Alternate Approach To Concomitant Carotid And Coronary Disease: Perioperative Iabp Use During Carotid Endarterectomy
Paige-Ashley S. Campbell, Chelsea Dorsey, MD, Valluvan Jeevanandam, MD, Ross Milner, MD.
University of Chicago Pritzker School of Medicine, Chicago, IL, USA.
Objective: With demographics shifting towards an increasingly older population in the United States, it is imperative that patients with a complex cardiovascular history are approached in a systematic fashion. Currently, there is no clear protocol on how best to surgically manage elderly patients who present with symptomatic coronary artery disease and severe carotid artery stenosis. It has been well established that patients with severe uncorrected internal carotid artery disease have an increased risk of experiencing a cerebrovascular accident during coronary artery bypass grafting (CABG). One approach that has been recognized in other settings as a cost-effective strategy to stabilize high-risk elderly patients preoperatively is the use of an intraaortic balloon pump (IABP). To better understand the best approach to take in these patients with concomitant disease, we analyzed the outcomes of four patients who underwent placement of an intraaortic balloon pump prior to carotid endarterectomy (CEA) as a bridge to CABG.
Methods: Between 2017 and 2019, four patients, who presented with multi-vessel symptomatic coronary artery disease and greater than 90% stenosis of at least one internal carotid artery, underwent either staged or simultaneous CEA and CABG. There was placement of an intra-aortic balloon pump in all patients prior to the CEA. Time to CABG ranged from a simultaneous procedure to 23 days post CEA.
Results: The only death within 30-days post-operation involved the patient who had CEA and CABG performed simultaneously. None of the surviving patients experienced a myocardial infarction. Two of the four patients experienced acute kidney injury after surgery and one patient developed atrial fibrillation postoperatively. No postoperative neurological complications were experienced by any of the patients.
Conclusion: A staged procedure with placement of an IABP can be successfully used in carefully selected patients presenting with concomitant severe carotid and coronary artery disease. The stabilization provided by IABP was a protective factor against adverse post-operative events and appeared to allow for flexibility in the time between CEA to CABG for patients. Additional studies are necessary to further understand the impact of such an approach
| Patient | Age | RCA stenosis (%) | LCA stenosis (%) | LV Ejection Fraction (%) | CAD (% stenosis) | Time between CEA and CABG |
| I | 84 | 80-99 | 50-79 | 66 | LAD -70% OM2 -30-40% RCA - 95 | staged-24 hours |
| II | 83 | 0-49 | 80-99 | 55-60 | LCx - 100%, RCA - 30-40% | staged-23 days |
| III | 80 | 80-99 | 50-69 | 55 | LAD-70% OM1-75% OM2-90% | staged-9 days |
| IV | 65 | 0-49 | 80-99 | 65-75 | LAD-80-90% LCx-70% | simultaneous |
Table 1: Baseline characteristics and staging approach of high-risk patients undergoing CEA/CABG
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