TITLE:
Coronary Artery Bypass Surgery for Patients with Severe Cerebrovascular Atherosclerosis: Importance of Preoperative Assessment and Perioperative Management
AUTHORS:
Hajime Imura, Dai Nishina, Yuuji Maruyama, Makoto Shirakawa, Motoko Tanoue, Daigo Suzuki, Takahide Yoshio, Masami Ochi
KEYWORDS:
Coronary Arterial Bypass Grafting; Stroke; Cerebrovascular Disease
JOURNAL NAME:
Surgical Science,
Vol.4 No.12,
December
5,
2013
ABSTRACT: Objective: Cerebrovascular atherosclerosis is known to play a crucial role in
perioperative stroke in coronary arterial bypass grafting (CABG). This study is
to identify the degree of severity of cerebrovascular lesions for which
patients can still undergo CABG with an acceptably low risk in current
techniques. Methods: Cerebrovascular atherosclerosis was evaluated and graded for 200
consecutive patients prior to CABG. Grading was initially based on the level of
stenosis in carotid, vertebral, and cerebral arteries: grade-0: normal or
mild stenosis in cerebral arteries or stenosis % - 69% in
others; grade-2: severe in cerebral arteries or 70% - 89% in
others; grade-3: occlusion in cerebral arteries or 90% - 100% in
others. The grading was finally adjusted to a risk of regional ischemia by
considering symptoms, number of lesions, and
brain perfusion in scintigram. Therefore, some patients were up-graded.
Off-pump CABG was scheduled for all patients. The lowest systolic arterial
pressure during surgery was differently controlled in each grade: grade-0: ≥70 mmHg; grade-1:
≥80 mmHg; grade-2: ≥80 mmHg with intra-aortic balloon pump (IABP); grade-3:
≥90 mmHg with IABP; grade-4: ≥90 mmHg with IABP and
administration of thyamiral. Results: Grade-1 and -2 included 38 and 29 patients respectively. Grade-3 initially included
36 patients and 14 of them were up-graded to grade-4 (extremely high risk
patients). Stroke was seen in one patient (0.5%), for whom mild speaking
disturbance occurred on the fifth day from CABG. Conclusion: Patients with
severe cerebrovascular atherosclerosis can undergo CABG with a low risk of
stroke. Intraoperative management of blood pressure may be critical for stroke
prevention in CABG.