- Email: [email protected]
Stroke prevention and carotid artery disease in cardiac surgical patients
1788
CORRESPONDENCE
Ann Thorae Surg 1994;58:1784-94
place to institute cardiopulmonary bypass and perform associated maneuvers. We submitted our report to illustrate that this treatment can, if necessary, be instituted expeditiously outside the surgical suite with a successful outcome. We regret omitting reference to the case mentioned by Dr Mehra and associates. This report did not appear in publication until December 1993, several months after our report had been accepted, and we were unaware of its existence. We are pleased that their experience with this technique was similarly successful. We congratulate our colleagues on their excellent results and appreciate the opportunity to reply to their comments. Daniel J. Waters, DO Michael Belz, CCP Mercy Heart Center 250 5 Crescent Dr Mason City, LA 50401
Stroke Prevention and Carotid Artery Disease in Cardiac Surgical Patients
To the Editor: We read with interest the article by Dr Wareing and associates [1) describing basic strategy for the reduction of stroke incidence in cardiac surgical patients. Wareing and associates reported a very aggressive and innovative approach toward stroke prevention, suggesting that better assessment and treatment of ascending aorta atherosclerosis and carotid artery stenosis reduces the incidence of stroke in cardiac surgery patients. We too have been interested in the problem of cerebrovascular damage during heart operations, and we have focused our studies on the carotid artery stenoses and anomalies. Accordingly, carotid duplex scanner screening was performed on all coronary patients admitted to our institution, regardless of age and presence of previous cerebrovascular symptoms. In a series of 907 coronary patients (748 male and 159 female patients; mean age, 59.1 :±: 8.49 years) the incidence of a carotid artery stenosis greater than 75% was 5.8% (53 patients). Most of these patients (70%) were asymptomatic, even those with bilateral subobstructive internal carotid artery stenosis (Fig 1). Carotid endoarterectomy was performed on these patients alone (22 patients, 41.5%, with no mortality) or, when indicated, associated with coronary artery bypass grafting either as a simultaneous approach (14 patients, 26.4%) or as a staged approach (17 patients, 32.1 %), according to cardiac status. Global mortality was 9.4% (5 patients) and was due to complications related to the extent of cardiac and extracardiac atherosclerotic disease (cardiac failure, 2 patients; acute mesentheric ischemia, 3 patients). Perioperative stroke rate was zero. Morphologic anomalies of the internal carotid artery were searched for similarly in a series of 653 patients (538 male and 115 female patients; mean age, 58.3 years) following the assumption that hemodynamic effects related to such anomalies could increase the risk of stroke during cardiopulmonary bypass. Kinking of the internal carotid artery was found in 37 patients (5.6%); in half of these patients kinking was associated with hypertension and hyperlipidemia. Three patients, affected by significant internal carotid artery stenosis, underwent carotid endarterectomy and Dacron patch arterioplasty before coronary artery bypass grafting; their postoperative period was uneventful. We observed a case of lethal stroke after coronary artery bypass grafting in a patient with a right-sided carotid artery kinking and calcified ascending aorta; postoperative computed © 1994 by The Society of Thoracic Surgeons
Fig 1. Digital subtraction angiogram showing a bilateral subobsiructive stenosis on internal carotid artery in a candidate for coronary artery bypass grafting without any preoperative neurologic symptoms.
