Hypothermic circulatory arrest for cerebral protection during combined carotid and cardiac surgery in patients with bilateral carotid artery disease.

Abstract

The authors evaluated the protective effect of hypothermic circulatory arrest for patients with bilateral carotid artery disease who underwent cardiac surgical procedures. Severe bilateral carotid artery disease coexisting with cardiac disease that requires surgical treatment is associated with a substantial incidence of stroke after operations that require cardiopulmonary bypass. The optimal method of management of patients with these coexisting conditions is not established clearly. Because hypothermia has a protective effect on neural and myocardial tissue during cardiac operations, a protocol employing profound hypothermia and a period of circulatory arrest was evaluated in a group of patients who underwent combined carotid and cardiac surgery who were considered to be at increased risk for the development of stroke. Fifty patients with bilateral carotid artery disease, including 24 patients with high-grade unilateral stenosis and contralateral occlusion and 6 patients with 80% to 99% bilateral stenosis, underwent combined carotid endarterectomy and cardiac surgery (coronary artery bypass grafting in all 50 patients and additional procedures in 8 patients). Profound systemic hypothermia (15 C) was instituted, and the carotid endarterectomy was performed during a period of circulatory arrest that averaged 30 minutes. The cardiac procedure was performed during the periods of cooling and rewarming. The 30-day mortality rate was 6% (3 patients). There were no early postoperative strokes or reversible ischemic neurologic deficits. There have been seven late deaths in the postoperative period, which extends to 54 months. None of these deaths were caused by stroke. There has been one late stroke, which occurred in the distribution of the unoperated carotid artery. This technique provides adequate protection of the brain and myocardium during combined carotid and cardiac surgical procedures and appears to reduce the frequency of stroke in the high-risk subgroup of patients with bilateral carotid artery disease.