Off-pump Coronary Artery Bypass Grafting Surgery In Patients With Significant Bilateral Carotid And Coronary Diseases
Ibrahim M. Yassin1, Farouk M. Oueida2, Hatem Al Taher3, Abdul-Waheed Butt3, Mustafa Al Refaei4, Khaled A. Eskander2.
1Cardio-Thoracic Surgery Department, Tanta University, Tanta, Egypt, 2Cardiac Surgery Department,Saud al-Babtin Cardiac Center SBCC, AL DAMMAM, Saudi Arabia, 3Anaesthesia Department,Saud al-Babtin Cardiac Center SBCC, AL DAMMAM, Saudi Arabia, 4Cardiology Department,Saud al-Babtin Cardiac Center SBCC, AL DAMMAM, Saudi Arabia.
OBJECTIVE: Patients with concomitant significant bilateral carotid and coronary vascular disease indicating CABG are more liable to intra-operative cerebral ischemia during the CABG Procedure and subsequently postoperative stroke. Off-Pump CABG is our technique of choice in these patients to avoid the hazardous effects of the Cardio-pulmonary Bypass (CPB) in this high risk group of patients. We sought to evaluate the intra-operative feasibility, findings and early follow up results of two different methodologies in management of these patients.
METHODS: Retrospective data collection from Jan.2011 to June2016 for Consecutive 88 Off -Pump CABG patients where CEA was done as a first stage (GroupI) using local anesthesia while the patients are awake compared to Consecutive 50 Off- Pump CABG patients with no CEA but only maintaining good cerebral perfusion pressure and oxygenation (Rso2) guided with Near infrared spectroscopy (NIRS). (Group1) was also categorized according to the type of the local anesthesia (Group1-S) if superficial and (Group1-I) if Intermediate.
RESULTS: There was no significant difference between the two groups regarding the pre-operative demographic data. The number of patients with preoperative Transient Ischemic Attacks(TIAs) was Significantly higher in (Group1)(42%)vs.(18%)(p<0.001)and also those with hypo echoic soft plaques (33%)vs.(16%)(p<0.001) but no significant difference in the number of pre-operative stroke(3.4%) vs. (8.0%). No intra-operative mortality in both groups. Both Superficial (Group1-S) (38patients) and Intermediate (Group1-I)(50patients) cervical local anesthesia are safe and give near equal excellent outcome. Two cases out of 88 were aborted due to brain ischemia during carotid clamping (2.2%),one in each group. One case developed hemi-paresis 6 hours after CEA (1.1 %) (TIA). Significant difference between the two subgroups regarding the need for incremental local xylocaine infiltration in the wound and postoperative analgesia (p=0.000). No significant difference between both groups regarding the incidence of postoperative ventilation time, stroke, Myocardial Infarction, Atrial Fibrillation, ICU Stay and Length of hospital stay.
CONCLUSIONS: Both Carotid endarterectomy in awake patient using local cervical anesthesia as a first stage and near infrared spectroscopy for continuous brain monitoring are safe procedures in patients with significant carotid stenosis listed for Off pump CABG. No significant difference in the early outcome of both groups
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