Fatal Myocardial Infarction Following Carotid Endarterectomy

Abstract

Routine coronary angiography has been recommended to all patients undergoing carotid endarterectomy at the Cleveland Clinic since 1978. Patients found to have severe, correctable coronary artery disease (CAD) have been advised to undergo myocardial revascularization as a staged or combined procedure in conjunction with carotid endarterectomy in an attempt to reduce the incidence of fatal myocardial infarction during the postoperative period, and during the late follow-up interval. In order to provide an historic standard with which the results of this approach may eventually be compared, complete follow-up information has been obtained for 95% of 335 consecutive patients who underwent carotid endarterectomy between 1969 and 1973. Fatal myocardial infarction accounted for 60% of early deaths within 30 days of operation and occurred in 1.8% of the entire series. Among the patients who survived operation, the five-year mortality rate was 27%, and the 11-year mortality rate was 48%. Myocardial infarction caused 37% of the deaths that occurred within five years after operation and 38% of the deaths that have occurred within 11 years. Differences in the incidence of fatal myocardial infarction within five years after operation between a group of 116 patients who had no clinical evidence of CAD and a group of 209 patients suspected to have CAD attained statistical significance (p less than 0.1) despite the fact that 67 patients suspected to have CAD eventually underwent myocardial revascularization. Improvement in actuarial survival (p less than 0.05) and reduction in the late mortality rate (p less than 0.01) were statistically significant for the subset of patients with suspected CAD who had aortocoronary bypass graft procedures.

Prevalence of concomitant atherosclerotic arterial diseases in patients with significant cervical carotid artery stenosis in Taiwan

“…It is obvious that some patients in this study might not benefit from surgery, as high peri-operative cardiovascular risk and poor late survival are expected [13,14,26,27]. CAD is the most important cause of perioperative complications and death in patients undergoing carotid endarterectomy [18][19][20][21]. In this study, the prevalence rate of concurrent CAD was very high.…”

“…The surgical risk in patients with coexisting coronary and carotid stenosis is significantly increased, whether a staged approach or simultaneous combined coronary bypass grafting and carotid endarterectomy is chosen [29][30][31][32]. Considering the high concurrent rate of multi-vessel or left main CAD in our series, endovascular treatment for the carotid stenosis might be a safe and effective option [18][19][20][21][33][34][35].…”

“…However, the benefit of endarterectomy is highly dependent on low surgical complication rates [13], and therefore may not be applicable to some patients [14]. Concomitant atherosclerotic diseases of other vascular territories are frequent in western patients with carotid stenosis [15][16][17], and coronary artery disease (CAD) is the most important cause of peri-operative complications and death [18][19][20][21]. The severity and extent of atherosclerosis involvement could be important for the management strategy.…”

Noninvasive Assessment of Spontaneous Baroreflex Sensitivity and Heart Rate Variability in Patients with Carotid Stenosis

“…Previous studies have shown that some patients with cerebral ischemia and no overt CAD have evidence of asymptomatic CAD on provocative tests (i.e. myocardial perfusion imaging or exercise ECG) for myocardial ischemia [22, 23, 24, 25]. This association is seen especially in patients with large-artery cerebrovascular disease rather than those with penetrating artery disease or cryptogenic stroke [26].…”

The Role of Preoperative Radionuclide Left Ventricular Ejection Fraction for Risk Assessment in Carotid Surgery

“…Perioperative end points included neurologic deficit, death, and cardiac complications de¬ fined as (1) requiring admission to, the intensive care unit and requiring specific therapy; (2) new ventricular arrhythmia for which the patient required treatment and for which the patient was not previously treated; and (3) myocardial infarction (MI) diagnosed by standard electrocardiographic criteria, elevation of creatine kinase with MB isozyme fraction over 5%, and an appropriate clinical picture. The patients were followed up a mean of 522 ±280 days after carotid surgery.…”