Surgical strategies in patients at high risk for stroke undergoing coronary artery bypass grafting

Abstract

Background. Perioperative stroke represents one of the major complications following coronary artery bypass grafting (CABG). The present study was designed to evaluate the use of an individualized surgical approach for reducing neurological injury in patients undergoing CABG at high risk of stroke from aortic atherosclerosis or carotid disease. Methods. Between January 1993 and June 1999, 6,138 patients undergoing elective CABG were evaluated by intraoperative transesophageal echocardiography. Patients were screened preoperatively for internal carotid artery disease. Based on the intraoperative transesophageal echocardiography findings the surgical technique was individualized: hypothermic circulatory arrest with aortic atherectomy, CABG combined with transmyocardial laser revascularization on the beating heart, off-pump CABG by midsternotomy, ministernotomy, minimally invasive direct CABG, hybrid procedure, and so on. Patients were divided into four groups: a low-risk group (no significant aortic or carotid disease); an aortic atheromatous disease group (A.ATH); a carotid disease group (CD); and a carotid disease combined with aortic atheromatous disease group (CD + A.ATH). Results. The incidence of stroke in the low-risk group (n = 5,043) was 0.92% compared with 0.96% in the A.ATH group (n = 918). In the CD group (n = 166) the incidence of stroke was 0.6% whereas it was 0% in the CD + A.ATH group (n = 11). Conclusions. Preoperative and intraoperative screening can detect extensive atherosclerosis of the proximal aorta and internal carotid artery. Selective use of surgical techniques in this group of high-risk patients can prevent adverse neurologic sequelae while achieving complete myocardial revascularization.