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Cardiac Surgery pp 1017–1031Cite as

Combined Procedures in Cardiac and Vascular Surgery

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Abstract

As a systemic disease, atherosclerosis often involves multiple vascular territories, and thus a considerable number of patients with coronary artery disease (CAD) have concurrent incidence of significant carotid artery stenosis. Apart from aortic atheromatous disease, carotid stenosis, particularly with radiographic demonstration of previous stroke or history of transient ischemic attack (TIA) within the last 6 months, is the most important factor for predicting an increased risk of perioperative stroke. Over more than four decades, there is ongoing debate as to which strategy is optimal with regard to the incidence of perioperative complications and long-term outcomes after coronary artery bypass grafting (CABG). In the absence of randomized controlled trials, no systematic evidence exists that staged or synchronous carotid revascularization and coronary revascularization confer any benefit over isolated CABG without carotid endarterectomy (CEA). Whereas in patients with symptomatic carotid stenosis scheduled for CABG, CEA performed by experienced teams achieving a combined rate of stroke or death at 30 days of <6 % may be beneficial, the situation is even more difficult in patients with asymptomatic carotid stenosis, particularly when it is unilateral. This is because any potential benefit conferred by prophylactic carotid revascularization may be offset by the increased risk of combined staged or synchronous procedures. Conversely, any evidence backing the isolated CABG approach that leaves the severe carotid stenosis untouched is just as scarce. Therefore, as long as clear regulations on the management of patients with CAD and carotid disease are not available, it is recommended to individualize the indication for carotid revascularization after discussion by a multidisciplinary team involving a neurologist and to determine the timing of the procedure by local expertise and clinical presentation, targeting the most symptomatic territory first. Although a considerable portion of patients requiring abdominal aortic aneurysm (AAA) repair have concurrent coronary artery disease, prospective randomized trials demonstrated that preventive CABG preceding major vascular procedures was not necessary. Similarly, the coexistence of CAD and peripheral artery disease is very common at 42 %, but only patients with acute coronary syndrome should not undergo elective vascular surgery.

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Authors and Affiliations

  1. Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University of Duisburg-Essen, Essen, Germany

    Heinz G. Jakob MD, PhD & Stephan C. Knipp MD

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  1. Heinz G. Jakob MD, PhD
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  2. Stephan C. Knipp MD
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Correspondence to Stephan C. Knipp MD .

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Editors and Affiliations

  1. Department of Surgery, The University of Chicago, Chicago, IL, USA

    Gerhard Ziemer

  2. HTTG - Surgery, Medizinische Hochschule Hannover, Hannover, Germany

    Axel Haverich

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Jakob, H.G., Knipp, S.C. (2017). Combined Procedures in Cardiac and Vascular Surgery. In: Ziemer, G., Haverich, A. (eds) Cardiac Surgery. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-52672-9_33

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