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UDC 616.132.2/.133-004.6-089
SURGICAL TREATMENT OF PATIENTS WITH COMBINED ATHEROSCLEROTIC DISEASE OF CAROTID AND CORONARY ARTERIES
1 Altai State Medical University, Barnaul
2 Altai Regional Cardiological Dispensary, Barnaul
N.G. Khorev12, P.A. Yermolin2, A.V. Sokolov2, A.P. Kosoukhov2, A.I. Duda2, V.O. Konkova1, Ya.N. Shoikhet1
The article analyzes the first experience of treatment of 114 patients with multifocal atherosclerosis with lesions of carotid and coronary arteries. Patients were divided into three groups, depending on the sequence of revascularization of the vascular pools. In the first group (29 patients), carotid endarterectomy (CEAE) was carried out simultaneously with aorto-coronary bypass (ACB). In the second group (13 patients), CEAE was performed first, and then, a few days later, without leaving the hospital - CEAE. In the third group (72 patients), CEAE was performed in patients with severe cardiac pathology, by which it is impossible to perform myocardial revascularization. Patients with multifocal atherosclerosis, requiring revascularization of carotid and coronary vascular pools, had a more severe state than patients with the possibility of isolated conduct of CEAE. The incidence of ischemic neurological complications in patients with multifocal atherosclerosis by single-stage or stage ACB and CEAE is higher than in patients with isolated CEAE.
Key words: multifocal atherosclerosis, carotid endarterectomy, aorto-coronary bypass, revascularization.
Until now, there is no unequivocal opinion on the method of treatment of patients with ischemic heart disease (IHD) and concomitant stenosis of the internal carotid artery (ICA) [1]. In this aspect, three strategies are considered [2]. The first includes isolated coronary artery bypass graft surgery (CABG) or carotid endarterectomy (CEAE), depending on the severity of the arterial basin lesion. The second strategy consists in the consecutive implementation of CEAE and CABG without discharge of the patient from the hospital. The third approach declares one-stage conduct of CEAE and CABG during one surgical intervention. The experience of recent years does not give a clear answer to this question about the choice of the method of treatment of these patients [3]. At the same time, the number of cerebrovascular complications increases to 14% in patients with ICA stenosis of more than 80% [4-9]. Perioperative stroke after CABG is the most severe neurologic complication, which frequency is about 2% and increases with age [10,11]. Despite the decrease in the total number of complications after CABG, the incidence of neurologic complications (stroke) remains unchanged [10]. A certain clarity in the sequence of CEAE in patients going to CABG was declared in the document of the working group on myocardial revascularization of the European Society of Cardiology and the European Association of Cardiothoracic Surgeons [12]. In the text of this document with a high level of evidence (1C), only one thesis is presented: "it is recommended to individualize the indications for revasculariza-tion of carotid arteries after discussion by the interdisciplinary team together with a neurologist."
The aim of the work is to compare different strategies for treating lesions of the carotid and cor-
onary arteries in patients with multifocal atherosclerosis.
Materials and methods
The material of surgical treatment of 114 patients with combined lesions of carotid and coronary arteries is presented. The patients were operated in the cardiosurgical department of the Altai Regional Cardiological Dispensary - the clinical base of the Department of Faculty Surgery of the Altai State Medical University during 2014-2016. Depending on the type, phasing or sequence of operations on the vessels of the head and heart, patients are divided into three groups. The first group (primary) consisted of 29 patients (mean age 61±8.4 years) who underwent carotid endarterectomy (CEAE) at one time, followed by aorto-coronary bypass graft surgery (CABG). The second group (comparisons) - 13 patients (mean age 64±7.3 years), who first had CEAE, then after 2-6 days - CABG. The third group (comparisons) - 72 patients (mean age 63±5,9 years) with severe cardiac pathology, to which CEAE was performed in an isolated version. In each case, the decision on the order of revascularization of different vascular pools was conducted by an interdisciplinary team. The brigade included a cardiovascular surgeon, an interventional cardiologist, a neurologist and an anesthesiologist. At the same time, the recommendations of the European Society of Cardiology and the European Association of Cardiothoracic Surgeons were taken into account [from Introduction 12]. The final diagnosis of the lesions of the carotid and coronary arteries was based on the data of cerebral angiography (Figure 1) and coronary angiography (Figure 2). Based on these data, the type and stage of the surgical intervention was planned.
