Coronary artery bypass grafting in patients with cerebrovascular disease
- Harold L Lazar, MD
Harold L Lazar, MD
- Professor of Cardiothoracic Surgery
- Boston University School of Medicine
- Christina A Wilson, MD, PhD
Christina A Wilson, MD, PhD
- Assistant Professor of Neurology
- University of Florida
- Steven R Messé, MD
Steven R Messé, MD
- Associate Professor of Neurology
- Hospital of the University of Pennsylvania
Cerebrovascular complications are among the most feared consequences after coronary artery bypass graft surgery (CABG). Patients with concomitant cerebrovascular and coronary heart disease represent a subset with advanced atherosclerosis in whom other areas of the arterial system are also involved. In addition to a higher risk of perioperative stroke (see 'Risk factors' below), these patients also have a higher incidence of left main coronary disease and a reduced left ventricular ejection fraction compared with patients who have isolated coronary heart disease [1,2].
This topic will focus mainly on coexistent coronary and extracranial carotid atherosclerosis. Issues that will be discussed include the management of the patient with an asymptomatic carotid stenosis undergoing CABG, the role of combined or staged CABG and carotid revascularization in these patients, and which strategies will result in the lowest operative morbidity and mortality.
The indications for CABG are discussed elsewhere. (See "Revascularization in patients with stable coronary artery disease: Coronary artery bypass graft surgery versus percutaneous coronary intervention" and "Coronary artery bypass graft surgery in patients with acute ST elevation myocardial infarction", section on 'Indications' and "Coronary angiography and revascularization for unstable angina or non-ST elevation acute myocardial infarction", section on 'Method of revascularization in multivessel disease'.)
STROKE ASSOCIATED WITH CABG
Neurologic complications are among the most feared complications of coronary artery bypass graft surgery (CABG). Information from large databases published before 2002 suggested that a new clinical stroke or transient ischemic attack (TIA) occurred in approximately 3 percent of patients [3,4]. While data from large retrospective reports published in 2008 and 2011 suggested that the overall incidence of perioperative stroke had declined to 1.6 percent [5,6], a 2014 prospective study found a clinically apparent perioperative stroke rate of 3.1 percent . Radiographically-evident but clinically-silent strokes occur much more frequently [7-9].
Approximately 40 percent of strokes occur intraoperatively and most of the remaining strokes occur during the first 48 hours postoperatively . Perioperative strokes have significant impact on length of hospital stay and mortality outcome, with 10-fold higher hospital mortality rates in patients who suffered a perioperative stroke [5,6]. Other well-recognized neurologic complications of CABG include delirium, seizures, and neurocognitive dysfunction. (See "Neurologic complications of cardiac surgery", section on 'Encephalopathy'.)
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- STROKE ASSOCIATED WITH CABG
- Risk factors
- - Aortic atherosclerosis
- - Carotid stenosis
- - Prevalence and predictors of carotid stenosis
- PREVENTION OF PERIOPERATIVE STROKE
- Screening for carotid disease
- Prophylactic carotid intervention
- CAROTID TREATMENT OPTIONS
- Method of carotid revascularization
- Timing of revascularization
- Observational studies
- Surgical techniques of combined CEA and CABG
- TIMING OF CABG AFTER STROKE
- SUMMARY AND RECOMMENDATIONS