by more thrombogenic surfaces. Perhaps it is worth reOkies and associates (Ann Thorac Surg 23:560, 1977). membering that direct coronary surgery was not sucIn each study, neurological complications have oc- cessful until the coronary vein bypass graft was used curred. Okies and associates report a combined mor- and we stopped directly attacking the coronary artality and neurological morbidity of nearly 20% (3 of teries. 16 patients) but conclude that these complications We currently prefer to operate the carotid arteries "seemed unrelated to the fact that these procedures first and take our chances with myocardial infarction, were done at one operation." which we find easier to treat than stroke. We will We have recently had experience with 4 patients in probably continue to combine innominate and corowhom combined brachiocephalic and coronary revas- nary artery surgery since they require the same incicularization was performed. Significant complica- sion. tions occurred in each patient: Joseph S. Carey, M . D . 1. An innominate artery bypass (8 mm Dacron) and Ramon A. Cukingnan, M.D. triple coronary artery bypass were performed; the 2001 Santa Monica Blvd, Suite 560 graft clotted ten days later, requiring reoperation to Santa Monica, C A 90404 perform an endarterectomy 2. Innominate endarterectomy, single coronary vein graft, and left aorta-subclavian vein bypass were performed; the patient sustained a right hemiplegia three days later (from which he completely Avoiding Gas Microemboli recovered), presumably related to a nonobstructive To The Editor: ulcerated plaque in the left carotid artery. 3. Left carotid endarterectomy and triple coronary With reference to the letter to the editor entitled "Exvein grafting were performed; three months later tracorporeal Pump Filter" (Ann Thorac Surg 24:197, the patient's carotid symptoms recurred, and an- 1977), I wish to give my experienced answer to the giography revealed restenosis of the endarterec- question of what to do to avoid introducing large tomized carotid artery which required reopera- numbers of gas microemboli into the patient at the onset of perfusion when using bloodless prime withtion. 4. A right carotid endarterectomy and triple coronary out an arterial filter. First of all, the basic rule should be not to produce vein graft were performed in a patient with bilatany gas bubbles in the arterial reservoir of the eral carotid stenosis; right hemiparesis occurred on the third postoperative day, but recovery was oxygenator or in the arterial perfusion line. These complete. Angiography three weeks later showed bubbles are released from the solution itself. This can occlusion of the right internal carotid artery at the be avoided by lowering and maintaining the temperasite of endarterectomy. A left carotid endarterec- ture of the prime between30" and 32°C during recirculation before bypass. Gas bubbles are released from tomy was subsequently performed. priming solution at 25°C (room temperature) when Thus of 4 patients 2 developed occlusion of the they come in contact with the heat exchanger, which carotid endarterectomy, and in a third a Dacron is probably set at 36" to 37°C. Acceleration of bubbling bypass occluded during the early postoperative even occurs when the priming solution is not recircuperiod; 2 strokes occurred, both related to disease of lated and when it is hyperoxygenated. The oxygen flow rate during recirculation should be the nonoperated carotid artery. Incidentally, the carotid endarterectomies were performed by highly reduced to 1 to 2 liters per minute. Any uncontrolled release of oxygen microbubbles experienced staff vascular surgeons who have an excannot be detrimental to the patient-the bubble will cellent track record. Although all 4 of these patients are currently doing be instantly absorbed by tissues. well, this series of complications has led us to conclude that the combination of vascular and coronary Frank C . Cieslak, B . S . , C.C.P. surgery may indeed influence the success of the indi- Cardiovascular Surgery Division vidual procedures. Patients with combined coronary Columbus-Cuneo-Cabrini Medical Center and vascular disease may have a more advanced type 2520 N Lakeuiew A u e of atherosclerosis. They may be more likely to develop Chicago, I L 60614
Complications of Combined Brachiocephalic and Coronary Revascularization To the Editor:
385