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Management of patients with severe, coexistent coronary artery and peripheral vascular disease
Management of patients with severe, coexistent coronary artery and peripheral vascular disease The coexistence of severe coronary artery and peripheral vascular lesions is not uncommon. Although diagnostic and sequential therapeutic techniques are standardized, the priority of surgical treatment is unresolved. Eight cases are reported in which simultaneous surgical correction of coronary atherosclerosis and carotid atherosclerosis, abdominal aortic aneurysm, or aortoiliac atherosclerosis was accomplished with success. Two additional cases demonstrate the complications which can occur when coexistent lesions are not corrected simultaneously. The surgical techniques employed are discussed. Because of these results, a further clinical trial seems warranted.
Robert L. Reis, M.D., and Hamner Hannah III, M . D . , Kansas City, Kan., and Kansas City, Mo.
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v ^ o r o n a r y artery and peripheral vascular atherosclerosis frequently coexist in the same patient. Occasionally, both the coronary and peripheral vascular lesions are severe, and each may cause significant symptoms or even be life threatening. This situation poses a therapeutic dilemma, because an operation to correct one vascular lesion may be attended by hypotension or hypertension with untoward effects related to the other vascular lesion. Although stenosis of the carotid artery or aneurysm of the abdominal aorta in association with coronary artery disease constitute the most serious combinations, patients with associated aortoiliac atherosclerotic occlusive disease may also present difficult problems. Thorough preoperative angiographic assessment of all vascular lesions facilitates management of these patients. Performing sequential operations with sophisticated physiological monitoring is one therapeutic approach. Simultaneous operative correction of coexistent lesions is another. The following case reports illustrate the principles or value of simultaneous surgical correction of coexistent, severe coronary and peripheral arterial occlusive disease. From the Section of Cardiothoracic Surgery, University of Kansas Medical Center, Kansas City, Kan. 66103, and the Department of Surgery, Menorah Medical Center, Kansas City, Mo. 64110. Received for publication Nov. 17, 1976. Accepted for publication Jan. 12, 1977.
Case reports Clinical data are summarized in Table I. CASE 1. F. B., a 55-year-old man, had severe, stable angina pectoris and an enlarging, 6 cm. aneurysm of the abdominal aorta (Fig. 1, D). Coronary angiograms disclosed severe three vessel disease (Fig. I, A to C). On April 12, 1973, the left anterior descending and obtuse marginal coronary arteries were bypassed with segments of autogenous saphenous vein, after which the abdominal aortic aneurysm was excised. He survived operation and remained well with only occasional angina at 2 year's follow-up. Comment. This patient was our first to undergo simultaneous correction of remote, coexistent, severe vascular lesions. Total blood replacement was high (27 units) because of postoperative mediastinal hemorrhage. This degree of blood replacement was considerably in excess of the average of 4 units for an openheart operation in our experience, but there were no bleeding problems of this magnitude in subsequent cases (vide infra). CASE 2. E. J. had unstable angina pectoris and a large aneurysm of the abdominal aorta. He was 58 years old and had had a myocardial infarction 6 years prior to admission. The coronary arterial and abdominal aortic lesions are shown in Fig. 2. On Feb. 2, 1974, he underwent bypass of the left anterior descending and circumflex coronary arteries followed by excision of the 12 cm. aneurysm of the abdominal aorta. Blood replacement during hospitalization was 8 units. The patient survived the operation and was well until lost to follow-up a year later. 909
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Fig. 1. PatientF. B., Case 1. Coronary angiograms demonstrate (A) total occlusion of right coronary artery, (B) stenosis of left anterior descending coronary artery proximal to first diagonal branch, and (C) late filling of distal obtuse marginal branch of circumflex system. D, Anteroposterior x-ray film of abdomen demonstrates aneurysm of abdominal aorta. Comment. The unstable nature of the angina pectoris and the tremendous size of the abdominal aneurysm prompted simultaneous operations. CASE 3. J. G., a 56-year-old man, had severe angina pectoris and a large aneurysm of the abdominal aorta. Cardiac
catheterization disclosed arteriosclerosis of the right and left coronary arteries. The patient underwent bypass of the left anterior descending and right posterior descending coronary arteries with autogenous saphenous vein on cardiopulmonary bypass. The procedure was followed immediately by abdominal aortic aneurysmectomy. His postoperative course was
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Fig. 2. Patient E. J., Case 2. Coronary angiograms demonstrate (A) normal right coronary artery with retrograde filling of totally occluded left anterior descending branch via septal and apical collaterals and (B) severe atherosclerosis of obtuse marginal branch of circumflex system and of first diagonal branch of left anterior descending. C, Anteroposterior x-ray film of abdomen demonstrates large aneurysm of abdominal aorta. somewhat protracted because of difficulties in increasing activity and because of pneumonia, which responded to antibiotics. He received 7 units of blood during his initial hospitalization. It was necessary to readmit this patient 2 weeks after discharge because of severe iliofemoral thrombophlebitis of the left leg. This problem was ultimately controlled with elevation of the left leg, anticoagulants, and elastic stockings. Comment. This patient was virtually impossible to mobilize postoperatively. The combination of inactivity, removal of the greater saphenous vein, and intra-abdominal dissection near the external iliac vein no doubt precipitated the severe iliofemoral thrombophlebitis. CASE 4. E. W., a 66-year-old man, had severe, stable angina pectoris. Shortly before admission, he had had transient ischemic episodes with left hemiparesis. Angiograms
Table I. Clinical data Patient F. B. E. J. J. G. E. W. N. E. R. D. A. D. D. S. L. W. M. V.
Age (yr.), sex 55, 58, 56, 66, 69, 54, 65, 40, 66, 57,
M M M M F M F F F M
Operation Double ACB and AAA Double ACB and AAA Double ACB and AAA Double ACB and bilateral CE Double ACB and bilateral CE Triple ACB and unilateral CE Triple ACB and unilateral CE Triple ACB and AFB Double ACB; postop. TIA; CE Triple ACB; postop. pregangrenous left leg; AFB
Legend: ACB, Aorta-coronary artery bypass. AAA, Abdominal aortic aneurysraectomy. CE, Carotid endarterectomy. AFB, Aortofemoral bypass. TIA, Transient ischemic attacks.
