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'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Schwartz LB, Bridgman AH, Kieffer RW, et al. Asymptomatic carotid artery stenosis and stroke in patients undergoing cardiopulmonary bypass. J Vasc Surg 1995; 21:146.
- Kelly R, Staines A, MacWalter R, et al. The prevalence of treatable left ventricular systolic dysfunction in patients who present with noncardiac vascular episodes: a case-control study. J Am Coll Cardiol 2002; 39:219.
- Roach GW, Kanchuger M, Mangano CM, et al. Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med 1996; 335:1857.
- Hogue CW Jr, Barzilai B, Pieper KS, et al. Sex differences in neurological outcomes and mortality after cardiac surgery: a society of thoracic surgery national database report. Circulation 2001; 103:2133.
- Filsoufi F, Rahmanian PB, Castillo JG, et al. Incidence, topography, predictors and long-term survival after stroke in patients undergoing coronary artery bypass grafting. Ann Thorac Surg 2008; 85:862.
- Tarakji KG, Sabik JF 3rd, Bhudia SK, et al. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA 2011; 305:381.
- Nah HW, Lee JW, Chung CH, et al. New brain infarcts on magnetic resonance imaging after coronary artery bypass graft surgery: lesion patterns, mechanism, and predictors. Ann Neurol 2014; 76:347.
- Knipp SC, Matatko N, Wilhelm H, et al. Evaluation of brain injury after coronary artery bypass grafting. A prospective study using neuropsychological assessment and diffusion-weighted magnetic resonance imaging. Eur J Cardiothorac Surg 2004; 25:791.
- Mirow N, Zittermann A, Körperich H, et al. Diffusion-weighted magnetic resonance imaging for the detection of ischemic brain lesions in coronary artery bypass graft surgery: relation to extracorporeal circulation and heparinization. J Cardiovasc Surg (Torino) 2011; 52:117.
- Likosky DS, Marrin CA, Caplan LR, et al. Determination of etiologic mechanisms of strokes secondary to coronary artery bypass graft surgery. Stroke 2003; 34:2830.
- Barbut D, Hinton RB, Szatrowski TP, et al. Cerebral emboli detected during bypass surgery are associated with clamp removal. Stroke 1994; 25:2398.
- Li Y, Walicki D, Mathiesen C, et al. Strokes after cardiac surgery and relationship to carotid stenosis. Arch Neurol 2009; 66:1091.
- D'Agostino RS, Svensson LG, Neumann DJ, et al. Screening carotid ultrasonography and risk factors for stroke in coronary artery surgery patients. Ann Thorac Surg 1996; 62:1714.
- Lee EJ, Choi KH, Ryu JS, et al. Stroke risk after coronary artery bypass graft surgery and extent of cerebral artery atherosclerosis. J Am Coll Cardiol 2011; 57:1811.
- Bottle A, Mozid A, Grocott HP, et al. Preoperative stroke and outcomes after coronary artery bypass graft surgery. Anesthesiology 2013; 118:885.
- Selnes OA, Gottesman RF, Grega MA, et al. Cognitive and neurologic outcomes after coronary-artery bypass surgery. N Engl J Med 2012; 366:250.
- Stamou SC, Hill PC, Dangas G, et al. Stroke after coronary artery bypass: incidence, predictors, and clinical outcome. Stroke 2001; 32:1508.
- Borger MA. Preventing stroke during coronary bypass: are we focusing on the wrong culprit? J Card Surg 2005; 20:58.
- van der Linden J, Hadjinikolaou L, Bergman P, Lindblom D. Postoperative stroke in cardiac surgery is related to the location and extent of atherosclerotic disease in the ascending aorta. J Am Coll Cardiol 2001; 38:131.
- Kronzon I, Tunick PA. Aortic atherosclerotic disease and stroke. Circulation 2006; 114:63.
- Naylor AR, Bown MJ. Stroke after cardiac surgery and its association with asymptomatic carotid disease: an updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2011; 41:607.
- Mahmoudi M, Hill PC, Xue Z, et al. Patients with severe asymptomatic carotid artery stenosis do not have a higher risk of stroke and mortality after coronary artery bypass surgery. Stroke 2011; 42:2801.
- Naylor AR. Managing patients with symptomatic coronary and carotid artery disease. Perspect Vasc Surg Endovasc Ther 2010; 22:70.
- Ghosh J, Murray D, Khwaja N, et al. The influence of asymptomatic significant carotid disease on mortality and morbidity in patients undergoing coronary artery bypass surgery. Eur J Vasc Endovasc Surg 2005; 29:88.
- Manabe S, Shimokawa T, Fukui T, et al. Influence of carotid artery stenosis on stroke in patients undergoing off-pump coronary artery bypass grafting. Eur J Cardiothorac Surg 2008; 34:1005.
- Baiou D, Karageorge A, Spyt T, Naylor AR. Patients undergoing cardiac surgery with asymptomatic unilateral carotid stenoses have a low risk of peri-operative stroke. Eur J Vasc Endovasc Surg 2009; 38:556.
- Roffi M, Ribichini F, Castriota F, Cremonesi A. Management of combined severe carotid and coronary artery disease. Curr Cardiol Rep 2012; 14:125.
- Bull DA, Neumayer LA, Hunter GC, et al. Risk factors for stroke in patients undergoing coronary artery bypass grafting. Cardiovasc Surg 1993; 1:182.
