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Eur J Cardiothorac Surg 1999;16:602-606
© 1999 Elsevier Science NL

Combined approach for internal carotid artery stenosis and cardiovascular disease in septuagenarians – a comparative study

Thomas Buscha, Horia Sirbua, Ivan Aleksica, Stephan Kazmaierb, Martin Friedricha, Wolfgang Buhreb, Harald Dalichaua

a Department of Thoracic and Cardiovascular Surgery, Klinik und Poliklinik für Thorax-, Herz- und Gefäßchirurgie, Georg-August-University, Goettingen, Robert-Koch-Strasse 40, 37075 Goettingen, Germany
b Department of Anaesthesiology, Emergency- and Intensive Care Medicine, Zentrum für Anaesthesiologie, Rettungs- und Intensivmedizin, Georg-August-University, Goettingen, Germany

Corresponding author. Tel.: +49-551-396-008; fax: +49-551-396-002
e-mail: tbusch{at}gwdg.de


   Abstract
Top
 Abstract
1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 References
 
Objective: The best surgical approach for concomitant carotid artery and cardiac disease remains controversial. Many studies proved the safety and efficiency of simultaneous surgery. We aimed to demonstrate the same benefits for patients >=70 years. Methods: We retrospectively evaluated 205 patients simultaneously operated upon between 1988 and 1998. Group A comprised patients <70 years (n=110), group B >=70 years. (n=95). Risk factors, neurologic and cardiac history, angiographic findings, operative data, morbidity and mortality (30-day-postoperatively) were analysed. The mean age was 62 years in group A and 75 years in group B. All patients with symptomatic carotid artery disease, stenosis >70% or ulcerative carotid disease had simultaneous surgery. Always, the carotid artery was addressed first. Results: Patients in group B had a higher prevalence of peripheral vascular disease (P=0.0005), renal insufficiency (P=0.0011) and COPD (P=0.03). Urgent operation was indicated in 19% of group A patients vs. 37% in group B. In group A 70% were asymptomatic regarding the carotid vs. 48% in group B. Left ventricular dysfunction was present in 45% (group A) and 58% (group B). In the present study 4% in group A and 7% in group B suffered a perioperative myocardial infarction. Pathologic changes of the contralateral carotid were found in 42 vs. 57% (A vs. B). Mortality due to cardiac causes was 1 and 5%, respectively. The combination of persistent neurologic deficit and neurologic death occurred in 3% in group A (n=3) and 5% in group B (n=5). Postoperative neuro-cognitive dysfunction was more common in group B (35 vs. 16%; P=0.01). Conclusions: The incidence of persistent neurologic deficits and neurologic mortality in patients >=70 years is acceptable, and low in patients <70 years. Preoperative risk factors are increasing with age and are related to the higher mortality in elderly patients. Due to our results we will conclude that the combined approach for carotid stenosis and cardiovascular disease is the method of choice in this high-risk population.

Key Words: Carotid artery stenosis • Cardiac disease • Coronary artery bypass grafting • Simultaneous surgery • Septuagenarians


   1. Introduction
Top
 Abstract
 1. Introduction
2. Material and methods
 3. Results
 4. Discussion
 References
 
The surgical approach for cardiac disease with concomitant carotid artery stenosis (CAS) remains controversial. Carotid endarterectomy (CEA) in the presence of untreated coronary artery disease (CAD) carries a risk of perioperative myocardial infarction of 17% and of perioperative death of 20% [1,2]. On the other hand, patients with untreated carotid artery stenosis face a 14% chance to suffer a stroke after surgical myocardial revascularization [2,3]. Numerous studies have demonstrated good results for combined disease either with simultaneous surgical treatment [3–8], with delayed surgery for one of the two entities [9–11] or with hypothermic circulatory arrest [12]. Perioperative morbidity and mortaliy depends on several factors: increasing patient age, unstable angina pectoris, coronary multi-vessel disease, left main stem stenosis, carotid stenosis >80%, recent stroke or transitory ischaemic attack (TIA) and non-elective surgery [3–6,10–12].