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Fig. 3 . Patient E. W., Case 4. Coronary angiograms demonstrate (A) patent right coronary artery with retrograde filling of totally occluded left anterior descending and (B) stenosis of left main coronary artery with visualization of obtuse marginal branch of circumflex system. Cervicocephalic angiograms show plaques in (C) right and (D) left internal carotid arteries (subtraction technique). showed severe disease of the left anterior descending and circumflex coronary arteries (Fig. 3, A andB) and stenosis of both internal carotid arteries (Fig. 3, C and/)). On Aug. 15, 1974, he underwent saphenous vein bypass of the left anterior descending and circumflex coronary arteries and bilateral carotid endarterectomy. His postoperative course was uncomplicated, and his blood requirement was 5 units. CASE 5. N. E., a 69-year-old woman, had severe angina pectoris, episodes of recurrent dizziness, and symptoms of intermittent claudication. Cardiac catheterization disclosed significant coronary atherosclerosis, and cervicocephalic angiograms demonstrated bilateral carotid artery stenosis. She underwent bypass of the left anterior descending and obtuse marginal coronary arteries and bilateral carotid endarterec-
tomy on cardiopulmonary bypass support. Her postoperative course was generally uncomplicated. The woman received 5 units of blood during her hospitalization. CASE 6. R. D., a 54-year-old man, had significant angina pectoris, an asymptomatic right carotid bruit, and aortoiliac atherosclerosis with probable gluteal claudication. He underwent bypass of the left anterior descending, diagonal, and obtuse marginal coronary arteries with autogenous saphenous vein and endarterectomy of the right carotid artery, all with the support of cardiopulmonary bypass. Postoperatively, he described a small defect of vision and was found to have a lesion in the right retina indicative of a small embolus. Otherwise, he did well. He received 4 units of blood during his hospitalization.
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Fig. 4. Patient A. D., Case 7. Coronary angiograms demonstrate (A) total occlusion of right coronary artery and (B) stenosis of left anterior descending coronary artery at origins of first diagonal and first septal perforator branches.
Fig. 4. Cont'd. C, Coronary angiogram demonstrating stenosis of circumflex coronary artery. D, Cervicocephalic angiogram shows stenosis of right internal carotid artery (subtraction technique). CASE 7. A. D., a 65-year-old woman, had severe, stable angina pectoris and had experienced left hemiparesis 6 weeks prior to admission. Although this episode would have to be considered a completed stroke because of its duration, she had a complete neurologic recovery. Coronary and carotid angiograms are shown in Fig. 4. On Nov. 21, 1975, she underwent saphenous vein bypass of the circumflex, first diagonal, and left anterior descending coronary arteries as well as right carotid endarterectomy. She did well postoperatively, having required 10 units of blood.
Comment. We performed carotid endarterectomy with the aid of cardiopulmonary bypass in order to take advantage of hypothermia, control of perfusion pressure, anticoagulation with heparin, and the improved rheologic properties of blood with hemodilution. CASE 8. L. W., a 66-year-old woman, was admitted with severe angina pectoris of recent onset. Coronary angiograms
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Fig. 5. Patient L. W., Case 8. A, Coronary angiogram demonstrates stenosis of left anterior descending branch. B, Cervicocephalic angiogram shows complete occlusion of the left internal carotid artery. disclosed significant stenosis of the left anterior descending coronary artery (Fig. 5, A). OnJan. 2, 1975, she underwent saphenous vein bypass of the left anterior descending coronary artery and its first diagonal branch. She received 3 units of blood. On Jan. 4, 1975, she experienced somnolence and weakness of the right arm and face. The blood pressure was 100/60 mm. Hg. The blood pressure was increased with vasopressors and intravascular volume augmentation, and the neurologic symptoms disappeared. In addition, a left carotid bruit became audible. Upon questioning, the patient related two episodes of amaurosis fugax on the left several weeks prior to admission. Carotid angiograms (Fig. 5, B) demonstrated complete occlusion of the left internal carotid artery. Endarterectomy of the left carotid artery was performed on Jan. 10, 1975, and the patient subsequently did well. Comment. This case illustrates the importance of careful preoperative assessment of the condition of the patient in general and of associated vascular disease in particular. In addition, it demonstrates the problem of possible stroke following aorta-coronary artery bypass in patients with carotid stenosis. Compare this case with Cases 4 , 5 , 6 , and 7, in which simultaneous operations were employed and, except for the small retinal embolus in Case 6, the postoperative courses were uncomplicated. Endarterectomy of the left carotid artery was performed despite complete occlusion of the internal branch because of the recent onset of symptoms, the suspicion of recent thrombosis of the left internal carotid artery, and the possible benefits of relieving external carotid stenosis 1 (presumed present because of the bruit).
CASE 9. D. S., a 40-year-old woman, had severe, stable angina pectoris and severe, intermittent claudication. Coronary angiograms disclosed disease of the left anterior descending and circumflex systems. Abdominal angiograms disclosed significant aortoiliac atherosclerosis. On Oct. 16, 1975, she underwent bypass of the circumflex, first diagonal, and left anterior descending coronary arteries with autogenous saphenous vein, followed by aortofemoral bypass with a knitted Dacron prosthesis. She did well postoperatively. Ten units of blood was required. Comment. In general, aortoiliac occlusive disease is corrected sequentially. In this case, however, the coronary bypass procedure was facile, and we elected to proceed with revascularization of the legs. The possible advantage of this approach is illustrated by the following case. CASE 10. M.V., a 57-year-old man, was admitted with severe, stable angina pectoris and severe, intermittent claudication. He had no pulses in either leg and had cervical bruits. An extensive angiographic evaluation disclosed severe coronary atherosclerosis and mild aortic regurgitation (Fig. 6, A and B), total occlusion of the right subclavian artery with right "subclavian steal" (Fig. 6, C and D), and significant aortoiliac and femoropopliteal atherosclerosis (Fig. 6, E and F). He had no cerebrovascular symptoms. On Oct. 30, 1975, saphenous vein bypass of the left anterior descending, right posterior descending, and circumflex coronary arteries was accomplished. This phase of the operation was quite difficult because of the aortic regurgitation and severity of coronary atherosclerosis. Therefore, we elected not to proceed with aortofemoral bypass. Four units of blood was infused following this operation. On Nov. 1, 1975, severe vascular insuf-
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1 Fig. 6. Patient M. V., Case 10. A, Left coronary angiogram demonstrates absent left anterior descending, patent obtuse marginal, and filling of posterior descending branch of totally occluded right coronary artery via collaterals. B, Aortic root injection shows two-plus aortic regurgitation.
