Open heart surgery under extracorporeal circulation in the cases with carotid artery stenosis and evaluation for carotid artery stenting

Abstract

Objective:Patients undergoing open heart surgery often have cerebral artery stenosis due to systemic atherothrombotic syndrome. In the cases using extracorporeal circulation (ECC) during the open heart surgery, there is concern whether the artificial changes of systemic and cerebral perfusion pressure contribute to the development of focal brain ischemia due to stenosis. We tried to evaluate the risk and safety of on-pump open heart surgery for patients having carotid artery stenosis, by investigating the progress of cases at our institution retrospectively. Methods: Of the patients who underwent open heart surgery with ECC in our institution from April 2007 to September 2012, a total of 11 patients (6 male/5 female, age from 66 to 80, median age 74) having asymptomatic carotid artery stenosis (50% or more stenosis by North American Symptomatic Carotid Endarterectomy Trial) were included in the study, and they were investigated for brain circulation and the degree of vessel stenosis by several methods before the surgery (seven coronary artery bypass grafting, three aortic valve replacement, and one both of them). The outcome of interest was the additional onset of neurological deficit, which was diagnosed by the strokologists during the period of intensive care after the surgery. Results: Of 11 cases, 5 cases showed over 200 cm/s of peak systolic velocity at the stenosis in ultrasound study. One case with 78% stenosis underwent carotid artery stenting before the open heart surgery. Finally, two cases exhibited symptomatic infarction after the on-pump surgery, but one of these cases clearly was embolic ischemia in a site other than the stenotic artery. That is, of 11 cases with carotid artery stenosis, we observed only one case exhibiting hemodynamic infarction in the site of 68% stenosis caused by artificial changes of cerebral perfusion pressure due to the use of ECC. The other cases did not show any symptomatic infarction in the stenotic site after the surgery with ECC irrespective of the degree of carotid stenosis. Conclusion: Severe stenosis alone is not a risk factor for regional brain ischemia in patients undergoing ECC. Appropriate evaluations of cerebral arteries including dynamic assessment of brain perfusion are needed in individual cases, subject to clinical judgment, before open heart surgery on patients with carotid artery stenosis.• Key words • heart surgery, extracorporeal circulation, brain ischemia, carotid artery stenosis, carotid artery stenting 1 2 3 4 230-0012 3-6-1