Figure 1. Cerebral angiography Bilateral stenosis of the ICA (arrows) on the left left 50%, right 90%.
Figure 2. Coronary angiography Left - occlusion of the anterior descending, stenosis of the envelope of the artery 70%, right - stenosis
of the right coronary artery 70%.
A feature of patients with multifocal lesion is a combination of severe cerebral and cardiac lesions. Therefore, with an extended stenosis of the ICA and a pronounced lesion of the vessel walls (Figure 3), which made it impossible to conduct endarterectomy, we developed an alternative version of reconstruction. This method is called "lateral angioplasty" of the internal carotid artery. The method implied a long patch of xenograft to eliminate the narrowing of the distal ICA without first removing the expressed calcified atheroma (Figure 4). This method was used in 4 (13,8%) patients of the first, 1 (7,7%) patient of the second patient and in 5 (6,9%) patients of the third group.
The arrow indicates stenosis of the ICA more than 90%. Further, the atherosclerotic lesion of the vessel extends above the angle of the lower jaw with the capture of the second segment of the ICA.
Figure 4. Stages of the operation of the lateral angioplasty of the ICA A - patch from a xenograft; beginning of suturing at the distal section of the ICA. B - a patch on the ICA is applied, the blood flow is restored.
The main clinical characteristics of the groups of operated patients are comparable (Table 1). The nature of cerebral circulation and the functional class of angina are comparable in patients of the first and second groups. However, in patients of the third group, where the CEAE was performed in isolation, the second functional class of angina was diagnosed in 70.1% of patients, which is significantly higher than in the patients of the first group, 31.0% (p = 0.0005), and the second - 30.7% (p = 0.0136) groups. At the same time, the proportion of symptomatic patients in the third group was 19.3%, which is significantly less than in patients of the first group, 65.5% (p = 0.0001), and the second - 69.2% (p = 0, 0.0002) groups. Patients who underwent a one-stage or stage CEAE + CABG were
heavier in cardiac and cerebral lesions. In the third group of patients with isolated CEAE, the proportion of patients with the 3rd functional class of angina and symptomatic stenosis of the ICA was less. Consequently, for an isolated CEAE, a multidisci-plinary team selected more "light" patients.
Characteristics of the lesion of the carotid and coronary arteries in the operated groups takes into account pre-operative assessments and the features of the operation that affect the results, complications and outcomes. Differences in the degree of narrowing of the ICA and the duration of the operation were not noted (Table 2). In patients of all groups, the degree of narrowing of the ICA was more than 70%, the duration of clamping of the carotid artery was no more than 40 minutes. In pa-
tients who underwent side angioplasty of the ICA (Figure 4), the ICA clamping time was 20-25 minutes.
The number of grafted coronary arteries in the first and second groups of patients did not have a statistically significant difference. Almost half of the patients in both groups were operated on a working heart (Table 3). In 56% of the patients
of the first group and 42.2% of the second group, three arteries were shunted. Exclusion of the stage of artificial circulation further minimized the risk of postoperative neurologic complications. The duration of the artificial circulation in the first group ranged from 70 to 130, and in the second group from 60 to 100 minutes.
Table 1
Clinical characteristics of operated patients Groups of operated patients
Clinical characteristics
1 2 3 One-time CEAE + Stage CEAE + ^faÍ
CABG (n=29) CABG (n=13) ^A?)
F
F
F
Abs. % Abs. % Abs. %
Gender:
male 23 79,3 11 84,6 58 80,5
female 6 20,7 2 15,4 14 19,9 0,9839 0,9674 0,8935
Hypertension 25 86,2 11 84,6 63 87,5 0,8916 0,8700 0,8785
Diabetes 8 27,6 5 38,4 22 30,5 0,7310 0,8104 0,1467
Stenosis:
symptomatic 19 65,5 9 69,2 14 19,4
asymptomatic 10 34,5 4 30,8 68 80,6 0,9061 0,0002 0,0001
Angina pectoris
2 f.class 9 31,0 4 30,7 51 70,8
3 f. class 20 69,0 9 69,3 21 29,2 0,7310 0,0136 0,0005
Note: CEAE - carotid endarterectomy; CABG - aorto-coronary bypass graft surgery; f.class - a functional class of angina acc. to the Canadian Cardiovascular Society, 1976.