Fig. 6. Cont'd. Cervicocephalic angiograms disclose (C) occlusion of right subclavian artery and (D) late visualization of right vertebral and axillary arteries (arrows) consistent with "subclavian steal." E and F, Abdominal aortograms demonstrate severe aortoiliac occlusive disease.
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ficiency of the left leg developed. Armed with the abdominal aortic angiograms, we performed urgent aortofemoral bypass, and the patient subsequently did well. Three additional units of blood was required. Comment. This case illustrates several points. First, coexisting vascular disease can be highly complex. Second, even aortoiliac disease, which is not usually viewed as life threatening, can rapidly escalate in importance, especially during periods of low cardiac output. Finally, thorough preoperative angiographic analysis is of value. Such evaluation not only allows planning of simultaneous procedures but also facilitates urgent sequential procedures by avoiding the need for angiograms in seriously ill patients, as was required in Case 8. Discussion The coexistence of coronary artery and peripheral vascular disease is well known. Myocardial infarction is the major cause of death following excision of aneurysms of the abdominal aorta 2-5 and contributes to the incidence of late death following carotid endarterectomy . 6 Tomatis and his associates7 performed coronary angiograms in 100 consecutive patients admitted for evaluation of peripheral vascular disease and found a 50 per cent incidence of coexistent, severe coronary artery disease (70 per cent stenosis of at least one major coronary artery). Although the diagnosis and surgical management of vascular lesions has become relatively standardized, the therapeutic dilemma of priority of surgical treatment in the setting of coexistent, severe lesions is less well resolved. Abdominal aortic aneurysmectomy and aortofemoral bypass are attended by the possibility of myocardial infarction during episodes of hypertension or hypotension in the operative and postoperative periods. Aorta-coronary bypass in the patient with an abdominal aortic aneurysm may be complicated by rupture of the aneurysm secondary to episodic hypertension, and the situation may be compounded by the hypocoagulable state which frequently follows cardiopulmonary bypass. Even severe aortoiliac occlusive lesions can be the site of postoperative complications in an occasional patient after aorta-coronary artery bypass (Case 10). Carotid stenosis in combination with hypotension, which not uncommonly occurs during or following aorta-coronary artery bypass, can cause cerebral ischemia (Case 8). On the other hand, carotid endarterectomy cannot be performed without concern for myocardial infarction in a patient with serious coronary occlusive disease.6 Because of these concerns and considerations, selected patients are candidates for simultaneous correc-
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tion of the coronary and peripheral vascular lesions. This report details 8 cases (1 to 7 and 9) in which simultaneous surgical correction of combinations of coronary artery disease and abdominal aneurysm, carotid stenosis, or aortoiliac atherosclerosis was successful. Two additional cases (8 and 10) illustrate problems which can arise when coexistent, significant vascular lesions are not corrected simultaneously. Although the addition of another operation, especially one involving the abdominal aorta, increases the need for blood transfusion, the total probably does not exceed that required for sequential procedures and therefore seems a minor disadvantage of the simultaneous approach. Bernhard and associates8 reported their experience with simultaneous versus sequential operations in patients with carotid stenosis and coronary atherosclerosis in 1972. Three of 15 patients in the group treated sequentially died of myocardial causes following carotid endarterectomy, whereas 16 patients underwent simultaneous operations without morbidity or deaths. Nunn6 has recently emphasized that coronary atherosclerosis is a major cause of late death (58 per cent) following carotid endarterectomy. Shore,9 Okies,10 and Fogarty11 have reported their experience with simultaneous surgical management of patients with coronary and carotid atherosclerosis. Diethrich12 has described this approach in patients with combinations of coronary and distal aortic disease as well as carotid stenosis. Absolon13 described a patient who underwent successful, simultaneous aorta-coronary artery bypass, left ventricular aneurysmectomy, and abdominal aortic aneurysmectomy. Because of the collected experience with simultaneous operations, a further clinical trial seems warranted. The protocol which we employed in patients with coexistent coronary and peripheral vascular lesions is as follows: Systemic perfusion during cardiopulmonary bypass is accomplished via a cannula in the ascending aorta. Patients with large or symptomatic aneurysms of the abdominal aorta undergo aneurysmectomy after aorta-coronary artery bypass and attainment of mediastinal hemostasis. Following completion of aortacoronary artery bypass, the sternum is approximated, but the upper rectus fascia is left open and the incision is extended to the symphysis pubis. Aneurysmectomy is accomplished with regional heparinization of the lower extremities. A knitted Dacron prosthesis is preclotted and employed for reconstruction of the abdominal aorta. Patients with severe, coexistent aortoiliac disease undergo preoperative angiographic studies. If the coronary phase of the operation is facile, aortofemoral bypass is accomplished with a preclotted,
