Combined carotid, cardiac surgery ups stroke risk
MedWire News: Carotid artery stenosis is not a direct causal factor in the majority of postoperative strokes in patients undergoing cardiac surgery, US researchers have shown.
Their retrospective cohort study of more than 4000 patients also demonstrated that concomitant carotid repair actually increases the risk for stroke following cardiac surgery, the reverse of the intended effect.
To reduce the risk for neurologic complications, the authors recommend undertaking preoperative heart imaging studies in order to identify disease-free areas for manipulation and clamping.
An estimated 1 million patients undergo cardiac surgery each year globally, with stroke being relatively common and among the most feared postoperative complications.
In this study, John Castaldo (Lehigh Valley Hospital and Health Network, Allentown, Philadelphia) and colleagues investigated the role of significant carotid stenosis in the pathogenesis of postoperative stroke following cardiac surgery. The participants were 4335 adults who underwent CABG, aortic valve replacement, or both, between 2001 and 2006.
In all, 76 patients (1.8%) suffered a perioperative stroke and eight deaths were considered to be secondary to stroke. All strokes were ischemic, only 5.3% were of the large-vessel type, and 76.3% occurred in patients without significant carotid stenosis.
In 60.0% of cases the stroke was not confined to a single carotid artery territory and in 94.7% of cases there was no direct correlation with significant carotid stenosis on preoperative imaging.
Finally, the rate of stroke was 15.1% in patients who underwent combined carotid and cardiac surgery versus 0% in patients with a comparable degree of carotid stenosis but who underwent cardiac surgery alone.
Castaldo et al say that combined carotid and cardiac procedures “should be avoided” and conclude that “multiple causes other than carotid stenosis could account for postoperative stroke in patients undergoing cardiac procedures.”
In an editorial accompanying the report, Louis Caplan (Beth Israel Deaconess Medical Center, Boston, Massachusetts) suggests that patients and preoperative information are reviewed prior to surgery by a multidisciplinary team that includes both the cardiologist and cardiac surgeon.
“This should be done at a time when further studies can be scheduled and reviewed before surgery,” he writes. “These recommendations will save brain tissue and lives… and may even save some money.”
MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a part of Springer Science+Business Media. © Current Medicine Group Ltd; 2009
By Joanna Lyford