Carotid stenosis with impaired brain flow reserve is associated with an increased risk of stroke in on-pump cardiovascular surgery†

Tsuda, Kazumasa; Shiiya, Norihiko; Washiyama, Naoki; Yamashita, Katsushi; Ohkura, Kazuhiro; Takahashi, Daisuke; Kando, Yumi; Natsume, Kayoko; Yamanaka, Ken; Takeuchi, Yuki

doi:10.1093/icvts/ivy049

Cited by 8 publications

(7 citation statements)

References 17 publications

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“…International guidelines recommend carotid duplex ultrasound in patients with previous stroke who have had an event within 6 months or have significant risk factors 21 . In select patients with severe cerebrovascular atherosclerosis, off‐pump CABG should be considered as the preferred approach to reduce risk of perioperative stroke 22,23 . By avoiding the risks associated with aortic cannulation and cross‐clamping, off‐pump CABG has been demonstrated to improve neurological outcomes in patients with a history of previous cerebrovascular events 24 .…”

Section: Discussionmentioning

confidence: 99%

Endovascular thrombectomy for large vessel occlusion acute ischemic stroke after cardiac surgery

Gupta

Sabab

Goh

et al. 2022

Journal of Cardiac Surgery

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Introduction Acute ischemic stroke (AIS) can be a catastrophic complication of cardiac surgery previously without effective treatment. Endovascular thrombectomy (EVT) is a potentially life‐saving intervention. We examined patients at our institution who had EVT to treat AIS post cardiac surgery. Methods We retrospectively reviewed a stroke database from January 1, 2016 to October 31, 2021 to identify patients who had undergone EVT to treat AIS following cardiac surgery. Demographic data, operation type, stroke severity, imaging features, management and outcomes (mortality and modified Rankin Score (mRS)) were assessed. Results Of 5022 consecutive patients with AIS, 870 underwent EVT. Seven patients (0.8%) had EVT following cardiac surgery. Operations varied: two coronary artery bypass grafting (CABG), two transcatheter AVR, one redo surgical aortic valve replacement (AVR), one mitral valve repair and one patient with combined aortic and mitral valve replacements and CABG. Meantime postsurgery to stroke symptoms onset was 3 days (range 0–9 days). Median NIHSS was 26 (range 10–32). Five patients had middle cerebral artery occlusion and two internal carotid artery (n = 2). Median time between onset of symptoms and recanalization was 157 min (range 97–263). Two patients received Intra‐arterial Thrombolysis. All patients survived and were discharged to another hospital (n = 3), home (n = 2), or rehabilitation facility (n = 2). Median 3‐month mRS was 3 (range 0–6). Conclusion We report the largest case series of EVT after cardiac surgery. EVT can be associated with excellent outcomes in these patients. Close neurological monitoring postoperatively to identify patients who may benefit from intervention is key.

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Section: Discussionmentioning

confidence: 99%

Endovascular thrombectomy for large vessel occlusion acute ischemic stroke after cardiac surgery

Gupta

Sabab

Goh

et al. 2022

Journal of Cardiac Surgery

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“…While CABG has played a significant role in revascularization for ischemic heart disease, neurological complications have been a primary concern. In particular, CIAD increases perioperative stroke and mortality risk [1, 2].…”

Section: Discussionmentioning

confidence: 99%

“…On the other hand, large retrospective studies have shown OPCAB to be associated with a lower incidence of stroke compared with that using conventional on-pump CABG [13, 14]. Particularly in high risk patients, such as those with cerebrovascular atherosclerosis, severe aortic atherosclerotic, or peripheral artery disease, OPCAB reduced stroke incidence [2, 15]. Therefore, we selected OPCAB for this patient.…”

Section: Discussionmentioning

confidence: 99%

“…Although embolism is the major cause for perioperative stroke, carotid and intracranial artery stenotic and/or occlusive disease (CIAD) is known to increase perioperative stroke and mortality risk after coronary artery bypass grafting (CABG) [1, 2]. Therefore, risk assessment and operative strategy should be carefully considered in such cases.…”

Section: Introductionmentioning

confidence: 99%

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Quantitative evaluation using single-photon emission computed tomography with acetazolamide is reliable for preoperative evaluation before cardiac surgery in severe carotid intracranial artery stenotic and/or occlusive disease: a case report

Tayama

Mori

Ueda

et al. 2019

J Cardiothorac Surg

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Background Severe carotid and intracranial artery stenosis disease (CIAD) is major risk for perioperative stroke in coronary artery bypass grafting. Then, preoperative risk assessment is quite important. Case presentation A 58-years old Japanese woman with bilateral carotid stenosis and bilateral middle cerebral artery occlusion was suffered from worsening effort angina due to severe three coronary vessel disease. Magnetic resonance imaging angiography demonstrated severe carotid and intracranial vessel stenosis. Selective carotid/cerebral angiography also showed severe stenosis and delayed filling of the right internal carotid artery and moderate stenosis of the left internal carotid artery, with occlusion of the bilateral middle cerebral arteries. However, quantitative evaluation with brain perfusion, single-photon emission computed tomography (SPECT) with acetazolamide showed depleted cerebral perfusion volume and vascular responses, particularly in the left middle cerebral artery area. However, both sides of MCA reserve cerebral blood flow was maintained at > 34 ml/100 g/min. So, we finally considered that her cerebral perfusion reserve was maintained a certain level and could tolerate open heart surgery. Then, she underwent off-pump coronary artery grafting. Before sternotomy, prophylactic intra-aortic balloon pump support was used to minimize possible perioperative stroke. As a result, hemodynamic status and brain regional oxygen saturation were stable throughout the operation, and recovered uneventfully. Conclusions Preoperative quantitative evaluation using brain perfusion SPECT with acetazolamide is useful in assessing hemodynamic cerebrovascular risk in patients with severe obstructive CIAD. Off pump coronary artery bypass grafting with intra aortic balloon pump assist is a good option for prevention of cerebrovascular morbidity in ischemic heart disease with severe CIAD.

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“…Besonders Patienten mit vorbestehender Vasosklerose und Stenosen der hirnversorgenden Gefäße sind gefährdet, in der perioperativen Phase einen thrombotischen Gefäßverschluss zu erleiden [14,15,31] onshemmern (PAH) oder Antikoagulanzien verstärkt wird [11,27]. Hämodynamische Infarkte, die durch zerebrale Hypoperfusion im Rahmen von hypotonen Episoden auftreten können und Grenzzonengebiete betreffen, machen einen geringen Anteil aller perioperativen Schlaganfälle aus [27].…”

Section: äTiologie Und Risikofaktorenunclassified

Perioperativer Schlaganfall

Fischer

Kahl

2020

Anaesthesist

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Carotid stenosis with impaired brain flow reserve is associated with an increased risk of stroke in on-pump cardiovascular surgery†

Abstract: Carotid stenosis is a risk factor for perioperative stroke in on-pump surgery. Patients with large Stage 2 area (>10%) are at increased risk of perioperative stroke when on-pump surgery is performed.

Cited by 8 publications

References 17 publications

Endovascular thrombectomy for large vessel occlusion acute ischemic stroke after cardiac surgery

Endovascular thrombectomy for large vessel occlusion acute ischemic stroke after cardiac surgery

Quantitative evaluation using single-photon emission computed tomography with acetazolamide is reliable for preoperative evaluation before cardiac surgery in severe carotid intracranial artery stenotic and/or occlusive disease: a case report

Perioperativer Schlaganfall

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