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knitted, Dacron prosthesis during the same episode of general anesthesia. If the coronary phase is difficult, aortofemoral bypass is deferred for 6 weeks unless complications (Case 10) prompt earlier intervention. Patients with coexistent carotid stenosis, symptomatic or asymptomatic (bruit only), undergo cerebrovascular angiograms preoperatively (Case 3). Carotid endarterectomy was accomplished with cardiopulmonary bypass in the cases (4, 5, 6, and 7) reported here. Bypass allows precise control of perfusion pressure and the induction of cerebral hypothermia and thus eliminates the need for a shunt in the absence of severe contralateral carotid stenosis. Heparinization and hemodilution are also salutory features of this approach. Fogarty11 and others8, l0 have performed carotid endarterectomy prior to institution of cardiopulmonary bypass. Monitoring of left atrial or pulmonary artery pressure, systemic arterial pressure, the electrocardiogram, chest drainage, and urine flow facilitates the intraoperative and postoperative management of these patients. Whether vascular lesions are managed simultaneously or sequentially, careful monitoring of appropriate physiological parameters is invaluable. Correction of asymptomatic carotid stenosis and bilateral carotid endarterectomy are controversial. Although Levin and Sondheimer14 question the wisdom of operating upon the contralateral, stenotic carotid artery, Javid,15, 18 Thompson,17, 18 and their associates have favored correction of asymptomatic lesions. Hickey19 reported successful bilateral carotid endarterectomy in 9 patients, despite depression of carotid body response to hypoxic stimuli postoperatively. Inordinate hypertension following carotid endarterectomy is probably the result of neurologic damage rather than instability of the carotid sinus.20 Although we have approached the problem of coexistent vascular lesions in patients admitted primarily for coronary disease, a similar thesis can be developed for patients admitted for treatment of peripheral vascular disease. As Tomatis and associates7 have shown, 50 per cent of such patients have severe coronary atherosclerosis. As the safety of aorta-coronary artery bypass increases, more of these patients may be candidates for simultaneous operations. In any event, their care is facilitated by sophisticated physiological monitoring. Finally, we believe the simultaneous approach should be considered in patients with combinations of carotid atherosclerosis and aortoiliac atherosclerosis or abdominal aneursym,21 although some authors question this approach.22 If the continued success of the simultaneous surgical approach to coexistent, severe vascular disease can be
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demonstrated, the physiological, psychological, and economic advantages of avoiding rehospitalization are obvious. We gratefully acknowledge the important role of our colleagues in cardiology, especially Dr. David M. Pugh and Dr. Lawrence L. Cohen, in the preoperative evaluation of these patients. We also acknowledge the efforts of Ms. Jane Gottlieb, Ms. Ruth Long, and Ms. Emma Theis in preparation of the manuscript. REFERENCES 1 Connolly, J. E., and Stemmer, E. A.: Endarterectomy of the External Carotid Artery: Its Importance in the Surgical Management of Extracranial Cerebrovascular Disease, Arch. Surg. 106: 799, 1973. 2 De Bakey, M. E., Crawford, E. S., Cooley, D. A., Morris, G. C , Jr., Royster, T. S., and Abbott, W. P.: Aneurysm of the Abdominal Aorta: Analysis of Results of Graft Replacement Therapy One to Eleven Years After Operation, Ann. Surg. 160: 622, 1964. 3 Szilagyi, D. E., Smith, R. F., DeRusso, F. J., Elliott, J. P., and Sherrin, F. W.: Contribution of Abdominal Aortic Aneurysmectomy to Prolongation of Life, Ann. Surg. 164: 678, 1966. 4 Baker, A. G., Jr., and Roberts, B.: Long-Term Survival Following Abdominal Aortic Aneurysmectomy, J. A. M. A. 212: 445, 1970. 5 Yashar, J. J., Indeglia, R. A., and Yashar, J.: Surgery for Abdominal Aortic Aneurysm: Factors Affecting LongTerm Results, Am. J. Surg. 123: 398, 1972. 6 Nunn, D. B.: Carotid Endarterectomy: An Analysis of 234 Operative Cases, Ann. Surg. 182: 733, 1975. 7 Tomatis, L. A., Fierens, E. E., and Verbrugge, G. P.: Evaluation of Surgical Risk in Peripheral Vascular Disease by Coronary Arteriography: A Series of 100 Cases, Surgery 71: 429, 1972. 8 Bernhard, V. M., Johnson, W. D., and Peterson, J. J.: Carotid Artery Stenosis: Association With Surgery for Coronary Artery Disease, Arch. Surg. 105: 837, 1972. 9 Shore, R. T., and Johnson, W. D.: Combined Surgical Treatment for Coronary Artery Surgery Complicated by Extracranial Carotid Disease (Abstr.), Chest 66: 336, 1974. 10 Okies, J. E., MacManus, Q., and Starr, A.: Myocardial Revascularization and Carotid Endarterectomy: A Combined Approach? (Abstr.), Chest 68: 422, 1975. 11 Fogarty, T. J.: Personal communication. 12 Diethrich, E. B., Samorano, C , and Koopot, R.: Simultaneous Correction of Coronary and Peripheral Vascular Arterial Lesions (Abstr.), Chest 68: 409, 1975. 13 Absolon, K. B., Bashour, F. A., and Kechejian, S.: Simultaneous Coronary Artery Bypass, Peripheral Endarterectomy, Ventricular Aneurysm Repair and Abdominal Aortic Graft Replacement: Twenty-fifth Congress, J. Soc. Int. Chir. p. 127, 1971. 14 Levin, S. M., and Sondheimer, F. K.: Stenosis of the Contralateral Carotid Artery: To Operate or Not, Vase. Surg. 7: 3, 1973.
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15 Javid, H., Ostermiller, W. E., Hengesh, J. W., Dye, W. S., Hunter, J. A., Najafi, H., and Julian, O. C : Carotid Endarterectomy for Asymptomatic Patients, Arch. Surg. 102: 389, 1971. 16 Javid, H., Ostermiller, W. E., Hengesh, J. W., Dye, W. S., Hunter, J. A., Najafi, H., and Julian, O. C : Natural History of Carotid Bifurcation Atheroma, Surgery 67: 80, 1970. 17 Thompson, J. E.: The Development of Carotid Artery Surgery, Arch. Surg. 107: 643, 1973. 18 Thompson, J. E., Austin, D. J., and Patman, R. D.: Carotid Endarterectomy for Cerebrovascular Insufficiency: Long-Term Results in 592 Patients Followed up to 13 Years, Ann. Surg. 172: 663, 1970. 19 Hickey, R. F., Ehrenfeld, W. K., Hamilton, F. N., and
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Larson, C. P.: Bilateral Carotid Endarterectomy With Attempted Preservation of Carotid Body Function, Ann. Surg. 175: 268, 1972. 20 Lehv, M. S., Salzman, E. W., and Silen W.: Hypertension Complicating Carotid Endarterectomy, Stroke 1: 307, 1970. 21 Wylie, E. J., and Ehrenfeld, W. K.: Extra-cranial Occlusive Cerebrovascular Disease: Diagnosis and Management, Philadelphia, 1970, W. B. Saunders Company, p. 129. 22 Treiman, R. L., Foran, R. F., Shore, E. H., and Levin, P. M.: Carotid Bruit: Significance in Patients Undergoing Abdominal Aortic Operation, Arch. Surg. 106: 803, 1973.
