AW: [HSF] a carotid and coronary case

[Edward Bender]

These are my typical patients.  In spite of what the Cleveland Clinic  
among others has published about combined procedures, I still think  
the approach should be guided by the experience of the surgeon.  In  
patients with truly emergent cerebral ischemic symptoms (ie,  
stuttering TIA's), we rarely have the opportunity to know the  
coronary anatomy ahead of time.  On the other hand, in patients with  
known surgical coronary disease, it is very easy to know the presence  
or absence of important carotid disease (we, like many other  
programs, get carotid dopplers on all pre-op hearts).  If your team  
(especially the surgeon) can do carotids with less than 1% stroke  
rate, I think that a combined procedure is safe and effective.  Note  
that I used the term "I think" and that I can not prove this to be  
true.  Doing the carotid endarterectomy with a shunt in place, under  
general anesthesia by the heart team in the heart room followed by  
immediate CABG is a safe and effective procedure.  I do about 15-20  
of these a year for the past 10 years with no strokes.  On the other  
hand, I did do a staged carotid due to symptoms, followed by CABG  
necessitated by myocardial ischemia with a normal post-op neuro  
picture, but a lowered EF due to MI after carotid.  I would  
personally do the combined operation in a patient like this.

Now what about the statement that he needs 3 arterial grafts?  If he  
is hemiparetic, this implies that he has issues with mobility and  
transferiing from bed to chair, etc.  Is he also diabetic?  Do you  
really need to use all arteries in someone like this - the  
implication being that you are using bilateral mammaries with greater  
risk of sternal complications in someone who probably already places  
excess strain on the sternum?

Ed Bender, MD


On Aug 3, 2007, at 10:27 AM, Dr. Roberto Battellini wrote:

>
>
> How would the members operate a case with:
>
> Man 52 years old, had a stroke with hemiparesis after the right  
> carotid was
> occluded. Left carotid 95% stenosed. He needs 3 arterial grafts for  
> 3 vessel
> disease. The right hemisphere is perfused from the left carotid.
>
> Roberto
>
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