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CARDIAC SURGERY SIMPLIFIED BY DR ABHISHEK, SRIVASTAVA, MODULE 30….COMBINED CAROTID AND, CORONARY ARTERY DISEASE, BULLET POINTS, An association between coronary and carotid, artery disease is well known., About 7% of patients referred for coronary artery, bypass grafting have severe asymptomatic carotid, artery stenosis., With severe stenosis, almost half have bilateral, involvement., Duplex carotid ultrasound is an excellent screening, tool to assess the status of the carotid arteries., Symptomatic carotid stenosis or severe bilateral, stenosis warrant carotid endarterectomy either as, a staged procedure or concomitantly with coronary, artery bypass surgery., Isolated CABG is recommended for patients with, asymptomatic carotid artery stenosis.

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INTRODUCTION, Atherosclerosis is a generalized disorder often, involving multiple vascular system., Stroke after cardiac surgery is devastating., Many cardiac surgical centers preoperative screen, patients for concomitant carotid lesion prior to, CABG., Selective screening of following patients at the, time of CABG is recommended…, History of diabetes, Hypertension, Peripheral arterial disease, History of transient ischemic stroke, Carotid bruit on exam, Amaurosis fugax, New onset extremity weakness, LM coronary artery disease, MANAGEMENT OPTIONS

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Management options for Coexistent carotid and, coronary artery disease include…, Combined CABG +carotid endarterectomy, CABG followed by CEA or CEA followed by CABG, Off pump CABG with or without CEA, COMBINED CAROTID ENDARTERECTOMY AND, CORONARY ARTERY BYPASS GRAFTING, The combined approach consists of CEA followed, by CABG in the same anesthesia setting., This approach is selected in patients with, symptoms which can directly associated to carotid, lesion or with significant bilateral disease., It is an option when patients present with acute, coronary syndrome, left main disease or an, unfavorable coronary Anatomy where CABG can, not be delayed., Rates of perioperative MI were much lower with, the combined approach rather than CEA – CABG.

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In asymptomatic disease the 30 day composite end, point of death/stroke was higher in patients, undergoing combined vs isolated CABG., STAGED CAROTID ENDARTERECTOMY AND, CORONARY ARTERY BYPASS GRAFTING, The staged approach of prior carotid, endarterectomy followed by CABG is reserved for, patients who present with stable coronary artery, disease. The main concern of this approach, remains inter stage myocardial infarction., Risk of operative stroke is lowest when staged, CEA-CABG procedure was conducted., There is increased risk of MI., This approach is recommended in patients with, chronic stable angina and good myocardial, reserve., Also recommended in symptomatic carotid, disease., ROLE OF CAROTID ARTERY STENTING

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Result of ACT trial(Asymptomatic carotid trial I), and CREST trial (Carotid revascularization, endarterectomy versus Stenting trial) report, compareble event rates of death,stroke and, myocardial infarction between carotid, endarterectomy and carotid artery Stenting., Reduced rate of in hospital stroke for synchronous, CAS/CABG as compared to CEA/CABG., The need for aggressive anti platelet therapy after, CAS is an important consideration which may delay, CABG.

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Approach to combined carotid artery and coronary, artery disease...

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END OF COMBINED CAROTID AND CORONARY, ARTERY DISEASE...