Cardiovascular Journal of Africa: Vol 26 No 1 (January/February 2015)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 1, January/February 2015 AFRICA 17
Effect of hypothermia in patients undergoing
simultaneous carotid endarterectomy and coronary
artery bypass graft surgery
Yucel Ozen, Eray Aksoy, Sabit Sarikaya, Ebuzer Aydin, Ozge Altas, Murat Bulent Rabus, Kaan Kirali
Abstract
Purpose: We sought to determine whether hypothermia
provided any benefit in patients undergoing simultaneous
coronary artery bypass graft surgery (CABG) and carotid
endarterectomy (CEA) using one of two different surgical
strategies.
Methods: Group 1 patients (n = 34, 88.2% male, mean age
65.94 ± 6.67 years) underwent CEA under moderate hypo-
thermia before cross clamping the aorta, whereas group 2
patients (n = 23, 69.6% male, mean age 65.78 ± 9.29 years)
underwent CEA under normothermic conditions before
initiating cardiopulmonary bypass (CPB). Primary outcome
of interest was the occurrence of any new neurological event.
Results: The two groups were similar in terms of base-
line characteristics. Permanent impairment occurred in one
patient (2.9%) in group 1. One patient from each group (2.9
and 4.3%) had transient neurological events and they recov-
ered completely on the sixth and 11th postoperative days,
respectively. Overall, there was no statistically significant
difference between the two groups with regard to occurrence
of early neurological outcomes (n = 2, 5.8% vs n = 1, 4.3%, p
= 0.12).
Conclusions: This study could not provide evidence regarding
benefit of hypothermia in simultaneous operations for carotid
and coronary artery disease because of the low occurrence
rate of adverse outcomes. The single-stage operation is safe
and completion of the CEA before CPB may be considered
when short duration of CPB is required.
Keywords: carotid endarterectomy, coronary artery disease,
hypothermia
Submitted 21/1/14, accepted 18/9/14
Published online 26/1/15
Cardiovasc J Afr 2015; 26: 17–20
DOI: 10.5830/CVJA-2014-056
The co-existence of coronary, carotid, peripheral and renal
atherosclerotic diseases is not infrequent and it was reported
that 24% of patients with coronary artery disease have at least
one additional atherosclerotic lesion.1 In previous studies, 4.6 to
8.0% of patients with coronary artery disease (CAD) had severe
coronary artery stenosis (CAS), the extent of the atherosclerotic
involvement being significantly correlated with the carotid
and coronary arteries.2,3 Simultaneous surgical management
of concomitant coronary and carotid artery disease has been
the focus of interest in the past two decades since success rates
of coronary artery bypass grafting (CABG) has substantially
increased while a preventive approach for adverse neurological
outcomes has gained popularity.4 Carotid stenosis and previous
history of cerebrovascular disease were reported to be among
the most prominent risk factors for peri-operative stroke and
neurocognitive decline in patients undergoing CABG.5
The optimal decision for the timing of carotid endarterectomy
(CEA) is controversial in patients submitted for CABG since data
focusing on establishing the best strategy of practice are limited.6
There have been numerous cross-sectional studies reporting
favourable outcomes for both simultaneous and staged CEA and
CABG procedures,7-9 and some authors have suggested that the
decision to perform the two procedures simultaneously should
be made based on strict patient selection criteria.10 Nevertheless,
delaying the CEA was found to be an independent predictor
of early stroke and death in one recent randomised trial.11 This
uncertainty led to an increasing trend towards individualisation
of the treatment in patients with concomitant disease.
Some earlier studies implied the potential role of hypothermia
as a preventative measure against adverse postoperative
outcomes in patients undergoing single-stage on-pump CABG
and CEA.12,13 However, these studies fell short of their goal of
determining whether hypothermia provides protection, because
none of them involved a control group of patients undergoing
CEA under normothermic conditions. In this study we sought to
determine whether hypothermia provided any benefit in patients
undergoing simultaneous CABG and CEA using one of two
different surgical strategies.
Methods
This retrospective cohort study was undertaken in a single
tertiary educational hospital and was made up of 57 patients
who underwent concomitant CEA and CABG between 2006
and 2013. Patients’ archived records, counselling charts and
laboratory tests were reviewed in January 2013.
Patients were divided into two groups. Group 1 patients
( n = 34, 88.2% male, mean age 65.94 ± 6.67 years) were those
undergoing CEA under moderate hypothermia, after initiation
of cardiopulmonary bypass (CPB) and before cross clamping
Kartal Kosuyolu Heart and Research Hospital, Istanbul, Turkey
Yucel Ozen, MD,
Eray Aksoy, MD
Sabit Sarikaya, MD
Ebuzer Aydin, MD
Ozge Altas, MD
Murat Bulent Rabus, MD
Kaan Kirali, MD, PhD