In our study, 3–12% of all patients with symptomatic CAD have a CAS of 70% or more causing additional morbidity and mortality in this high-risk group [5,13,14]. Bernhard et al. [15] were the first to report on a group of patients with simultaneous CEA and coronary artery bypass grafting in 1972. Many studies have demonstrated excellent short- and long-term results after simultaneous surgery [16,17] in the meantime and economic considerations have gained increasing relevance for medical decisions since then [8].

To our knowledge, all studies published so far have not addressed the issue of combined surgery for CAS and cardiac disease in patients above the age of 70 years. In the present study, we aimed to investigate the safety and feasibility of a combined approach for these group of patients, excluding those with haemodynamical instability due to unstable angina pectoris.


   2. Material and methods
Top
 Abstract
 1. Introduction
 2. Material and methods
3. Results
 4. Discussion
 References
 
All patients undergoing CEA and cardiac surgical interventions between 1988 and 1998 were retrospectively evaluated. The total patient population consists of 205 cases. Demographic data, preoperative risk factors as described in the literature, neurologic and cardiac history, results of cardiac catheterization and carotid angiography, intraoperative data and postoperative morbidity and mortality were recorded. All patients were divided into two groups: group A, patients <=70 years and group B: patients >70 years. The patients were hospitalized primarily for cardiac symptoms which developed with the onset of angina or heart failure due to coronary artery disease. Work-up for CAS was initiated if the patients reported symptoms suggestive for CAS, had a history of TIA's, stroke or were found to have a carotid bruit. Initial work-up consisted of transcranial Doppler examination of the carotid arteries and CT scan of the brain. The indication for surgical therapy relied on intraarterial angiography of the supraaortic vessels. Surgery was recommended if the CAS was >=70% but asymptomatic, for any symptomatic CAS irrespective of the degree of stenosis and if ulcerated plaques were identified.

Simultaneous surgery was performed with general anaesthesia by the same surgical team. The CAS was approached first during parallel harvesting of the saphenous vein in order to obtain a venous patch. In all cases, transcranial Doppler monitoring was performed intraoperatively. If mean cerebral blood flow velocity fell by 50% or more after carotid cross-clamping an intraluminal shunt was initiated. The neck incision was left open until heparin had been antagonized with protamine. After CEA cardiac surgical intervention on cardiopulmonary bypass followed. All procedures were performed under conditions of moderate hypothermia (32°C) and antegrade cardioplegic arrest with Bretschneider's cardioplegic solution.

Perioperative myocardial infarction was diagnosed if new Q-waves, persistent ST-segment changes with a concomitant increase in CK/MB-serum-levels or a new left bundle branch block occurred.

Perioperative stroke was identified as permanent or transient after neurological consultation. The localization was related to the carotid artery operated upon as either ipsilateral or contralateral.

Results in text and tables are expressed as mean±standard deviation (SD) or percent were appropriate. Fisher's exact test was used for categorical variables. A level of P<0.05 was considered statistically significant. For continuous variables we used the Mann–Whitney U-test. All statistical procedures were performed on a microcomputer using the SPSS/PC+TM statistical software package.


   3. Results
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
4. Discussion
 References
 
Between 1988 and 1998 205 patients with simultaneous surgery for CAS and cardiac disease were identified. Group A (<70 years) consisted of 110 patients, group B (>=70 years) of 95 patients. The major demographic and clinical findings are displayed in Table 1.


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  		Table 1. Demographic and clinical characteristicsa

 
With regard to preoperative risk evaluation, group B patients had a significantly higher incidence of peripheral vascular disease, renal insufficiency, chronic obstructive pulmonary disease, heart failure, unstable angina pectoris and stroke (Table 1). In group A, 43% had symptoms of cardiac disease versus 54% in group B at the time of admission to hospital. In patients below 70 years, 30% did have symptoms of CAS as opposed to 52% in group B.