Robert L. Reis, M.D., and Hamner Hannah III, M . D . , Kansas City, Kan., and Kansas City, Mo.
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v ^ o r o n a r y artery and peripheral vascular atherosclerosis frequently coexist in the same patient. Occasionally, both the coronary and peripheral vascular lesions are severe, and each may cause significant symptoms or even be life threatening. This situation poses a therapeutic dilemma, because an operation to correct one vascular lesion may be attended by hypotension or hypertension with untoward effects related to the other vascular lesion. Although stenosis of the carotid artery or aneurysm of the abdominal aorta in association with coronary artery disease constitute the most serious combinations, patients with associated aortoiliac atherosclerotic occlusive disease may also present difficult problems. Thorough preoperative angiographic assessment of all vascular lesions facilitates management of these patients. Performing sequential operations with sophisticated physiological monitoring is one therapeutic approach. Simultaneous operative correction of coexistent lesions is another. The following case reports illustrate the principles or value of simultaneous surgical correction of coexistent, severe coronary and peripheral arterial occlusive disease. From the Section of Cardiothoracic Surgery, University of Kansas Medical Center, Kansas City, Kan. 66103, and the Department of Surgery, Menorah Medical Center, Kansas City, Mo. 64110. Received for publication Nov. 17, 1976. Accepted for publication Jan. 12, 1977.
Case reports Clinical data are summarized in Table I. CASE 1. F. B., a 55-year-old man, had severe, stable angina pectoris and an enlarging, 6 cm. aneurysm of the abdominal aorta (Fig. 1, D). Coronary angiograms disclosed severe three vessel disease (Fig. I, A to C). On April 12, 1973, the left anterior descending and obtuse marginal coronary arteries were bypassed with segments of autogenous saphenous vein, after which the abdominal aortic aneurysm was excised. He survived operation and remained well with only occasional angina at 2 year's follow-up. Comment. This patient was our first to undergo simultaneous correction of remote, coexistent, severe vascular lesions. Total blood replacement was high (27 units) because of postoperative mediastinal hemorrhage. This degree of blood replacement was considerably in excess of the average of 4 units for an openheart operation in our experience, but there were no bleeding problems of this magnitude in subsequent cases (vide infra). CASE 2. E. J. had unstable angina pectoris and a large aneurysm of the abdominal aorta. He was 58 years old and had had a myocardial infarction 6 years prior to admission. The coronary arterial and abdominal aortic lesions are shown in Fig. 2. On Feb. 2, 1974, he underwent bypass of the left anterior descending and circumflex coronary arteries followed by excision of the 12 cm. aneurysm of the abdominal aorta. Blood replacement during hospitalization was 8 units. The patient survived the operation and was well until lost to follow-up a year later. 909
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Fig. 1. PatientF. B., Case 1. Coronary angiograms demonstrate (A) total occlusion of right coronary artery, (B) stenosis of left anterior descending coronary artery proximal to first diagonal branch, and (C) late filling of distal obtuse marginal branch of circumflex system. D, Anteroposterior x-ray film of abdomen demonstrates aneurysm of abdominal aorta. Comment. The unstable nature of the angina pectoris and the tremendous size of the abdominal aneurysm prompted simultaneous operations. CASE 3. J. G., a 56-year-old man, had severe angina pectoris and a large aneurysm of the abdominal aorta. Cardiac
catheterization disclosed arteriosclerosis of the right and left coronary arteries. The patient underwent bypass of the left anterior descending and right posterior descending coronary arteries with autogenous saphenous vein on cardiopulmonary bypass. The procedure was followed immediately by abdominal aortic aneurysmectomy. His postoperative course was
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Fig. 2. Patient E. J., Case 2. Coronary angiograms demonstrate (A) normal right coronary artery with retrograde filling of totally occluded left anterior descending branch via septal and apical collaterals and (B) severe atherosclerosis of obtuse marginal branch of circumflex system and of first diagonal branch of left anterior descending. C, Anteroposterior x-ray film of abdomen demonstrates large aneurysm of abdominal aorta. somewhat protracted because of difficulties in increasing activity and because of pneumonia, which responded to antibiotics. He received 7 units of blood during his initial hospitalization. It was necessary to readmit this patient 2 weeks after discharge because of severe iliofemoral thrombophlebitis of the left leg. This problem was ultimately controlled with elevation of the left leg, anticoagulants, and elastic stockings. Comment. This patient was virtually impossible to mobilize postoperatively. The combination of inactivity, removal of the greater saphenous vein, and intra-abdominal dissection near the external iliac vein no doubt precipitated the severe iliofemoral thrombophlebitis. CASE 4. E. W., a 66-year-old man, had severe, stable angina pectoris. Shortly before admission, he had had transient ischemic episodes with left hemiparesis. Angiograms
Table I. Clinical data Patient F. B. E. J. J. G. E. W. N. E. R. D. A. D. D. S. L. W. M. V.
Age (yr.), sex 55, 58, 56, 66, 69, 54, 65, 40, 66, 57,
M M M M F M F F F M
Operation Double ACB and AAA Double ACB and AAA Double ACB and AAA Double ACB and bilateral CE Double ACB and bilateral CE Triple ACB and unilateral CE Triple ACB and unilateral CE Triple ACB and AFB Double ACB; postop. TIA; CE Triple ACB; postop. pregangrenous left leg; AFB
Legend: ACB, Aorta-coronary artery bypass. AAA, Abdominal aortic aneurysraectomy. CE, Carotid endarterectomy. AFB, Aortofemoral bypass. TIA, Transient ischemic attacks.