Table 2
The main characteristics of the carotid lesion and duration of clamping of the carotid arteries
Группы оперированных больных
Index 1. One-time CEAE + CABG n=29 2. Stage CEAE + CABG 3. Isolated CEAE n=13 n=72
Degree of stenosis of ICA, % (min-max) 70-90 80-90 70-90
Time of clamping of the ICA, min (min-max) 20-40 20-30 15-30
Note: min-max - the minimum and maximum value
Results and discussion
In the work, a comparison of three groups of patients with a combined lesion of the arteries of the heart and brain was performed. From the point of view of clinical characteristics, patients of all three groups are comparable. However, taking into account the clinical manifestations of specific symptoms - angina, transient ischemic attack (TIA) or stroke - patients of the first and second groups are heavier than patients of the third group (Table 1). Therefore, in a sense, comparing the results of surgical treatment in these patients is not
always correct. At the same time, we can not form homogeneous groups, since the decision on the order of revascularization is carried out individually on the basis of the decision of the consultation and the multidisciplinary team [from the introduction 12]. Moreover, the selection of patients was carried out from the number of patients with IHD, hypertension and other heart diseases entering the cardiology clinic for consultation or hospi-talization. Therefore, this design of the study was intended to demonstrate an algorithm for selecting patients with multifocal atherosclerosis for various
surgical options. Probably, the material presented by us testifies to the necessity of surgical treatment
of such patients in the departments having the possibility of operations on coronary vessels.
Table 3
Main characteristics of aorto-coronary artery bypass graft surgery
Группы больных
Index 1 One-time CEAE + CABG (n=29) 2 Stage CEAE + CABG (n=13) P1-2
Abs. % number Abs. number %
Number of patients with number of shunted arteries: one two three I 3,4 II 37,9 17 58,6 7 6 53,8 42,2 0,012 0,045 0,5190
Number of patients operated on-pump 17 58,6 7 53,8 0,6632
Number of patients operated of-pump 12 41,4 6 46,2 0,8120
Note: on-pump - using the device of artificial circulation; of-pump - without using the device of artificial circulation (on the "working"
The nearest results of various variants of surgical treatment of multifocal atherosclerosis with lesions of carotid and coronary arteries were stud-
ied within 30 days. A comparison of specific postoperative complications and lethality in the study groups of patients was performed (Table 4).
Table 4
Postoperative complications and lethality in groups of patients with multifocal atherosclerosis
Groups of operated patients
Complication 1. One-time CEAE + CABG n=29 2. Stage CEAE + CABG n=13 3. Isolated CEAE n=72 P1-2 P2-3 P1-3
Abs. number % Abs. number % Abs. number %
TIA 2 6,9 1 7,7 2 2,8 0,9662 0,0162 0,0091
Stroke 1 3,4 1 7,7 - 0,0055 0,00001 0,0015
Heart Attack 1 3,4 - - 1 1,4 0,0033 0,00001 0,5015
Died 1 3,4 - - - - 0,0033 - 0,00001
Note: TIA - transient ischemic attack
As can be seen from the presented table, the frequency of postoperative TIA in patients of the first and second groups did not differ. At the same time, the incidence of TIA in the first group was 6.9% and the second group was 7.7%, significantly more often than in the third group, 2.8% (respectively, p = 0.162 and 0.0091). Unlike the first and second groups, in patients of the third group strokes were not registered. Consequently, cerebral complications often occurred in patients with simultaneous or stage intervention on the carotid and coronary arteries. This fact is explained by the fact that these patients had a severe lesion with a brain vessel
involving the intracranial arteries. The question is different, could these patients count on a stage-by-stage operation on the carotid and coronary arteries? It is difficult to answer this question unequivocally. At least, the risks of a stroke or a heart attack during terminal treatment were higher.
We provide convincing evidence of the absence of a difference in the frequency of cerebral complications in patients with a one-stage (1st group) and stage (2nd group) treatment of multifocal atherosclerosis. One patient of the first group died of myocardial infarction. There were no lethal outcomes in patients of other groups.