Angiographic findings of left heart catheterization and supraaortic studies are shown in Table 2. The majority of patients had triple-vessel disease, almost one third had left main stenosis. Left ventricular function (LVF) was reduced in 36% of group A patients (n=40), 6% had an left ventricular ejection fraction (LVEF) of less than 25% (n=6). In group B reduced LVF was present in 47% (n=45), 10% (n=9) had an LVEF of less than 25%. Carotid kinking and coiling with stenosis below 50% was present in 4% (n=4) of group A and 1% (n=1) in group B. Unilateral stenosis of vertebral arteries was found in 13% (n=14) of group A and in 16% (n=15) of group B, bilateral stenosis was present in 7% (n=8) vs. 14% (n=13) in patients of group B. In 5% (n=5) of group A patients and 8% (n=8) of group B patients a significant stenosis of the unilateral subclavian artery was shown angiographically, bilateral stenosis were seen in 1% (n=1) vs. 4% (n=4) in group B patients.


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  		Table 2. Angiographic data

 
Intraoperative data are shown in Table 3. None of our patients was scheduled for simultaneous surgery on an emergency basis due to haemodynamic instability, because all patients with preinfarction syndrome underwent operative revascularization immediately without any delays for further diagnostic studies of the carotid arteries.


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  		Table 3. Characteristics of surgery

 
In group A, two patients underwent aortic valve replacement (AVR) plus CABG (coronary artery bypass grafting) in conjunction with CEA, and one patient mitral valve replacement (MVR) with CEA. In group B there were six patients with AVR plus CABG and CEA, three with MVR and CEA and one patient with mitral valve reconstruction and CEA. None of these patients developed CEA-related neurological complications and only two patients of group B died during the postoperative hospital stay. The majority of patients received an IMA (left internal mammary artery) graft to the LAD (left anterior decending) (83% in group A vs. 76% in group B).

Carotid endarterectomy in eversion-technique was performed in 42% (n=46) of group A and 34% (n=32) of group B, patchplasty in 58% (n=64) versus 66% (n=63) of group B patients. An intraluminal shunt was used in 57% of procedures in group A (n=62) and 48% in group B (n=46).

The incidence of postoperative complications is given in Table 4. One patient in group A (1%) died from neurological causes. In group B there were three deaths due to neurological complications (3%). However, one of these patients died from a contralateral intracranial haemorrhage, thereby reducing the surgical mortality to 2% (two patients). In three patients CT-scan showed ipsilateral ischaemic areas related to CEA.


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  		Table 4. In-hospital and 30-day postoperative complicationsa

 
A persistent neurological deficit was found in three patients in group A (3%) and five patients (5%) in group B. Postoperative CT scans failed to demonstrate a morphological substrate in one patient in each group, the remaining six patients showed signs of ipsilateral ischaemic regions related to CEA.

Many more patients were perturbed after surgery in group B than in group A (35 vs. 16%, P=0.01), which was defined as a neuro cognitive dysfunction (patients are not oriented to time and person) without relation to CEA. Length of intensive care unit stay (2 vs. 3 days, A vs. B, (ns)) and total length of hospital stay (12 vs. 16 days, (ns)) were similar between groups.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
References
 
The results of this retrospective analysis demonstrate that combined cardiac and carotid surgery can be performed with low mortality in septuagenarians. The combined rates of perioperative stroke and mortality was less than 6% in this group of patients compared to 3% in patients <70 years. However, to our knowledge the present study is the first in which mortality and neurologic outcome of combined carotid endarteriectomy and bypass surgery was analysed with special respect to age.

