One of the most common and feared complications
after myocardial revascularization is a perioperative
neurological event. In addition to having a significant
effect on morbidity and mortality in the early and
late periods, it prolongs the stay in the intensive care
unit and the duration of discharge. It causes loss of
workforce and reduced quality of life.[
4-
6]
It has not yet been clarified whether carotid artery
disease causes perioperative stroke in individuals who
have undergone coronary bypass operations. It has
been suggested that some of the strokes may occur
from residual carotid plaques during or after the
operation, as well as from the harmful effects of the
CPB, particularly the loss of pulsatile flow and the
decrease in systemic perfusion pressure during CPB,
which causes ischemia and related stroke distal to
the carotid stenosis.[2,6] However, Reed et al.[7] also
reported that more than 50% of strokes occur in the postoperative period. This indicates that there are
other mechanisms as well. More research is needed on
this topic.[2,7]
Discussions are still ongoing about the surgical
sequencing of patients with both CABG and CEA
indications.[8] Surgical strategies such as staged,
reverse staged, or simultaneous approaches were
reported to minimize perioperative neurological
and cardiac complications in these patients.[9] In
patients with significant carotid artery stenosis who
underwent CABG alone, the perioperative neurologic
event rate was reported between 7.4 and 20.3%, and
the mortality rate was between 6.9 and 13.8%.[10,11] In
addition, a high morbidity rate of 7 to 8% was reported
in patients requiring CABG but undergoing isolated
CEA, and this is mostly the result of perioperative
myocardial infarction.[11] Therefore, simultaneous
operation in which both CEA and CABG are
performed is recommended.[12,13] Trachiotis and
Pfister[14] and Akins et al.[15] reported that combined
CEA and CABG surgery were very effective in
reducing neurological and myocardial complications.
In addition, Takach et al.[16] stated in their study
that the simultaneous approach is as safe as the
staged approach even in the high-risk patient group.
However, the discussion of how the simultaneous
approach will be conducted has continued since
Bernhard et al.[17] reported the simultaneous operation
for the first time. The incidence of stroke is high
(10%) in patients who initially underwent CABG
and then CEA under cardiopulmonary bypass. In
patients who underwent CEA and then coronary
bypass operation, the incidence of perioperative
myocardial infarction was found higher, and it has
been reported that 25 to 30% of death rates are due
to myocardial infarction.[18,19] Evagelopoulos et al.[20]
performed combined surgery in 313 patients in which
the carotid artery was prepared first and performed
CEA after cooling to 30°C with median sternotomy,
systemic heparinization, standard cannulation, and
CPB. The early mortality rate with this technique
was found to be 8.9% (4.2% cardiac origin). Khaitan
et al.[21] reported that cerebral protection could be
safely applied with 25°C hypothermia. In our series,
we found that major neurological morbidity was 3.1%
and mortality was 6.3% in our patients. In addition,
6.3% of our patients developed a transient ischemic
attack.
Although there is no consensus on the ideal
mean blood pressure for cerebral protection in CPB, Tufo et al.[22] reported that the risk of neurological
events increased fourfold when the blood pressure
remained below 50 mmHg for more than 10 min.
In the simultaneous surgical technique used in our
study, CEA is performed first, and then CABG is
performed. Cerebral perfusion was maintained by the
routine use of carotid shunts in all patients during
CEA. In addition, we aimed to prevent cerebral
hypoperfusion by keeping the perfusion pressure above
70 mmHg during CPB.
It has been reported in various publications
that cardiopulmonary bypass and aortic and
carotid cross-clamp time are the most important
determinants of perioperative stroke development
in CABG surgery. Each of these two periods is of
particular importance in combined surgery. In a
study of 2,211 patients undergoing coronary artery
surgery, it was reported that pump time exceeding
120 min was a predictor of perioperative stroke.[23]
In our series, the mean aortic cross-clamp time was
99.7±5.7 min, and the mean CPB time was found
125.6±7.6 min.
The main limitation of this study is that it included
a single center. Therefore, the number of patients and
the follow-up period are limited. Long-term follow-up
results are needed.
In conclusion, combined CEA and CABG
intervention may be recommended in the presence of
severe carotid stenosis with coronary artery disease.
When evaluated together with the literature, it can be
said that the results of the simultaneous approach will
be satisfactory.
Ethics Committee Approval: The study protocol was
approved by the Turgut Özal University Ethics Committee
(Date/no: 12.01.2011/03). The study was conducted in
accordance with the principles of the Declaration of Helsinki.
Patient Consent for Publication: A written informed
consent was obtained from each patient.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Author Contributions: Idea/concept: Y.N.; Design:
Ö.N.A., Y.N; Control/supervision: Y.N.; Data collection
and/or processing, analysis and/or interpretation: Ö.N.A.,
Y.N.; Literature review: Ö.N.A.; Writting the article: Ö.N.A.;
Critical review: Y.N.
Conflict of Interest: The authors declared no conflicts
of interest with respect to the authorship and/or publication
of this article.
Funding: The authors received no financial support for
the research and/or authorship of this article.
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