non-selective carotid artery ultrasound screening in patients undergoing coronary artery bypass...
TRANSCRIPT
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Non-Selective Carotid Artery Non-Selective Carotid Artery Ultrasound Screening in Ultrasound Screening in
Patients Undergoing Coronary Patients Undergoing Coronary Artery Bypass Grafting: Is It Artery Bypass Grafting: Is It
Necessary?Necessary?Khalil Masabni, Joseph F. Sabik III, Sajjad Raza,
Theresa Carnes, Hemantha Koduri, Mehdi H. Shishehbor, Heather L. Gornik, Eugene H.
Blackstone
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DisclosuresDisclosures
All authors: none
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Routine Carotid Screening
Performed in many institutions
Assumed benefit• Altering management to decrease
perioperative stroke
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Don’t initiate routine evaluation of carotid artery disease prior to cardiac surgery in the absence of symptoms or other high-risk criteria
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Patient
72-year-old man presenting for CABG with 3-system disease
Comorbidities• Hypertension
• Hyperlipidemia
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Findings
Preoperative carotid ultrasound• Right ICA 40% – 59%
stenosis
• Left ICA 80% – 99% stenosis
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Decision-Making
Proceed with CABG?• No carotid revascularization
Alter management?• Staged carotid revascularization
• Concomitant carotid revascularization
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Questions
In patients undergoing CABG, does preoperative non-selective carotid screening
• Alter management?
• Affect neurologic outcomes?
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PatientsPatients
3/2011 to 9/2013
Isolated CABG and combined CABG–carotid revascularization
n = 1,382
Non-selective carotid screening
n = 1,236 (89%)
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DefinitionsDefinitions
No or Mild Stenosis• Bilateral 0%–59% stenosis
Moderate Stenosis• Unilateral 60%–79% stenosis
Severe Stenosis• Bilateral 60%–79% stenosis
• Unilateral 80%–100% stenosis
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Screened PatientsScreened Patientsn = 1,236n = 1,236
< moderate < moderate CASCAS
moderatemoderateCAS CAS
severesevereCASCAS
6%
87%87%7%
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Screening ResultsScreening Results< Moderate Stenosis< Moderate Stenosis
n = 1,069n = 1,069
Confirmatory testing• 0 (0%)
Combined CABG – CEA• 0 (0%)
Isolated CABG• 1,069 (100%)
Off-pump CABG• 75 (7%)
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Screening ResultsScreening ResultsModerate StenosisModerate Stenosis
n = 90n = 90
Confirmatory testing• 4 (4%): CTA=4
Combined CABG – CEA• 1 (1%)
Isolated CABG• 89 (99%)
Off-pump CABG• 11 (12%)
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Screening ResultsScreening ResultsSevere StenosisSevere Stenosis
n = 77n = 77
Confirmatory testing• 18 (23%): CTA=16, MRA=1, angio=1
Combined CABG – CEA• 18 (23%)
Isolated CABG• 59 (77%)
Off-pump CABG• 6 (8%)
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< moderate< moderate
100100
00
8080
6060
4040
2020
%%
On-pump Off-pump
On-pump vs Off-pumpOn-pump vs Off-pump
moderatemoderate severesevere
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Stroke: By Stenosis SeverityStroke: By Stenosis Severity
<moderate<moderate
1010
00
88
66
44
22
%%
% patients with stroke
moderatemoderate severesevere
1.3%1.3%2.3%2.3%
2.6%2.6%
P=.3P=.3
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Isolated CABG• 1.3% (14/1,069)
On-pump CABG• 1.3% (13/994)
Off-pump CABG• 1.3% (1/75)
Stroke: By ManagementStroke: By Management< Moderate Stenosis< Moderate Stenosis
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Isolated CABG• 2.2% (2/89)
On-pump CABG• 1.3% (1/79)
Off-pump CABG• 9.1% (1/11)
Combined CABG – CEA• 0% (0/1)
Stroke: By ManagementStroke: By Management Moderate StenosisModerate Stenosis
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Isolated CABG• 1.7% (1/59)
On-pump CABG• 1.4% (1/71)
Off-pump CABG• 17% (1/6)
Combined CABG – CEA• 5.6% (1/18)
Stroke: By ManagementStroke: By Management Severe StenosisSevere Stenosis
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< moderate< moderate
2020
00
1616
1212
88
44
%%
% stroke with On-pump% stroke with Off-pump
On-pump vs Off-pumpOn-pump vs Off-pump
moderatemoderate severesevere
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79%
21%21%
IntraoperativeIntraoperative
Timing of Stroke
PostoperativePostoperative
All Stroke Patients (n=19)
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Timing and LocationTiming and Location
Right ICA (%)
Left ICA (%)
LateralityTiming (days after surgery)
Patient 1 100 20-39 Right 2
Patient 2 60-79 40-59 Bilateral Intraoperative
Patient 3 60-79 40-59 Bilateral 3
≥ moderate stenosis undergoing CABG
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Right ICA (%)
Left ICA (%)
LateralityTiming (days after surgery)
Patient 1 100 20-39 Right 2
Patient 2 60-79 40-59 Bilateral Intraoperative
Patient 3 60-79 40-59 Bilateral 3
Timing and LocationTiming and Location≥ moderate stenosis undergoing CABG
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Right ICA (%)
Left ICA (%)
LateralityTiming (days after surgery)
Patient 1 20-39 80-99 Right 4
Timing and LocationTiming and Location≥ moderate stenosis undergoing CABG-CEA
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Summary
Routine carotid screening• Altered management in minority of
patients
• Did not prevent perioperative stroke
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Summary
On-pump vs off-pump CABG• Not influenced by severity of
carotid disease
• Stroke was similar in patients undergoing on-pump or off-pump surgery
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Summary
Laterality of stroke• Ipsilateral to carotid stenosis in
only 1
• Cause of perioperative stroke is unlikely to be related to carotid disease
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Clinical Inferences
Routine carotid artery screening• Questionable
Other strategies should be used to reduce perioperative stroke
• Intraoperative epiaortic scanning
• Avoid extremes of blood pressure
• Postoperative anti-platelet therapy
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Patient
72-year-old man presenting for CABG with 3-system disease
Procedure performed• Isolated CABG with no carotid
revascularization
Postoperative complications• None