Increased Incidence of Proximal Aortic Atherosclerotic Disease in Patients with Internal Carotid Occlusion
Background: Atherosclerotic involvement of the proximal aorta is a major cause of embolic operative stroke in cardiac surgery. Its incidence is less well known in patients with severe carotid disease.
Methods: We reviewed the incidence of proximal atherosclerotic aortic disease in patients with internal carotid occlusion (group 1) and then compared it to a group of patients with normal carotids undergoing cardiac surgery (group 2). Both groups had preoperative carotid Doppler and epiaortic ultrasound analysis at the time of surgery.
Results: Epiaortic ultrasound results showed that the degree of atherosclerosis in group 1 was normal in 9 patients (10.2%), mild in 34 (38.6%), moderate in 29 (33%), and severe in 16 (18.2%). In group 2, the degree of atherosclerosis was normal in 70 patients (9.3%), mild in 466 (61.8%), moderate in 150 (19.9%), and severe in 68 (9.0%). Stroke rate was higher in group 1 at 4.5% versus 1.1% for group 2 (P = .029). No difference in surgical mortality was found.
Conclusions: Patients with internal carotid occlusions undergoing heart surgery have a higher incidence of proximal aortic atherosclerotic disease. Epiaortic ultrasound examination is strongly recommended.
Rizzo RJ, Whittemore AD, Couper GS, et al. 1992. Combined carotid and coronary revascularization: the preferred approach to the severe vasculopath. Ann Thorac Surg 54:1099-109.nSchwartz LB, Bridgeman AH, Kieffer RW, et al. 1995. Asymptomatic carotid artery stenosis and stroke in patients undergoing cardiopulmonary bypass. J Vasc Surg 21:146-53.nShaw PJ. 1993. The neurological sequelae of cardiopulmonary bypass: the Newcastle experience. In: Smith P, Taylor K, editors. Cardiac surgery and the brain. London, UK: Hodder and Stoughton. p 24-33.nTunio AM, Hingorani A, Ascher E. 1999. The impact of an occluded internal carotid artery on the mortality and morbidity of patients undergoing coronary artery bypass grafting. Am J Surg 178:201-5.nAmarenco P, Cohen A, Tzourio C, et al. 1994. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med 331:1474-9.nBaribeau YR, Westbrook BM. 1990. Intra-operative epicardial echocardiography. In: Izzat MB, Sanderson JE, St. John Sutton MG, editors. Echocardiography in adult cardiac surgery. 8th ed. Oxford, UK: Isis Medical Media. p 223-9.nBaribeau YR, Westbrook BM, Charlesworth DC, Maloney CT. 1998. Arterial inflow via an axillary artery graft for the severely atheromatous aorta. Ann Thorac Surg 66:33-7.nBluth EL, Stavros AT, Marich KW, Wetzner SM, Aufrichtig D, Baker JD. 1988. Carotid duplex sonography: a multicenter recommendation for standardized imaging and Doppler criteria. Radiographics 8:487-506.nBrener BJ, Brief DK, Alpert J, et al. 1984. A four-year experience with preoperative non-invasive carotid evaluation of two thousand twenty-six patients undergoing cardiac surgery. J Vasc Surg 1:326-38.nBrener BJ, Brief DK, Alpert JA, et al. 1987. The risk of stroke in patients with asymptomatic carotid stenosis undergoing cardiac surgery: A follow-up study. J Vasc Surg 5:269-79.nDa Silva AF, McCollum P, Szymanska T, de Cossart L. 1996. Prospective study of carotid endarterectomy and contralateral carotid occlusion. Br J Surg 83:1370-2.nDashe JF, Pessin MS, Murphy RE, Payne DD. 1997. Carotid occlusive disease and stroke risk in coronary artery bypass graft surgery. Neurology 49:678-86.nHertzer NR, O'Hara PJ, Mascha EJ, Krajewski LP, Sullivan TM, Beven BG. 1997. Early outcome assessment for 2228 consecutive carotid endarterectomy procedures: the Cleveland Clinic Experience from 1989 to 1995. J Vasc Surg 26:1-10.nHosoda Y, Watanabe M, Hirooka Y, Ohse Y, Tanaka A, Watanabe T. 1991. Significance of atherosclerotic changes of the ascending aorta during coronary bypass surgery with intraoperative detection of echography. J Cardiovasc Surg (Torino) 32:301-6.nMackey WC, Khabbaz K, Bojar R, O'Donnell TF Jr. 1996. Simultaneous carotid endarterectomy and coronary bypass: perioperative risk and long-term survival. J Vasc Surg 24:58-64.nMickleborough LL, Walker PM, Takagi Y, Ohashi M, Ivanov J, Tamariz M. 1996. Risk factors for stroke in patients undergoing coronary artery bypass. J Thorac Cardiovasc Surg 112:1250-9.nPerler BA, Burdick JF, Williams M. 1992. Does contralateral internal carotid artery occlusion increase the risk of carotid endarterectomy? J Vasc Surg 16:347-53.nRibakove GH, Katz ES, Galloway AC, et al. 1992. Surgical implications of transesophageal echocardiography to grade the atheromatous aortic arch. Ann Thorac Surg 53:758-63.nWareing TH, Davila-Roman VG, Barzilai B, Murphy SF, Kouchoukos NT. 1992. Management of the severely atherosclerotic aorta during cardiac operations: a strategy for detection and treatment. J Thorac Cardiovasc Surg 103:453-62.nWareing TH, Davila-Roman VG, Daily BB, et al. 1993. Strategy for the reduction of stroke incidence in cardiac surgical patients. Ann Thorac Surg 55:1400-8.nDavila-Roman VG, Barzilai B, Wareing TH, et al. 1994. Atherosclerosis of the ascending aorta: prevalence and role as an independent predictor of cerebrovascular events in cardiac patients. Stroke 25:2010-6.nDemopoulos LA, Tunick PA, Bernstein NE, Perez JL, Kronzon I. 1995. Protruding atheromas of the aortic arch in symptomatic patients with carotid artery disease. Am Heart J 129:40-4.nFaggioli GL, Curl GR, Ricotta JJ. 1990. The role of carotid screening before bypass. J Vasc Surg 12:724-31.n
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