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Fig. 3 . Patient E. W., Case 4. Coronary angiograms demonstrate (A) patent right coronary artery with retrograde filling of totally occluded left anterior descending and (B) stenosis of left main coronary artery with visualization of obtuse marginal branch of circumflex system. Cervicocephalic angiograms show plaques in (C) right and (D) left internal carotid arteries (subtraction technique). showed severe disease of the left anterior descending and circumflex coronary arteries (Fig. 3, A andB) and stenosis of both internal carotid arteries (Fig. 3, C and/)). On Aug. 15, 1974, he underwent saphenous vein bypass of the left anterior descending and circumflex coronary arteries and bilateral carotid endarterectomy. His postoperative course was uncomplicated, and his blood requirement was 5 units. CASE 5. N. E., a 69-year-old woman, had severe angina pectoris, episodes of recurrent dizziness, and symptoms of intermittent claudication. Cardiac catheterization disclosed significant coronary atherosclerosis, and cervicocephalic angiograms demonstrated bilateral carotid artery stenosis. She underwent bypass of the left anterior descending and obtuse marginal coronary arteries and bilateral carotid endarterec-
tomy on cardiopulmonary bypass support. Her postoperative course was generally uncomplicated. The woman received 5 units of blood during her hospitalization. CASE 6. R. D., a 54-year-old man, had significant angina pectoris, an asymptomatic right carotid bruit, and aortoiliac atherosclerosis with probable gluteal claudication. He underwent bypass of the left anterior descending, diagonal, and obtuse marginal coronary arteries with autogenous saphenous vein and endarterectomy of the right carotid artery, all with the support of cardiopulmonary bypass. Postoperatively, he described a small defect of vision and was found to have a lesion in the right retina indicative of a small embolus. Otherwise, he did well. He received 4 units of blood during his hospitalization.
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Fig. 4. Patient A. D., Case 7. Coronary angiograms demonstrate (A) total occlusion of right coronary artery and (B) stenosis of left anterior descending coronary artery at origins of first diagonal and first septal perforator branches.
Fig. 4. Cont'd. C, Coronary angiogram demonstrating stenosis of circumflex coronary artery. D, Cervicocephalic angiogram shows stenosis of right internal carotid artery (subtraction technique). CASE 7. A. D., a 65-year-old woman, had severe, stable angina pectoris and had experienced left hemiparesis 6 weeks prior to admission. Although this episode would have to be considered a completed stroke because of its duration, she had a complete neurologic recovery. Coronary and carotid angiograms are shown in Fig. 4. On Nov. 21, 1975, she underwent saphenous vein bypass of the circumflex, first diagonal, and left anterior descending coronary arteries as well as right carotid endarterectomy. She did well postoperatively, having required 10 units of blood.
Comment. We performed carotid endarterectomy with the aid of cardiopulmonary bypass in order to take advantage of hypothermia, control of perfusion pressure, anticoagulation with heparin, and the improved rheologic properties of blood with hemodilution. CASE 8. L. W., a 66-year-old woman, was admitted with severe angina pectoris of recent onset. Coronary angiograms
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Fig. 5. Patient L. W., Case 8. A, Coronary angiogram demonstrates stenosis of left anterior descending branch. B, Cervicocephalic angiogram shows complete occlusion of the left internal carotid artery. disclosed significant stenosis of the left anterior descending coronary artery (Fig. 5, A). OnJan. 2, 1975, she underwent saphenous vein bypass of the left anterior descending coronary artery and its first diagonal branch. She received 3 units of blood. On Jan. 4, 1975, she experienced somnolence and weakness of the right arm and face. The blood pressure was 100/60 mm. Hg. The blood pressure was increased with vasopressors and intravascular volume augmentation, and the neurologic symptoms disappeared. In addition, a left carotid bruit became audible. Upon questioning, the patient related two episodes of amaurosis fugax on the left several weeks prior to admission. Carotid angiograms (Fig. 5, B) demonstrated complete occlusion of the left internal carotid artery. Endarterectomy of the left carotid artery was performed on Jan. 10, 1975, and the patient subsequently did well. Comment. This case illustrates the importance of careful preoperative assessment of the condition of the patient in general and of associated vascular disease in particular. In addition, it demonstrates the problem of possible stroke following aorta-coronary artery bypass in patients with carotid stenosis. Compare this case with Cases 4 , 5 , 6 , and 7, in which simultaneous operations were employed and, except for the small retinal embolus in Case 6, the postoperative courses were uncomplicated. Endarterectomy of the left carotid artery was performed despite complete occlusion of the internal branch because of the recent onset of symptoms, the suspicion of recent thrombosis of the left internal carotid artery, and the possible benefits of relieving external carotid stenosis 1 (presumed present because of the bruit).
CASE 9. D. S., a 40-year-old woman, had severe, stable angina pectoris and severe, intermittent claudication. Coronary angiograms disclosed disease of the left anterior descending and circumflex systems. Abdominal angiograms disclosed significant aortoiliac atherosclerosis. On Oct. 16, 1975, she underwent bypass of the circumflex, first diagonal, and left anterior descending coronary arteries with autogenous saphenous vein, followed by aortofemoral bypass with a knitted Dacron prosthesis. She did well postoperatively. Ten units of blood was required. Comment. In general, aortoiliac occlusive disease is corrected sequentially. In this case, however, the coronary bypass procedure was facile, and we elected to proceed with revascularization of the legs. The possible advantage of this approach is illustrated by the following case. CASE 10. M.V., a 57-year-old man, was admitted with severe, stable angina pectoris and severe, intermittent claudication. He had no pulses in either leg and had cervical bruits. An extensive angiographic evaluation disclosed severe coronary atherosclerosis and mild aortic regurgitation (Fig. 6, A and B), total occlusion of the right subclavian artery with right "subclavian steal" (Fig. 6, C and D), and significant aortoiliac and femoropopliteal atherosclerosis (Fig. 6, E and F). He had no cerebrovascular symptoms. On Oct. 30, 1975, saphenous vein bypass of the left anterior descending, right posterior descending, and circumflex coronary arteries was accomplished. This phase of the operation was quite difficult because of the aortic regurgitation and severity of coronary atherosclerosis. Therefore, we elected not to proceed with aortofemoral bypass. Four units of blood was infused following this operation. On Nov. 1, 1975, severe vascular insuf-
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1 Fig. 6. Patient M. V., Case 10. A, Left coronary angiogram demonstrates absent left anterior descending, patent obtuse marginal, and filling of posterior descending branch of totally occluded right coronary artery via collaterals. B, Aortic root injection shows two-plus aortic regurgitation.
