Carotid shunt provides cerebral protection during emergency coronary artery bypass grafting in a patient with bilateral high grade carotid stenosis: a case report
verfasst von:
John K Bellos, Nektarios Kogerakis, Charalampos Kiriazis, Alexandros Gougoulakis, Matthew Panagiotou
Management of patients with co-existent coronary and carotid disease is a controversial and challenging issue. The risk for stroke after coronary artery bypass grafting (CABG) in patients with hemodynamically significant carotid stenosis is up to 30%. In these patients a common practice is to proceed first with the restoration of cerebral perfusion and then perform the coronary revascularization. The rationale is that this strategy will reduce perioperative neurological morbidity and mortality. However, what happens when the carotid procedure is acutely complicated by cardiac instability which necessitates the interruption of the carotid procedure?
Case report
We describe a case of a patient with unstable angina and high grade asymptomatic bilateral carotid stenosis who underwent emergency combined CABG and carotid endarterectomy (CEA). Due to hemodynamic instability, ST-T changes, hypotension and bradycardia, upon completion of endarterectomy we placed a carotid shunt and the patient was put on cardiopulmonary bypass through median sternotomy. After triple CABG (duration of 90 minutes) we concluded the interrupted CEA procedure with primary closure of the carotid arteriotomy with the shunt in place. The postoperative course was uneventful and the patient was discharged after a week. In extreme cases with bilateral severe carotid stenosis and coronary artery disease where the carotid procedure should be interrupted, we suggest the use of carotid shunt which can provide adequate cerebral perfusion giving time to cardiac surgeon to perform the life saving cardiac procedure first.
The online version of this article (doi:10.1186/1749-8090-6-33) contains supplementary material, which is available to authorized users.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
JB, AG, MP came up with original conception and design. JB, AG, MP, NK, CK reviewed the medical literature, and were major contributors in writing the manuscript. NK, CK formatted the media. All authors read and approved the final manuscript.
Background
Management of patients with co-existent coronary and carotid disease is a controversial and challenging issue [1]. The risk for stroke after coronary artery bypass grafting (CABG), in patients with hemodynamically significant carotid stenosis is up to 30% [2]. Therefore, in these patients a common practice is to proceed first with the restoration of cerebral perfusion and then perform the coronary revascularization. The rationale is that this strategy will reduce perioperative neurological morbidity and mortality. However, according to our knowledge, there is no published data concerning combined carotid endarterectomy (CEA) and CABG where intraoperatively the carotid procedure was acutely complicated by cardiac instability necessitating the interruption of the carotid procedure. We describe our experience using a temporary carotid shunt in order to maintain cerebral perfusion until CABG was completed and then the operation was concluded with the closure of carotid arteriotomy.
Case presentation
Patient's history and management
A 80 year old male patient with a history of coronary artery disease (CAD) and severe left ventricular dysfunction was urgently admitted in our institution with unstable angina. Ejection fraction was 20%. Coronary angiography revealed severe triple vessel disease. Moreover, duplex ultrasound which was performed urgently in intensive care unit (ICU), showed bilateral severe carotid stenosis (80-90% stenosis and unstable plaque in the right internal carotid artery and 70-80% stenosis in the left side). Both vertebral arteries were patent without reverse flow or any significant hemodynamic changes. The patient continued to be in unstable angina, therefore we decided to perform emergency combined surgery without a preoperative angiogram. After induction of general anesthesia the right carotid bifurcation was exposed by a standard lateral approach and simultaneously the left great saphenous vein was harvested. Immediately after the completion of endarterectomy and before starting the closure of arteriotomy the patient became hemodynamic unstable with ST-T changes, bradycardia and hypotension. Under these conditions we decided to interrupt the carotid procedure and place a Javid carotid shunt (Bard Peripheral Vascular Inc, AZ, USA), and immediately proceed with a median sternotomy and cardiopulmonary bypass (CPB) (Figure 1A). We performed an emergency triple CABG with saphenous vein grafts under extracorporeal circulation (ECC) and moderate hypothermia (28°C). After the patient's weaning from CPB and his pressure stabilization (90 minutes later) the CEA was completed with primary closure of carotid arteriotomy (Figure 1B). The patient was transferred to the ICU for one day and was discharged on the seventh postoperative day with improved left ventricular function and without neurological complications.
Figure 1
Line drawings depict stages of the operative procedure: A) Due to hemodynamic instability we stopped the carotid endarterectomy procedure, we placed a carotid shunt and we proceeded to emergency sternotomy, B) After the completion of 3 coronary artery bypass grafting and patient's weaning from cardiopulmonary bypass, we continued with the primary closure of carotid arteriotomy.
×
Anzeige
Discussion
The optimal management of patients with combined carotid and coronary artery disease remains controversial. Various strategies have been proposed such as CEA alone, or CABG alone, or staged CEA and CABG, or staged carotid artery stenting (CAS) and CABG, and simultaneous CEA and CABG, or simultaneous CAS and CABG. In the majority of these approaches the CEA or CAS precedes the CABG because it seems that reduces the perioperative neurological morbidity and mortality. We report a case where the CEA procedure was interrupted by the CABG. The carotid procedure was finished after the completion of the CABG. All these handlings were possible through a temporary carotid shunt which proved sufficient to maintain adequate cerebral perfusion for 90 minutes. To our knowledge prolonged cerebral perfusion through a shunt during on pump emergency CABG in patients with bilateral severe carotid stenosis has not been previously reported.
