Does intensive management of cerebral hemodynamics and atheromatous aorta reduce stroke after coronary artery surgery?
BACKGROUND
Atheromatous aorta and carotid artery disease are known predictors for stroke after coronary artery bypass grafting (CABG). The clinical significance of intracranial cerebral artery disease is not known. This study was designed to determine whether a therapeutic strategy based on perioperative detection of intracranial and extracranial occlusive cerebrovascular disease and atheromatous aorta could reduce perioperative stroke.


METHODS
We studied 485 patients who underwent isolated CABG. The control group was 247 patients who underwent standard-protocol CABG. The 238 subjects in the intervention group underwent preoperative magnetic resonance angiography of the head and neck and intraoperative epiaortic scanning. Cerebral hemodynamics were evaluated by single photon emission computed tomography and acetazolamide tests in patients with significant occlusive cerebrovascular disease. Surgical outcomes were compared.


RESULTS
In the intervention group, magnetic resonance angiography detected significant intracranial or extracranial occlusive cerebrovascular disease, or both, in 40 patients. Prophylactic cerebrovascular interventions were performed in 7 patients who had disturbed cerebral hemodynamics. Aorta no-touch off-pump coronary artery bypass (OPCAB) was chosen intraoperatively in 37 patients with moderate to severe atheromatous aorta. The in-hospital stroke rate was 0.42% in the intervention group vs 2.8% in the control group (p = .068). A multivariate analysis revealed that the perioperative interventional protocol was the most powerful predictor of reduced risk of perioperative stroke (odds ratio, 0.023; 95% confidence interval, 0.001 to 0.469).


CONCLUSIONS
Prophylactic cerebrovascular interventions and the selective use of aorta no-touch OPCAB can significantly reduce the incidence of perioperative stroke. Careful vascular evaluation before and during CABG can improve surgical outcomes.
Nakamura
Masanori
M
Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University, Sapporo, Hokkaido, Japan. masanori@sapmed.ac.jp
Okamoto
Fumiyuki
F
Nakanishi
Katsuhiko
K
Maruyama
Ryushi
R
Yamada
Akira
A
Ushikoshi
Satoshi
S
Terasaka
Shunsuke
S
Kuroda
Satoshi
S
Sakai
Keisuke
K
Higami
Tetsuya
T
D000368:Aged; D000369:Aged, 80 and over; D050197:Atherosclerosis / Q000150:complications / Q000000981:diagnostic imaging; D002545:Brain Ischemia / Q000517:prevention & control*; D016893:Carotid Stenosis / Q000150:complications* / Q000000981:diagnostic imaging / Q000473:pathology; D016022:Case-Control Studies; D002560:Cerebrovascular Circulation; D016001:Confidence Intervals; D047549:Coronary Artery Bypass, Off-Pump / Q000379:methods / Q000401:mortality*; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D005260:Female; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D018810:Magnetic Resonance Angiography; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D011300:Preoperative Care / Q000379:methods; D011859:Radiography; D018570:Risk Assessment; D020521:Stroke / Q000453:epidemiology* / Q000517:prevention & control; D016019:Survival Analysis; D016896:Treatment Outcome