tomographic scan findings revealed bilateral multifocal brain damage. Our findings suggested that duplex scanning screening is mandatory in cardiac surgical patients, because major internal carotid artery stenoses frequently can be found in asymptomatic patients. Accordingly, preoperative recognition of internal carotid artery stenosis and carotid endarterectomy are highly effective in preventing perioperative stroke in coronary artery bypass grafting procedures; otherwise, mortality appears to be mostly related to severity of widespread atherosclerotic disease. Asymptomatic isolated internal carotid artery kinking is not a significant risk factor for neurologic complications during cardiac operations. However, kinking should be evaluated carefully for its frequent association with atherosclerotic plaques in coronary patients. When major stenosis occurs, internal carotid artery kinking deserves surgical treatment. Raoul Borioni, MD Mariano Garofalo, MD Antonio Pellegrino, MD Guglielmo M. Actis Dato, MD Luigi Chiariello, MD Department of Cardiovascular Surgery Universitii di Roma Tor Vergata European Hospital Via Portuense 700 00149 Rome, Italy
Reference 1. Wareing TH, Davila-Roman VG, Daily BB, et aL Strategy for the reduction of stroke incidence in cardiac surgical patients. Ann Thorac Surg 1993;55:1400-8. 0003-4975/94/$7.00
CORRESPONDENCE
Ann Thorae Surg 1994;58:1784-94
place to institute cardiopulmonary bypass and perform associated maneuvers. We submitted our report to illustrate that this treatment can, if necessary, be instituted expeditiously outside the surgical suite with a successful outcome. We regret omitting reference to the case mentioned by Dr Mehra and associates. This report did not appear in publication until December 1993, several months after our report had been accepted, and we were unaware of its existence. We are pleased that their experience with this technique was similarly successful. We congratulate our colleagues on their excellent results and appreciate the opportunity to reply to their comments. Daniel J. Waters, DO Michael Belz, CCP Mercy Heart Center 250 5 Crescent Dr Mason City, LA 50401
Stroke Prevention and Carotid Artery Disease in Cardiac Surgical Patients
To the Editor: We read with interest the article by Dr Wareing and associates [1) describing basic strategy for the reduction of stroke incidence in cardiac surgical patients. Wareing and associates reported a very aggressive and innovative approach toward stroke prevention, suggesting that better assessment and treatment of ascending aorta atherosclerosis and carotid artery stenosis reduces the incidence of stroke in cardiac surgery patients. We too have been interested in the problem of cerebrovascular damage during heart operations, and we have focused our studies on the carotid artery stenoses and anomalies. Accordingly, carotid duplex scanner screening was performed on all coronary patients admitted to our institution, regardless of age and presence of previous cerebrovascular symptoms. In a series of 907 coronary patients (748 male and 159 female patients; mean age, 59.1 :±: 8.49 years) the incidence of a carotid artery stenosis greater than 75% was 5.8% (53 patients). Most of these patients (70%) were asymptomatic, even those with bilateral subobstructive internal carotid artery stenosis (Fig 1). Carotid endoarterectomy was performed on these patients alone (22 patients, 41.5%, with no mortality) or, when indicated, associated with coronary artery bypass grafting either as a simultaneous approach (14 patients, 26.4%) or as a staged approach (17 patients, 32.1 %), according to cardiac status. Global mortality was 9.4% (5 patients) and was due to complications related to the extent of cardiac and extracardiac atherosclerotic disease (cardiac failure, 2 patients; acute mesentheric ischemia, 3 patients). Perioperative stroke rate was zero. Morphologic anomalies of the internal carotid artery were searched for similarly in a series of 653 patients (538 male and 115 female patients; mean age, 58.3 years) following the assumption that hemodynamic effects related to such anomalies could increase the risk of stroke during cardiopulmonary bypass. Kinking of the internal carotid artery was found in 37 patients (5.6%); in half of these patients kinking was associated with hypertension and hyperlipidemia. Three patients, affected by significant internal carotid artery stenosis, underwent carotid endarterectomy and Dacron patch arterioplasty before coronary artery bypass grafting; their postoperative period was uneventful. We observed a case of lethal stroke after coronary artery bypass grafting in a patient with a right-sided carotid artery kinking and calcified ascending aorta; postoperative computed © 1994 by The Society of Thoracic Surgeons
Fig 1. Digital subtraction angiogram showing a bilateral subobsiructive stenosis on internal carotid artery in a candidate for coronary artery bypass grafting without any preoperative neurologic symptoms.
tomographic scan findings revealed bilateral multifocal brain damage. Our findings suggested that duplex scanning screening is mandatory in cardiac surgical patients, because major internal carotid artery stenoses frequently can be found in asymptomatic patients. Accordingly, preoperative recognition of internal carotid artery stenosis and carotid endarterectomy are highly effective in preventing perioperative stroke in coronary artery bypass grafting procedures; otherwise, mortality appears to be mostly related to severity of widespread atherosclerotic disease. Asymptomatic isolated internal carotid artery kinking is not a significant risk factor for neurologic complications during cardiac operations. However, kinking should be evaluated carefully for its frequent association with atherosclerotic plaques in coronary patients. When major stenosis occurs, internal carotid artery kinking deserves surgical treatment. Raoul Borioni, MD Mariano Garofalo, MD Antonio Pellegrino, MD Guglielmo M. Actis Dato, MD Luigi Chiariello, MD Department of Cardiovascular Surgery Universitii di Roma Tor Vergata European Hospital Via Portuense 700 00149 Rome, Italy
Reference 1. Wareing TH, Davila-Roman VG, Daily BB, et aL Strategy for the reduction of stroke incidence in cardiac surgical patients. Ann Thorac Surg 1993;55:1400-8. 0003-4975/94/$7.00