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J Thorac Cardiovasc Surg 1997;113:423-424
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Cost reduction by combined carotid endarterectomy and coronary bypass

Department of Cardiothoracic Surgery
University of Mississippi Medical Center
2500 N. State St.
Jackson, MS 39216-4505

To the Editor:

I read with great interest the article by Daily and associates ¹ in the June 1996 issue of the Journal, in which they examined the cost effectiveness of doing first-time isolated carotid endarterectomy, coronary bypass, or combined procedures, and I would like to share my experience.

While working at the Ospedale San Michele in Cagliari, Italy, from 1988 to 1992, I used the combined procedures in all 24 patients referred with associated coronary and carotid disease. Twenty-one of these patients were found to have unilateral (18 patients) or bilateral (3 patients) carotid stenosis greater than 60% during work-up for coronary revascularization. Carotid endarterectomy was indicated whether neurologically symptomatic or asymptomatic. Three other patients were referred for bilateral (2 patients) or unilateral (1 patient) carotid artery disease and were found to have triple vessel coronary artery disease with or without left main coronary artery stenosis during work-up for carotid endarterectomy. None of these patients had an incipient myocardial infarction or stroke at the time of the operation. Only one patient with carotid disease was treated with the combined procedure, that is, the most critical or symptomatic stenosis.

The endarterectomy was performed during hypothermia. Rationale for this type of combined procedure was twofold: (1) more comfort for the patient to have two lesions treated in a single operation and hospital stay and (2) possibly less risk of neurologic accidents related to the carotid crossclamp at moderate hypothermia.

Some technical details need to be mentioned. All of the procedures were conducted in the same standardized fashion ¹: The carotid artery was dissected before the sternum was split, with an average time of 20 minutes. Cardiopulmonary bypass was started and increased in a gradual fashion, keeping the venous line partially clamped to avoid any hypotension. Therefore, during the whole cooling time (to 28° C), the heart was always kept partially filled and was ejecting to maintain a pulsatile flow and the blood pressure was kept close to prebypass values (above 100 mm Hg systolic) until spontaneous ventricular fibrillation ensued. At this point, the venous line was completely opened, the aorta was clamped, and the heart was emptied through the aortic cardioplegia vent cannula. Next, 800 to 1000 ml of St. Thomas' Hospital crystalloid cardioplegic solution was infused into the aortic root, and a 200 ml additional dose was repeated after each distal anastomosis into the aortic root and into the graft. Topical cooling was used. After the last distal anastomosis and infusion of cardioplegic solution, the internal, common, and external carotid arteries were clamped and opened longitudinally and endarterectomy without shunt was performed with an average time of 15 minutes. In five patients a saphenous vein patch was used. After completion of the carotid closure, the carotid and aortic crossclamps were removed, rewarming was started, and the proximal anastomoses were performed. The cervical incision was closed at the same time as the sternum.

No patients in this group had neurologic deficits or myocardial infarctions, and all were discharged in good condition, free of symptoms. One patient did have a moderate elevation of cardiac enzymes (creatine kinase MB) without new q-waves.

I believe this approach can be used safely if (1) a single surgeon performs both procedures, (2) the patient is not critically symptomatic from either a cardiac or a neurologic standpoint, and (3) the heart is allowed to eject during the cooling time to keep a pulsatile flow and a pressure over 100 mg Hg systolic, thus avoiding any sudden changes in pressure or perfusion.

I am glad the referred article comes from a widely known department of thoracic surgery in the United States. For many surgeons in this country the standard of care has been the staged procedure, because some articles ^2-5 have reported higher morbidity and mortality for the combined procedure. Other factors may have influenced the management of these patients, including legal issues and fears of responsibility in the case of perioperative stroke, when combined procedures were performed by different surgeons.

In conclusion, from my personal experience, I believe that combined carotid and myocardial revascularization, both at moderate hypothermia, in symptomatically stable patients can be safely performed with more comfort for the patient, less cost than the staged procedure, and possibly more safety.

12/8/78170

References

1. Daily P, Freeman RK, Dembitsky WP, Adamson RM, Moreno-Cabral R, Marcus S, et al. Cost reduction by combined carotid endarterectomy and coronary artery bypass grafting. J Thorac Cardiovasc Surg 1996;111:1185-93.[Abstract/Free Full Text]
   
2. Hertzer NR, Loop FD, Taylor PC, Beven EG. Staged and combined surgical approach to simultaneous carotid and coronary vascular disease. Surgery 1978;84:803-11.[Medline]
   
3. 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;85:577-89.[Abstract]
   
4. Jones EL, Craver JM, Michalik RA, et al. Combined carotid and coronary operations: When are they necessary? J Thorac Cardiovasc Surg 1984;87:7-16.[Abstract]
   
5. Cosgrove DM, Hertzer NR, Loop FD. Surgical management of synchronous carotid and coronary artery disease. J Vasc Surg 1986;3:690-4.[Medline]
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Giorgio Aru Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Aru, G. Search for Related Content PubMed PubMed Citation Articles by Aru, G.