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Epidural/Echo/Coagulation

Modified distal carotid artery perfusion for combined carotid endarterectomy and off pump coronary artery bypass surgery: 074

Muralidhar, K.; Sanjay, B.; Rajnish, G.; Murthy, K.; Ravindra, S.; Rao, P. V.; Praveen, K.; Shetty, D. P.

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European Journal of Anaesthesiology: June 2004 - Volume 21 - Issue - p 31
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Introduction: Conventionally, a combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) is performed as a one stage procedure [1]. Here, we describe a technique that uses a combined ‘off-pump’ CABG and a modified distal carotid artery perfusion without the use of cardio pulmonary bypass.

Method: Between Sept 2001 and Sept 2003, patients who had documented coronary artery disease and significant carotid artery disease (demonstrated by carotid duplex scanning and carotid angiography) underwent a combined ‘off-pump’ CABG and CEA. The CEA was done prior to ‘off-pump’ CABG under standard general anaesthesia. After sternotomy, a 24-F antero-grade cardioplegia cannula (Chase medical, Ref: ANT-10145, Richardson, Texas, USA) was placed in the ascending aorta and its distal end was connected to a coronary osteal perfusion cannula (Medtronic, DLP, Minneapolis, MN, USA) (COPC) though a 3-way stopcock connection. The other end of COPC was placed into the distal internal carotid artery (ICA) and was snugged (figure). CEA was performed under the control of vascular clamps and distal ICA was perfused during the time of CEA and repair. ‘Off-pump’ CABG was then performed using the octopus II stabilizing device. All patients were electively ventilated and early extubation of the trachea was achieved after satisfying the standard criteria.

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Results: During a 2 year period 9 patients underwent combined CEA and off-pump CABG. Mean age, sex (M/F), weight, BSA and number of grafts were 68.5 ± 7.7years, 7/2, 65 ± 4.6 kg, 1.6 ± 0.9m2 and 2.4 ± 0.5 respectively. All patients woke up after surgery in 2.3 + 1 hr and then were successfully extubated. There were no residual sequelae, neurological or otherwise. Postoperative carotid Doppler showed a normal flow pattern in the carotid system in all patients.

Conclusion: Traditionally, cerebral perfusion is maintained during CEA by the use of shunts inserted into the proximal and distal carotid arteries. In our technique, proximal carotids are not cannulated thereby improving the surgical access and avoiding disruption of plaques, if any. The technique of distal internal carotid after perfusion using the method described above is safe, easily reproducible and cost effective.

Reference:

1 Brodkin Al, Murkin JM. Protection of the brain during cardiac surgery. In: Hensley FA, Martin DE eds. A practical approach to cardiac anesthesia, Boston: Little Brown & Company, 1995; 599.
© 2004 European Society of Anaesthesiology