Fig. 6. Cont'd. Cervicocephalic angiograms disclose (C) occlusion of right subclavian artery and (D) late visualization of right vertebral and axillary arteries (arrows) consistent with "subclavian steal." E and F, Abdominal aortograms demonstrate severe aortoiliac occlusive disease.
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ficiency of the left leg developed. Armed with the abdominal aortic angiograms, we performed urgent aortofemoral bypass, and the patient subsequently did well. Three additional units of blood was required. Comment. This case illustrates several points. First, coexisting vascular disease can be highly complex. Second, even aortoiliac disease, which is not usually viewed as life threatening, can rapidly escalate in importance, especially during periods of low cardiac output. Finally, thorough preoperative angiographic analysis is of value. Such evaluation not only allows planning of simultaneous procedures but also facilitates urgent sequential procedures by avoiding the need for angiograms in seriously ill patients, as was required in Case 8. Discussion The coexistence of coronary artery and peripheral vascular disease is well known. Myocardial infarction is the major cause of death following excision of aneurysms of the abdominal aorta 2-5 and contributes to the incidence of late death following carotid endarterectomy . 6 Tomatis and his associates7 performed coronary angiograms in 100 consecutive patients admitted for evaluation of peripheral vascular disease and found a 50 per cent incidence of coexistent, severe coronary artery disease (70 per cent stenosis of at least one major coronary artery). Although the diagnosis and surgical management of vascular lesions has become relatively standardized, the therapeutic dilemma of priority of surgical treatment in the setting of coexistent, severe lesions is less well resolved. Abdominal aortic aneurysmectomy and aortofemoral bypass are attended by the possibility of myocardial infarction during episodes of hypertension or hypotension in the operative and postoperative periods. Aorta-coronary bypass in the patient with an abdominal aortic aneurysm may be complicated by rupture of the aneurysm secondary to episodic hypertension, and the situation may be compounded by the hypocoagulable state which frequently follows cardiopulmonary bypass. Even severe aortoiliac occlusive lesions can be the site of postoperative complications in an occasional patient after aorta-coronary artery bypass (Case 10). Carotid stenosis in combination with hypotension, which not uncommonly occurs during or following aorta-coronary artery bypass, can cause cerebral ischemia (Case 8). On the other hand, carotid endarterectomy cannot be performed without concern for myocardial infarction in a patient with serious coronary occlusive disease.6 Because of these concerns and considerations, selected patients are candidates for simultaneous correc-
The Journal of Thoracic and Cardiovascular Surgery
tion of the coronary and peripheral vascular lesions. This report details 8 cases (1 to 7 and 9) in which simultaneous surgical correction of combinations of coronary artery disease and abdominal aneurysm, carotid stenosis, or aortoiliac atherosclerosis was successful. Two additional cases (8 and 10) illustrate problems which can arise when coexistent, significant vascular lesions are not corrected simultaneously. Although the addition of another operation, especially one involving the abdominal aorta, increases the need for blood transfusion, the total probably does not exceed that required for sequential procedures and therefore seems a minor disadvantage of the simultaneous approach. Bernhard and associates8 reported their experience with simultaneous versus sequential operations in patients with carotid stenosis and coronary atherosclerosis in 1972. Three of 15 patients in the group treated sequentially died of myocardial causes following carotid endarterectomy, whereas 16 patients underwent simultaneous operations without morbidity or deaths. Nunn6 has recently emphasized that coronary atherosclerosis is a major cause of late death (58 per cent) following carotid endarterectomy. Shore,9 Okies,10 and Fogarty11 have reported their experience with simultaneous surgical management of patients with coronary and carotid atherosclerosis. Diethrich12 has described this approach in patients with combinations of coronary and distal aortic disease as well as carotid stenosis. Absolon13 described a patient who underwent successful, simultaneous aorta-coronary artery bypass, left ventricular aneurysmectomy, and abdominal aortic aneurysmectomy. Because of the collected experience with simultaneous operations, a further clinical trial seems warranted. The protocol which we employed in patients with coexistent coronary and peripheral vascular lesions is as follows: Systemic perfusion during cardiopulmonary bypass is accomplished via a cannula in the ascending aorta. Patients with large or symptomatic aneurysms of the abdominal aorta undergo aneurysmectomy after aorta-coronary artery bypass and attainment of mediastinal hemostasis. Following completion of aortacoronary artery bypass, the sternum is approximated, but the upper rectus fascia is left open and the incision is extended to the symphysis pubis. Aneurysmectomy is accomplished with regional heparinization of the lower extremities. A knitted Dacron prosthesis is preclotted and employed for reconstruction of the abdominal aorta. Patients with severe, coexistent aortoiliac disease undergo preoperative angiographic studies. If the coronary phase of the operation is facile, aortofemoral bypass is accomplished with a preclotted,
