Abstract
BackgroundManagement 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 reportWe 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.
Highlights
Management of patients with co-existent coronary and carotid disease is a controversial and challenging issue
We describe our experience using a temporary carotid shunt in order to maintain cerebral perfusion until coronary artery bypass grafting (CABG) was completed and the operation was concluded with the closure of carotid arteriotomy
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
Summary
Management of patients with co-existent coronary and carotid disease is a controversial and challenging issue [1]. Ultrasound which was performed urgently in intensive care unit (ICU), showed bilateral severe carotid stenosis (8090% 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. 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). 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
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