In 1962, David Sabiston performed the first-ever autovenous CABG of the right coronary artery. In the early postoperative period, the patient died of ischemic stroke [cit. by 1]. Further accumulating the experience of coronary surgery, D. Newman et al. [2] convincingly showed that stroke is the most frequent severe complication after CABG, with both symptomatic and asymptomatic BCA stenosis. At the same time, the myocardi-al infarction is the dominant cause of death after CEAE, especially with asymptomatic stenoses [3]. These facts made us pay attention to the combined defeat of the arteries of the heart and brain, which worsens the results of surgical treatment of atherosclerosis. Such a combination of pathological processes in different vascular pools is designated as "multifocal atherosclerosis - a conditional term referring to a special category of hemodynamically significant atherosclerotic lesions of several vascular pools, determining the initial severity of the disease, making it difficult to select adequate treatment tactics, which casts doubt on the optimism of the prognosis" [4]. This is confirmed in our study, where it is shown that patients with one-stage or stage treatment are heavier and have worse outcomes than patients after isolated CEAE. On the other hand, could the patients of the first and second group count only on CABG or CEAE? To some extent, the answer to this question is provided by the prediction of acute ischemic events after myocardial revascularization, which was carried out by the New England Cardiovascular Disease Study Group (Northern New England Cardiovascular Disease Study Group (NNECDSG) study group [5]. In our study, predicting the risk of stroke in the postoperative period after CABG with the use of the scale of assessment of stroke risk (Pack2 Score) [6]. Using this scale, the average score in patients of the first and second groups was 2,6±0.7 and 2.5±0.5 (p> 0.05), respectively. Therefore, the predicted incidence of stroke in these groups is within 6%, which corresponds to our data (Table 4). In the third group of patients, where no intervention was performed on the coronary arteries, we noted a lower incidence of neurological events. These patients did not require CABG and in terms of the volume of multifocal lesion were easier.
More than half of the patients of the first and second group of CABG were carried out by the offpump method. Recent work convincingly demonstrates the advantage of operations on the working heart in patients with multifocal atherosclerosis, including to reduce the risk of stroke [6].
Conclusions
1. Selection of patients and decision-making on the treatment of patients with multifocal atherosclerosis should be carried out by a multidisci-
plinary team in a hospital with experience of heart operations.
2. Patients with multifocal atherosclerosis, requiring revascularization of carotid and coronary vascular pools, are heavier than patients with the possibility of isolated conduct of CEAE.
3. The incidence of ischemic neurologic complications in patients with multifocal atherosclerosis in single-stage or stage CABG and CEAE is higher than with isolated CEAE.
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Contacts
Khorev Nikolay Germanovich, Doctor of Medical Sciences, Professor of the Department of Faculty Surgery named after Professor I.I. Neimark, hospital surgery with the course of FVE of the Altai State Medical University, Barnaul. 656038, Barnaul, Lenina Prospekt, 40.
Tel: (3852) 201256. Email: science@agmu.ru
Ermolin Pavel Aleksandrovich, Candidate of Medical Sciences, Head of the Cardiosurgical Department No. 1 of the Altai Regional Cardiological Dispensary, Barnaul.
656055, Barnaul, ul. Malakhova, 46. Tel.: (3852)508950. Email: info@akkd.ru
Sokolov Alexey Viktorovich, resident the Department of Faculty Surgery named after Professor I.I. Neimark, hospital surgery with the course of FVE of the Altai State Medical University, Barnaul. 656038, Barnaul, Lenina Prospekt, 40. Tel: (3852) 201256. Email: science@agmu.ru
Kosoukhov Andrei Petrovich, Chief Physician of the Altai Regional Cardiological Dispensary, Barnaul.
656055, Barnaul, ul. Malakhova, 46. Tel.: (3852)508950. Email: info@akkd.ru
Duda Alexey Ivanovich, Deputy Chief Medical Officer of the Altai Regional Cardiological Dispensary, Barnaul.
656055, Barnaul, ul. Malakhova, 46. Tel.: (3852)508950. Email: info@akkd.ru
Konkova Victoria Olegovna, resident the Department of Faculty Surgery named after Professor I.I. Neimark, hospital surgery with the course of FVE of the Altai State Medical University, Barnaul. 656038, Barnaul, Lenina Prospekt, 40. Tel: (3852) 201256. Email: science@agmu.ru
Shoykhet Yakov Nakhmanovich, corresponding member of RAS, Doctor of Medical Sciences, Professor of the Department of Faculty Surgery named after Professor I.I. Neimark, hospital surgery with the course of FVE of the Altai State Medical University, Barnaul.
656045, Barnaul, Zmeinogorsky Trakt, 75. Tel.: (3852) 268233. Email: science@agmu.ru
