ASYMPTOMATIC CARTOID DISEASE COMBINED WITH ISCHEMIC HEART DISEASE

ASYMPTOMATIC CARTOID DISEASE COMBINED WITH ISCHEMIC HEART DISEASE Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital Split

Surgical Myocardial Revascularization (perioperative complications) • Myocardial infarction • Cerebrovascular accident • Death Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Cerebrovascular Accident (perioperative complication - CABG) • Permanent disability • Prolonged hospital stay - 25 days • Increase in treatment costs - double Ø Mortality 23% Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Incidence of Perioperative CVA • Patient’s age < 45 yrs. - 0. 2% 60 -70 yrs. - 3% > 75 yrs. - 8% Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Aortocoronary bypass (CABG) • Average of CABG patients Ø 56 yrs. (1980. ) Ø 69 yrs. (2010. ) Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Aortocoronary bypass (CABG) • Distribution of CABG patients by age Ø 6% ( ≥ 70 yrs. ); 1990. Ø 45% ( ≥ 70 yrs. ); 2010. Ø 13% ( ≥ 80 yrs. ); 2010. Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Risk Factors for Perioprative CVA • Age • Gender - female • Diabetes • Atherosclerosis • Renal insufficiency • Smoking • TIA • CVA • ”Left main” stenosis Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Risk Factors for Perioprative CVA • Extracorporeal circulation - duration • ”Non-pulsatile blood flow” • Perioperative hypotension • Large vessels manipulation • ”Prothrombotic millieu” - heparin-protamine conversion Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Perioperative CVA • Embolization (thrombus, atherosclerothic plaque, air) Ø Carotid atherosclerotic disease - ulcerated plaque Ø Aortic atherosclerotic disease Ø Atrial and ventricular thrombus Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital - heart rate disorders - LV aneurysm - acute MI

Perioperative CVA • ”Low flow” phenomenon (CNS hypoperfusion) Ø low perfusion pressure with ECC (<60 mm. Hg) Ø absence of collateral circulation Ø vascular spasm Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Perioperative CVA • Intracranial bleeding (hemorrhagic CVA) Ø ECC anticoagulation - heparin Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Carotid Atherosclerotic Disease as Risk Factor for Perioperative CVA Stenosis of ACI > 70% is considered significant Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Significant Stenosis of ACI as Risk Factor for Perioperative CVA • Cerebrovascular accident (incidence) Ø 9. 2% (stenosis of ACI > 70%) Ø 1. 3% (without ACI stenosis) Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Significant Stenosis of ACI as Risk Factor for Perioperative CVA Odds ratio for CVA in patients with significant ACI stenosis is 9. 9 times higher (> 60 yrs. ). Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Incidence of ACI stenosis in patients with CAD • ACI stenosis > 70% - 8. 7% • Patient’s age < 60 yrs. - 3. 8% ≥ 60 yrs. - 11. 3% Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

CVA in patients with ACI stenosis Ø Embolization (ulcerated plaque, thrombus) Ø ”Low flow” phenomenon (CNS hypoperfusion) Ø ”Prothrombotic millieu” (heparin conversion) Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Atherosclerotic carotid disease Ø Asymptomatic Ø Symptomatic Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Carotid Artery Anatomy Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Intracranial Distribution of ACI Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Diagnostics • Physical examination - murmur auscultation • Doppler ultrasound (stenosis, occlusion, morphology) • MSCT - angiography Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Indications for ACI Surgery in CABG Ø Asymptomatic stenosis of ACI > 70% Ø Symptomatic stenosis Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Surgical Technique • Thrombendarterectomy (TEA) • Thrombendarterectomy + ”patch” plastic Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Surgical Thrombendarterectomy (TEA) Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Surgical Thrombendarterectomy (TEA) Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Combined Carotid and Coronary Surgery (TEA & CABG) • ”Staged carotid and coronary procedure” - two operations with time delay • ”Reversed staged procedure” - two operations with time delay • ”Concomitant carotid and coronary procedure” - two operations at the same time Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Combined Carotid and Coronary Surgery (TEA & CABG) Ø Bilateral significant ACI stenosis • ”Staged procedure” - stable CAD • ”Concomitant procedure” - unstable CAD Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Operative Outcomes • Perioperative CVA - 4% (< 9. 2%) • Mortality - 3. 5% (< 23%) Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital

Conclusion Asymptomatic carotid artery surgery in patients scheduled for CABG decreases incidence of perioperative CVA and mortality Asst. Prof. C. Bulat, MD, Ph. D Department of Cardiac Surgery University Hospital