Besides carotid artery stenosis, other stroke risk factors during CABG, frequently quoted in the literature, are: ascending aortic atherosclerosis, previous stroke or transient ischemic attack, age, hypertension, diabetes, smoking, peripheral vascular disease, left ventricular dysfunction, left main CAD, renal failure, and increased cardiopulmonary bypass time [3]. Our patient had the majority of these risk factors (age, left CAD, heavy smoker in the past, left ventricular dysfunction, peripheral arterial disease). The only preventive measure against stroke were the carotid shunt, which proved to be adequate, and the patent vertebral arteries.
In a recent case report the authors applied a 14 Fr cannula into the distal part of the internal carotid artery. A separate pump was connected in cannula and arterial blood at 23°C was delivered at a flow rate of 300 ml/min [4]. Although, based on classical findings, the normal carotid artery flow rate is 133-200 ml/min, the appropriate flow rate of the active cerebral perfusion is still unclear [5]. However, under CPB the cerebral autoregulation is severely impaired, thus a flow rate of 300 ml/min may result to hyperperfusion syndrome and cerebral hemorrhage. Moreover, differences between our technique and the previous mentioned are obvious. Our technique is less complicated, less expensive and less time consuming. Therefore, our report suggests that a carotid shunt could maintain cerebral perfusion and could provide cerebral protection for at least 90 minutes ECC in patient with high grade bilateral carotid stenosis.
Some surgeons prefer the off-pump CABG, especially in patients with severe carotid disease [6]. Off-pump CABG certainly has many advantages and in a recent study an aorto-carotid shunt was used in patients who underwent combined CEA and CABG with satisfactory results [7]. However, in our case this was not feasible because of patient's hemodynamic instability.
Anzeige
Finally, the important role of the shunt in the cerebral perfusion during CPB is enhanced by the fact that the patient was under diminished systemic pressure, moderate hypothermia and non pulsatile cerebral perfusion from the pump for 90 minutes.
Conclusion
This case highlights the value of conventional carotid shunt to maintain intra-operative cerebral perfusion during emergency CABG in unstable patients with simultaneous carotid and coronary disease. We propose our technique as a bail-out trick in combined cases of CEA and CABG when the endarterectomy cannot be completed due to life threatening cardiac and hemodynamic instability.
Consent
Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Acknowledgements
We would like to warmly thank Dr. Giannis Lazaridis for his valuable line drawings.
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
JB, AG, MP came up with original conception and design. JB, AG, MP, NK, CK reviewed the medical literature, and were major contributors in writing the manuscript. NK, CK formatted the media. All authors read and approved the final manuscript.
Carotid shunt provides cerebral protection during emergency coronary artery bypass grafting in a patient with bilateral high grade carotid stenosis: a case report
verfasst von
John K Bellos Nektarios Kogerakis Charalampos Kiriazis Alexandros Gougoulakis Matthew Panagiotou
Selbstverschuldete Fehler oder unerwartete Komplikationen machen jungen Chirurginnen und Operateuren mit Migrationshintergrund offenbar besonders zu schaffen. Benötigt werden routinemäßige Programme zum Umgang mit Zwischenfällen im OP.
Offenbar muss es nicht immer die bariatrische Chirurgie sein, wenn es darum geht, durch deutlichen Gewichtsverlust auch das Krebsrisiko günstig zu beeinflussen. Eine große Kohortenanalyse zur Behandlung mit GLP-1-Agonisten wurde dazu auf der ASCO-Tagung vorgestellt.
In der Notaufnahme wird die Chance, Opfer von häuslicher Gewalt zu identifizieren, von Orthopäden und Orthopädinnen offenbar zu wenig genutzt. Darauf deuten die Ergebnisse einer Fragebogenstudie an der Sahlgrenska-Universität in Schweden hin.
Darüber reden und aus Fehlern lernen, sollte das Motto in der Medizin lauten. Und zwar nicht nur im Sinne der Patientensicherheit. Eine negative Fehlerkultur kann auch die Behandelnden ernsthaft krank machen, warnt Prof. Dr. Reinhard Strametz. Ein Plädoyer und ein Leitfaden für den offenen Umgang mit kritischen Ereignissen in Medizin und Pflege.
Update Chirurgie
Bestellen Sie unseren Fach-Newsletterund bleiben Sie gut informiert.
Das Karpaltunnelsyndrom ist die häufigste Kompressionsneuropathie peripherer Nerven. Obwohl die Anamnese mit dem nächtlichen Einschlafen der Hand (Brachialgia parästhetica nocturna) sehr typisch ist, ist eine klinisch-neurologische Untersuchung und Elektroneurografie in manchen Fällen auch eine Neurosonografie erforderlich. Im Anfangsstadium sind konservative Maßnahmen (Handgelenksschiene, Ergotherapie) empfehlenswert. Bei nicht Ansprechen der konservativen Therapie oder Auftreten von neurologischen Ausfällen ist eine Dekompression des N. medianus am Karpaltunnel indiziert.
Das Webinar beschäftigt sich mit Fragen und Antworten zu Diagnostik und Klassifikation sowie Möglichkeiten des Ausschlusses von Zusatzverletzungen. Die Referenten erläutern, welche Frakturen konservativ behandelt werden können und wie. Das Webinar beantwortet die Frage nach aktuellen operativen Therapiekonzepten: Welcher Zugang, welches Osteosynthesematerial? Auf was muss bei der Nachbehandlung der distalen Radiusfraktur geachtet werden?
Inhalte des Webinars zur S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“ sind die Darstellung des Projektes und des Erstellungswegs zur S1-Leitlinie, die Erläuterung der klinischen Relevanz der Klassifikation EAES 2015, die wissenschaftliche Begründung der wichtigsten Empfehlungen und die Darstellung stadiengerechter Therapieoptionen.
