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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 3, May/June 2021
130
AFRICA
Methods
This retrospective study was approved by the Selcuk University
ethics committee, Konya, Turkey. Over a period of five years
(January 2008 to December 2013), 98 CEA operations were
performed in our cardiovascular department, of which 73 (74%)
were operated under CB anaesthesia and 25 (26%) under GA.
Among the 98 patients who underwent CEA operations,
CABG was performed in 34 patients due to coronary artery
disease (CAD). In 18 of these 34 patients, CABG was performed
in the same session with CEA (GA group). As the skill and
experience of our clinic increased in terms of CEA under CB
anaesthesia, physicians began performing these procedures in
patients scheduled to undergo concomitant CABG for CAD.
For these 16 patients, CEA was first performed under CB
anaesthesia, followed by CABG performed, as a separate
procedure during the same hospital stay, under GA (CB-GA
group). The regional anaesthesia technique consisted of a
superficial cervical plexus block using 0.25% plain bupivacaine
with additional local infiltration as needed during the course
of the operation. Heparin was administered before carotid
clamping (100 IE/kg).
Patient data were obtained from in-patient charts, out-patient
records, operating room notes, and telephone calls. The range of
pre-operative symptoms included asymptomatic, non-disabling
ischaemic stroke, transient ischaemic attack (TIA) and
stroke. Cerebrovascular accident history was investigated by
a neurologist through direct interview and medical charts.
Non-disabling stroke was defined by a residual deficit, associated
with a score of ≤ 2 according to the modified Rankin scale.
TIA was defined as an abrupt onset of symptoms and/or signs
related to a focal cerebral or visual deficit (amaurosis fugax)
attributed to focal loss lasting less than 24 hours. Stroke was
defined as an abrupt onset of symptoms and/or signs related
to a focal and/or global deficit of cerebral functions lasting
more than 24 hours and not attributable to causes other than
cerebrovascular accident.
8
Asymptomatic patients had no history
of cerebrovascular symptoms.
The following peri-operative variables were considered:
demographics (age, gender), presence of current or previous
smoking, diabetes mellitus (DM), hypertension (HT),
hypercholesterolaemia, presence of peripheral obstructive
disease (POD), history of CAD (previous MI, stable or unstable
angina, percutaneous or surgical coronary revascularisation),
renal dysfunction and obesity.
Duplex ultrasonography (USG) was performed in all
patients and findings were confirmed by magnetic resonance
angiography (MRA). Indications for surgery were either a
stenotic lesion measuring > 50% of the carotid artery together
with a neurological event or, for those who were asymptomatic,
a stenotic lesion measuring > 70%.
Carotid artery endarterectomy was performed in all patients.
After the procedure, heparin was not routinely reversed.
Standard heparinisation was used to control the active clotting
time during cardiopulmonary bypass. Internal mammary artery
and saphenous vein grafts were prepared, and the coronary
bypass process was completed. All patients were followed in the
intensive care unit postoperatively for at least 24 hours.
In the GA group, patients were intubated. Somatosensory
evoked potential (SSEP) monitoring and stump pressure
monitoring were routinely used. If SSEP monitoring showed
slowing to ≤ 50% of the pre-clamping response or the stump
pressure was below 50 mmHg, carotid shunting was performed
in the CB-GA group. At the time of carotid clamping, patients
were examined neurologically by testing their ability to squeeze
a ball that made a sound; shunting was performed using an
Inahara-Pruitt outlying shunt if the response was deemed
inadequate. CEA was performed using patch closure [saphenous,
Dacron or PTFE (polytetrafluoroethylene)] or primary closure.
Bleeding was defined as a need to change postoperative
dressings one or more times, a requirement for neutralisation
with protamine, or re-operation of the patient because of
haematoma. Wound infection was controlled by specialists in
infection. For postoperative assessment of cranial nerve damage,
the 10th, 11th and 12th cranial nerves were examined. Patients
with suspected nerve damage were consulted by a neurologist.
All patients were examined by the same neurologist both pre-
and postoperatively.
Obstructions identified by Doppler ultrasonography within
the first 30 days were interpreted as early restenosis and
obstructions identified in the following 30 days were considered
late restenosis. All patients who had complaints consistent with
symptoms of MI, together with electrocardiograph and troponin
changes in the postoperative period were considered to have
clinical features of MI.
The primary endpoint was death in the postoperative 30 days.
Secondary endpoints were postoperative complications such
as bleeding or haematoma, infection, cranial nerve damage,
non-disabling ischaemic stroke, TIA, amaurosis fugax, early
restenosis, late restenosis and postoperative MI.
Statistical analysis
This was performed using the PASW v.18 software package. For
comparisons between groups, independent samples
t
-tests were
used for continuous variables and
χ
2
or Fisher’s exact test were
used for categorical variables. In the analysis,
p
-values < 0.05
were considered statistically significant.
Results
In total, 34 patients treated for both carotid artery disease and
CAD were included in this study. Of these 34 patients, 18 (53%)
were operated under GA in the same session (GA group). For
the other 16 patients (47%), CEA was first performed under CB
anaesthesia, followed by CABG performed under GA (CB-GA
group). Pre-operative patient data are shown in Table 1.
Intra-operative data of the patient groups are shown in Table
2. The clamping time was shorter in the GA than in the CB-GA
group (Table 2). No significant difference in shunting was seen
between groups (two patients in the GA group vs three patients
in CB-GA group).
No significant differences were found between the groups
in terms of postoperative bleeding, infection, cranial nerve
damage, early or late restenosis, TIA, stroke or death (Table 3).
Postoperative MI occurred in four patients in the CB-GA group,
but was not observed in any patient in the GA group (
p
= 0.039)
(Table 3). In two of these four patients with postoperative MI,
left main coronary artery (LMCA) lesions were observed, while
the other two patients exhibited multi-vessel disease. These
patients were assessed by a cardiologist and emergency CABG