Simultaneous surgery of carotid and coronary atherosclerosis. Personal experience and indications

From november 1982 to december 1994 among 3613 patients undergone myocardial revascularization 118 simultaneous single stage coronary bypasses (CABG) and carotid endarterectomies (TEA) were performed in 100 patients (2.7%) including 13 urgent or emergent operations. The by-pass patient ratio was 2,75 and combined procedures were 4 aortic valve replacement and 7 cardiovascular reconstructions. In this period we distinguish two phases of cerebral protection technique: in the 1st TEA was performed before extracorporeal circulation (40 pts) and in the 2nd under hypothermic extracorporeal circulation (60 pts). The overall operative mortality rate was 11% (CL 70% = 7,9-14,1), in the elective cases 6,9% (CL = 4,1-9,5); the causes of death were cardiac related in 8% and neurological morbidity 2,2%. In a stepwise logistic analysis three variables showed significant association with hospital mortality: elective versus urgent operation, associated surgical procedures, carotid contralateral thrombosis. The probability of dying intraoperatively was 4,3% in the absence and 25,8% in the presence of these risk factors (p = 0.001); 17,8% was in the presence of only one of them. Actuarial survival at 5 and 10 years respectively 79,9% (CL = 73-86,8) and 56,6% (cL 43,4-69,8). The authors review the indication of simultaneous coronaric and carotid revascularization on the basis of surgical, anaesthesiological and cerebral protection techniques results. They conclude that synchronous operation can be performed safety in elective patients with low cardiac risk and significantly carotid stenosis, asymptomatic or bilateral, utilizing hypothermic extracorporeal circulation as further cerebral protection method.