- Kaul TK, Fields BL, Wyatt DA, et al. Surgical management in patients with coexistent coronary and cerebrovascular disease. Long-term results. Chest 1994; 106:1349.
- Durand DJ, Perler BA, Roseborough GS, et al. Mandatory versus selective preoperative carotid screening: a retrospective analysis. Ann Thorac Surg 2004; 78:159.
- Qureshi AI, Alexandrov AV, Tegeler CH, et al. Guidelines for screening of extracranial carotid artery disease: a statement for healthcare professionals from the multidisciplinary practice guidelines committee of the American Society of Neuroimaging; cosponsored by the Society of Vascular and Interventional Neurology. J Neuroimaging 2007; 17:19.
- Masabni K, Sabik JF 3rd, Raza S, et al. Nonselective carotid artery ultrasound screening in patients undergoing coronary artery bypass grafting: Is it necessary? J Thorac Cardiovasc Surg 2016; 151:402.
- Faggioli GL, Curl GR, Ricotta JJ. The role of carotid screening before coronary artery bypass. J Vasc Surg 1990; 12:724.
- Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:2610.
- Gold JP, Torres KE, Maldarelli W, et al. Improving outcomes in coronary surgery: the impact of echo-directed aortic cannulation and perioperative hemodynamic management in 500 patients. Ann Thorac Surg 2004; 78:1579.
- Nakamura M, Okamoto F, Nakanishi K, et al. Does intensive management of cerebral hemodynamics and atheromatous aorta reduce stroke after coronary artery surgery? Ann Thorac Surg 2008; 85:513.
- Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation 2011; 124:e54.
- Authors/Task Force members, Windecker S, Kolh P, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541.
- Paciaroni M, Caso V, Acciarresi M, et al. Management of asymptomatic carotid stenosis in patients undergoing general and vascular surgical procedures. J Neurol Neurosurg Psychiatry 2005; 76:1332.
- Naylor AR. Does the risk of post-CABG stroke merit staged or synchronous reconstruction in patients with symptomatic or asymptomatic carotid disease? J Cardiovasc Surg (Torino) 2009; 50:71.
- Naylor AR, Mehta Z, Rothwell PM, Bell PR. Carotid artery disease and stroke during coronary artery bypass: a critical review of the literature. Eur J Vasc Endovasc Surg 2002; 23:283.
- Hines GL, Scott WC, Schubach SL, et al. Prophylactic carotid endarterectomy in patients with high-grade carotid stenosis undergoing coronary bypass: does it decrease the incidence of perioperative stroke? Ann Vasc Surg 1998; 12:23.
- Gott JP, Thourani VH, Wright CE, et al. Risk neutralization in cardiac operations: detection and treatment of associated carotid disease. Ann Thorac Surg 1999; 68:850.
- Versaci F, Reimers B, Del Giudice C, et al. Simultaneous hybrid revascularization by carotid stenting and coronary artery bypass grafting: the SHARP study. JACC Cardiovasc Interv 2009; 2:393.
- Naylor AR, Mehta Z, Rothwell PM. A systematic review and meta-analysis of 30-day outcomes following staged carotid artery stenting and coronary bypass. Eur J Vasc Endovasc Surg 2009; 37:379.
- Naylor R, Cuffe RL, Rothwell PM, et al. A systematic review of outcome following synchronous carotid endarterectomy and coronary artery bypass: influence of surgical and patient variables. Eur J Vasc Endovasc Surg 2003; 26:230.
- Moore WS, Barnett HJ, Beebe HG, et al. Guidelines for carotid endarterectomy. A multidisciplinary consensus statement from the ad hoc Committee, American Heart Association. Stroke 1995; 26:188.
- Daily PO, Freeman RK, Dembitsky WP, et al. Cost reduction by combined carotid endarterectomy and coronary artery bypass grafting. J Thorac Cardiovasc Surg 1996; 111:1185.
- Hertzer NR, Loop FD, Taylor PC, Beven EG. Combined myocardial revascularization and carotid endarterectomy. Operative and late results in 331 patients. J Thorac Cardiovasc Surg 1983; 85:577.
- Rizzo RJ, Whittemore AD, Couper GS, et al. Combined carotid and coronary revascularization: the preferred approach to the severe vasculopath. Ann Thorac Surg 1992; 54:1099.
- Dubinsky RM, Lai SM. Mortality from combined carotid endarterectomy and coronary artery bypass surgery in the US. Neurology 2007; 68:195.
- Chaturvedi S, Bruno A, Feasby T, et al. Carotid endarterectomy--an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005; 65:794.
- Shishehbor MH, Venkatachalam S, Sun Z, et al. A direct comparison of early and late outcomes with three approaches to carotid revascularization and open heart surgery. J Am Coll Cardiol 2013; 62:1948.
- Minami K, Sagoo KS, Breymann T, et al. Operative strategy in combined coronary and carotid artery disease. J Thorac Cardiovasc Surg 1988; 95:303.
- Matar AF. Concomitant coronary and cerebral revascularization under cardiopulmonary bypass. Ann Thorac Surg 1986; 41:431.
- Kouchoukos NT, Daily BB, Wareing TH, Murphy SF. Hypothermic circulatory arrest for cerebral protection during combined carotid and cardiac surgery in patients with bilateral carotid artery disease. Ann Surg 1994; 219:699.
- 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