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knitted, Dacron prosthesis during the same episode of general anesthesia. If the coronary phase is difficult, aortofemoral bypass is deferred for 6 weeks unless complications (Case 10) prompt earlier intervention. Patients with coexistent carotid stenosis, symptomatic or asymptomatic (bruit only), undergo cerebrovascular angiograms preoperatively (Case 3). Carotid endarterectomy was accomplished with cardiopulmonary bypass in the cases (4, 5, 6, and 7) reported here. Bypass allows precise control of perfusion pressure and the induction of cerebral hypothermia and thus eliminates the need for a shunt in the absence of severe contralateral carotid stenosis. Heparinization and hemodilution are also salutory features of this approach. Fogarty11 and others8, l0 have performed carotid endarterectomy prior to institution of cardiopulmonary bypass. Monitoring of left atrial or pulmonary artery pressure, systemic arterial pressure, the electrocardiogram, chest drainage, and urine flow facilitates the intraoperative and postoperative management of these patients. Whether vascular lesions are managed simultaneously or sequentially, careful monitoring of appropriate physiological parameters is invaluable. Correction of asymptomatic carotid stenosis and bilateral carotid endarterectomy are controversial. Although Levin and Sondheimer14 question the wisdom of operating upon the contralateral, stenotic carotid artery, Javid,15, 18 Thompson,17, 18 and their associates have favored correction of asymptomatic lesions. Hickey19 reported successful bilateral carotid endarterectomy in 9 patients, despite depression of carotid body response to hypoxic stimuli postoperatively. Inordinate hypertension following carotid endarterectomy is probably the result of neurologic damage rather than instability of the carotid sinus.20 Although we have approached the problem of coexistent vascular lesions in patients admitted primarily for coronary disease, a similar thesis can be developed for patients admitted for treatment of peripheral vascular disease. As Tomatis and associates7 have shown, 50 per cent of such patients have severe coronary atherosclerosis. As the safety of aorta-coronary artery bypass increases, more of these patients may be candidates for simultaneous operations. In any event, their care is facilitated by sophisticated physiological monitoring. Finally, we believe the simultaneous approach should be considered in patients with combinations of carotid atherosclerosis and aortoiliac atherosclerosis or abdominal aneursym,21 although some authors question this approach.22 If the continued success of the simultaneous surgical approach to coexistent, severe vascular disease can be
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demonstrated, the physiological, psychological, and economic advantages of avoiding rehospitalization are obvious. We gratefully acknowledge the important role of our colleagues in cardiology, especially Dr. David M. Pugh and Dr. Lawrence L. Cohen, in the preoperative evaluation of these patients. We also acknowledge the efforts of Ms. Jane Gottlieb, Ms. Ruth Long, and Ms. Emma Theis in preparation of the manuscript. REFERENCES 1 Connolly, J. E., and Stemmer, E. A.: Endarterectomy of the External Carotid Artery: Its Importance in the Surgical Management of Extracranial Cerebrovascular Disease, Arch. Surg. 106: 799, 1973. 2 De Bakey, M. E., Crawford, E. S., Cooley, D. A., Morris, G. C , Jr., Royster, T. S., and Abbott, W. P.: Aneurysm of the Abdominal Aorta: Analysis of Results of Graft Replacement Therapy One to Eleven Years After Operation, Ann. Surg. 160: 622, 1964. 3 Szilagyi, D. E., Smith, R. F., DeRusso, F. J., Elliott, J. P., and Sherrin, F. W.: Contribution of Abdominal Aortic Aneurysmectomy to Prolongation of Life, Ann. Surg. 164: 678, 1966. 4 Baker, A. G., Jr., and Roberts, B.: Long-Term Survival Following Abdominal Aortic Aneurysmectomy, J. A. M. A. 212: 445, 1970. 5 Yashar, J. J., Indeglia, R. A., and Yashar, J.: Surgery for Abdominal Aortic Aneurysm: Factors Affecting LongTerm Results, Am. J. Surg. 123: 398, 1972. 6 Nunn, D. B.: Carotid Endarterectomy: An Analysis of 234 Operative Cases, Ann. Surg. 182: 733, 1975. 7 Tomatis, L. A., Fierens, E. E., and Verbrugge, G. P.: Evaluation of Surgical Risk in Peripheral Vascular Disease by Coronary Arteriography: A Series of 100 Cases, Surgery 71: 429, 1972. 8 Bernhard, V. M., Johnson, W. D., and Peterson, J. J.: Carotid Artery Stenosis: Association With Surgery for Coronary Artery Disease, Arch. Surg. 105: 837, 1972. 9 Shore, R. T., and Johnson, W. D.: Combined Surgical Treatment for Coronary Artery Surgery Complicated by Extracranial Carotid Disease (Abstr.), Chest 66: 336, 1974. 10 Okies, J. E., MacManus, Q., and Starr, A.: Myocardial Revascularization and Carotid Endarterectomy: A Combined Approach? (Abstr.), Chest 68: 422, 1975. 11 Fogarty, T. J.: Personal communication. 12 Diethrich, E. B., Samorano, C , and Koopot, R.: Simultaneous Correction of Coronary and Peripheral Vascular Arterial Lesions (Abstr.), Chest 68: 409, 1975. 13 Absolon, K. B., Bashour, F. A., and Kechejian, S.: Simultaneous Coronary Artery Bypass, Peripheral Endarterectomy, Ventricular Aneurysm Repair and Abdominal Aortic Graft Replacement: Twenty-fifth Congress, J. Soc. Int. Chir. p. 127, 1971. 14 Levin, S. M., and Sondheimer, F. K.: Stenosis of the Contralateral Carotid Artery: To Operate or Not, Vase. Surg. 7: 3, 1973.
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15 Javid, H., Ostermiller, W. E., Hengesh, J. W., Dye, W. S., Hunter, J. A., Najafi, H., and Julian, O. C : Carotid Endarterectomy for Asymptomatic Patients, Arch. Surg. 102: 389, 1971. 16 Javid, H., Ostermiller, W. E., Hengesh, J. W., Dye, W. S., Hunter, J. A., Najafi, H., and Julian, O. C : Natural History of Carotid Bifurcation Atheroma, Surgery 67: 80, 1970. 17 Thompson, J. E.: The Development of Carotid Artery Surgery, Arch. Surg. 107: 643, 1973. 18 Thompson, J. E., Austin, D. J., and Patman, R. D.: Carotid Endarterectomy for Cerebrovascular Insufficiency: Long-Term Results in 592 Patients Followed up to 13 Years, Ann. Surg. 172: 663, 1970. 19 Hickey, R. F., Ehrenfeld, W. K., Hamilton, F. N., and
The Journal of Thoracic and Cardiovascular Surgery
Larson, C. P.: Bilateral Carotid Endarterectomy With Attempted Preservation of Carotid Body Function, Ann. Surg. 175: 268, 1972. 20 Lehv, M. S., Salzman, E. W., and Silen W.: Hypertension Complicating Carotid Endarterectomy, Stroke 1: 307, 1970. 21 Wylie, E. J., and Ehrenfeld, W. K.: Extra-cranial Occlusive Cerebrovascular Disease: Diagnosis and Management, Philadelphia, 1970, W. B. Saunders Company, p. 129. 22 Treiman, R. L., Foran, R. F., Shore, E. H., and Levin, P. M.: Carotid Bruit: Significance in Patients Undergoing Abdominal Aortic Operation, Arch. Surg. 106: 803, 1973.