1. Coronary Surgery
Carotid Stenosis > 50%
CABG
5-8%
CABG > 65
17%
CABG + Left main
50%
2. Risk Factors for Stroke Following CABG
Overall stroke risk 1-3.5%
Mural thrombi in the left ventricle
Atheromatous lesions in the ascending aorta
Air embolism
History of previous stroke
3. Carotid Artery Stenosis and CABG
Carotid stenoses are less of a risk factor for stroke with CABG
because with CPB:
Cerebral vascular resistance lowered
Hypothermia reduces brain metabolism and oxygen requirement
Hemodilution
Auto-regulation of cerebral blood flow is related more to flow
than MAP
Indications for combined coronary and carotid procedures are limited
Indications for combined coronary and carotid artery procedures
Severe CAD: unstable angina, left main stenosis or 3 vessel
CAD with poor LV function and
An actively symptomatic carotid artery stenosis
4. Indications for Staged Operations for Coronary and Carotid Artery Disease
Significant 1, 2 or 3 vessel CAD requiring CABG in a patient with asymptomatic
high grade CAS with medically controlled symptoms
Patient with actively symptomatic carotid artery stenosis with stable
angina and adequate LV function
5. Combined Coronary and Carotid Artery Disease
Controversial Areas
Stable angina requiring CABG and coexistent asymptomatic high grade
(> 80%) bilateral carotid stenosis
Redo CEA or CABG with coexistent lesions in the other vascular system
6. Operative Strategies for Combined Procedures
Ensure adequate exposure of neck in addition to chest and legs
Pre - bypass vs. on bypass CEA
After CEA, wound left open until systemic heparinization reversed
7. Results of Combined Procedures
Morbidity and mortality for patients requiring combined procedures
is higher than for either procedure alone
Mortality 4%
Post-operative stroke 9%
Peri-operative MI 6%
Therefore: Only 1-3% of patients requiring CABG or CEA will be candidates
for combined procedures
Duplex
Angiography
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