The optimal surgical approach for combined cardiac disease and carotid artery stenosis is still a matter of discussion, reflected by different surgical approachs. Many studies [5,7,17] have confirmed that combined surgery for cardiac disease and CAS is a safe and efficient procedure including the most recent studies by Akins [4], Daily [8] and Rizzo [6]. In contrast Jones and coworkers [10] and Coyle et al. [11] published good results with a two-stage surgical intervention. Kouchoukos et al. [12] utilized hypothermic circulatory arrest for combined surgical interventions. Weiss and coworkers [18] cool the patient to 20°C and perform the CEA during cross-clamping of the aorta. In our institution, combined surgery of cardiac disease and CAS is the standard approach and thus the results obtained in patients with increased risk (like those greater 70 years of age) must be comparable to patients <70 years of age to justify combined surgery. Because of the increasing age of patients referred for cardiac surgery, the results of simultaneous surgery in elderly patients deserve special attention. The low postoperative mortality from permanent neurological causes in group A (1%) and the low rate of perioperative strokes (2%) are good results in patients below the age of 70 years. The stroke-rate in group B (2%) and the mortality from neurological causes (3%) is acceptable low for older patients, in particular when compared to the recent literature [1–11,16,17]. Patients >70 years developed an increased rate of pulmonary complications during the hospital stay, which is probably related to the higher incidence of patients with chronic obstructive lung disease in this group. In addition, the rate of neurological disorders related to extracorporal circulation (ECC) are increased in patients >70 years of age. All other outcome variables were not significantly different between groups. Multiple studies have reported higher incidences of stroke, myocardial infarction (MI) and higher mortality with simultaneous interventions than for patients undergoing CEA [6,8,9,11] or CABG only [6–8,10,14]. However, all these studies demonstrated significant differences with respect to severity of atherosclerosis and presence of risk factors. Even most recent studies by O'Hara et al. [19] describing the results of CEA in octogenarians and by Hoballah et al. [20] in nonagenarians do not report lower incidences of perioperative strokes. Nevertheless, it remains obvious that patients with cardiac disease and concomitant CAS form a high-risk group of surgical patients. Our results demonstrate that in these patients low rates of perioperative stroke are achievable (2%). Risk factors for concomitant carotid artery stenosis according to Berens and coworkers [21] and D'Agostino [22] include age over 70 years, diabetes, left main stenosis, peripheral arterial occlusive disease, previous vascular surgical interventions, female sex, previous stroke or TIAs and smoking. These findings were confirmed indirectly by Schwartz [13], Salisidis [14] and Mickelborough [23] who proved that identical risk factors accounted for a higher rate of neurological complications after cardiac surgery utilizing cardiopulmonary bypass. In our study cohort, patients >70 years were more likely to have peripheral vascular disease, renal and pulmonary insufficiency, unstable angina, heart failure and stroke, which may contribute to their overall risk. In our opinion, the general condition of the patient and the presence of preoperative organ dysfunction must be taken into account before planning combined surgery. In agreement with Hertzer et al. [1–3] we think that our combined approach is justified in view of the frequently diffuse nature of CAD in these patients, the high incidence of left main stenosis, frequent urgent surgical interventions (37%) and a majority of patients presenting with left ventricular dysfunction (58%). Therefore, a 7% incidence of perioperative MIs in patients >70 years compares favorably with recent publications [24,25]. The increasing financial constraints imposed on any health care system can be softened by simultaneous surgery as reported by Daily and coworkers [8]. Undoubtedly, this aspect will gain more influence in the future. This is reflected in the fact that 87% of all simultaneous cases were done during the last 6 years in our institution. As stated by Daily [8] most costs are generated due to perioperative complications necessitating prolonged hospitalization. The average length of ICU stay, and hospital stay compared favorably in view of economical aspects.

In summary, our results support the opinion that the combined approach to cardiac disease and carotid artery stenosis is the method of choice. Due to the high incidence of preoperatively existing risk factors, mainly due to generalised arteriosclerosis, the patients scheduled for combined surgery generally represents a high risk population. However, the results of the present study demonstrates that combined cardiac and carotid surgery can be performed with considerably low mortality and morbidity in patients <70 years. In patients above 70 years, we observed a significantly increase of preoperative risk factors, and morbidity and mortality was elevated in these patients. However, these findings did not reach statistical significance. Thus, our experience supports the impression that the combined approach is justified and indicated in patients older than 70 years, too. Furthermore, first results of cost containment analysis in our institution supports literature data, that combined surgery offers additional advantages with respect to oeconomical resources.


   References
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 References
 

  1. Hertzer N.R., Lees C.D. Fatal myocardial infarction following carotid endarterectomy. Ann Surg 1981;194:212-218.[Medline]
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Received June 28, 1999; received in revised form September 20, 1999; accepted September 28, 1999.





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