Vural ÖZCAN, Sabit SARIKAYA, Cengiz KÖKSAL, Mustafa ZENGİN

Koroner revaskülarizasyon gerektiren hastalarda ek vasküler cerrahi girişimler

İnvasiv kardiolojideki ilerlemelere paralel olarak, günümüzde koroner bypass ameliyatına aday hasta grubu daha yaşlı ve yüksek riskli hastalardır. Yaşlı hastalarda yaygın aterosklerotik tutulum nedeniyle aynı anda değişik vasküler sistemler tutulabilir ve bu nedenle bu grup hastalarda peoperatif değerlendirme ve intraoperatif tedavi stratejisi önem kazanmaktadır. Çalışmamızda 2001-2002 yılları arasında koroner bypass yapılan 130 hasta retrospektif olarak değerlendirildi. On altı hastada ciddi koroner arter hastalığına ek olarak kritik periferik arter hastalığı saptandı. On hastamıza eş zamanlı cerrahi girişim uygulandı. Bu hastaların sekizine koroner bypass ile eş zamanlı karotis endarterektomisi, birine aortobifemoral bypass, birine ise karotis endarterektomisi ve krosfemoral bypass yapıldı. Altı hastamıza ise basamaklı cerrahi tedavi uygulandı. Eş zamanlı cerrahi yapılan hasta grubumuzda mortalite sıfır iken; basamaklı tedavi yapılan bir hastamızı kaybettik. Eş zamanlı cerrahi yapılan hastalarımızdan sekizinde atan kalpte koroner bypass tekniğini kullandık. Basamaklı tedavi yaptığımız hastalarda koroner bypass kardiopulmoner bypass altında yapıldı. Koroner arter hastalığı ile aynı zamanda periferik arter hastalığı olan hasta grubunda seçilecek tedavi yaklaşımı tartışmalıdır. Atan kalpte koroner bypass cerrahisinin yaygınlaşması bu tartışmaya yeni bir boyut getirmiştir. Hasta grubumuzdaki sonuçlar göz önüne alındığında, koroner bypass ameliyatına aday hastalarda eşlik eden periferik vasküler hastalıkları araştırmak amacıyla noninvasiv vasküler tanı yöntemlerinin daha yaygın kullanılması gerektiğini ve ayrıca koroner bypass ile eş zamanlı vasküler cerrahi planlanan hastalarda, atan kalpte koroner bypass cerrahi tekniğinin tercih edilmesi gerektiğini düşünmekteyiz.

Vascular surgery concomittant to the coronary revascularization

Background and Design.- In accordance with the developments in invasive cardiology, more high risk and elderly patients are seen for coronary artery bypass grafting. These patients often have extensive atherosclerosis, involving more than one system that contributes to morbidity and mortality. Material and Methods.- Between years 2001-2002, 130 patients who underwent coronary artery bypass grafting were retrospectively reviewed for presenting peripheral vascular disease which necessitates surgical revascularization. Sixteen patients were encountered to have co-existing critical carotid artery disease and/or lower limb ischemia.Results.- In 10 patients the choice of treatment modality was synchronous procedures. Eight patients underwent carotid endarterectomy concomitant to the coronary bypass, one patient aortobifemoral bypass and one patient carotid endarterectomy and cross femoral bypass. Six patients underwent staged surgery. Although there was no mortality in synchronous approach group, one patient in the staged surgery group died. In concomitant approach group we used beating heart coronary revascularization for 8 patients. In all staged procedures CABG was doneunder cardiopulmonary bypass. Conclusion.-The surgical management of patients with coronary artery disease and co-existing peripheral vascular disease has remained contraversial, however, this contraversy has gained momentum with the advent of off-pump coronary artery bypass grafting. According to our results, we highly recommend more liberal use of noninvasive vascular diagnostic tools for patients scheduled for coronary revascularization. We also believe that off-pump coronary artery surgery, as it avoids the harmful effects of cardiopulmonary bypass, may be the choice of surgical method for combined approach.

PDF

___

1.Nehler MR, Krupski WC. Cardiac complications and surgery. In: Rutherford RB, ed. Vascular Surgery. Philadelphia: WB Saunders Company, 2000; 626-646.
2.Hertzer NR, Beven EG, Young JR. Coronary artery disease in peripheral vascular patients: A classification of 1000 coronary angiograms and results of surgical management. Ann Surg 1984; 199: 223-227.
3.Faggioli GL, Curl GR, Ricotti JJ. The role of carotid screening before coronary artery bypass. J Vase Surg 1990; 12:724-31.
4.Hertzer NR, Loop FD, Beven EG. Surgical staging for simultaneous coronary and carotid disease: A study including prospective randomization. J Vase Surg 1989; 9: 445-63.
5.Criqiu MH, Coughlin SS, Franek A. Non invasively diagnosed peripheral vascular disease as a predictor of mortality: results from a prospective study. Circulation 1985; 72: 768-73.
6.Estes JM, Khabboz KR, Barnatan M, Corpino P, Machey WC. Outcome after combined carotid endaterectomy and coronary artery bypass is related to patient selection. J Vase Surg 2001; 33: 179-84.
7.Schwartz LB, Bridgman AH, Kieffer RW, Wilcox RA. Asymptomatic carotid artery stenosis and stroke in patients undergoing cardiopulmonary bypass. J Vase Surg 1995; 21: 146-53.
8.Jones EL, Hodakowski GT. Combined coronary and carotid artery disease. In. Baue AE, ed. Glenn's Thoracic and Cardiovascular Surgery. Prentice-Hall International USA. 1996; 2095-2103.
9.Bilfinger TV, Hassan R, Giran F, Seifert FC. Coronary and carotid operations under prospective and standardized conditions: Incidence and outcome. Ann Thorac Surg 2000; 69: 1792-8.
10.Bernhard VM, Johnson WD, Peterson JJ. Carotid artery stenosis: Association with surgery for coronary artery disease. Arch Surg 1972; 105: 837-40.
11.Zacharias A, Schwann TA, Riardan CJ, Clark PM. Operative and 5-year outcomes of combined carotid and coronary revascularization: Review of a large contemparory experience. Ann Thrac Surg 2002; 73: 491-8.
12.Giangola G, Migaly J, Riles TS. Perioperative morbidity and mortality in combined vs staged approaches to carotid and coronary revascularization. Ann Thorac Surg 1996; 10: 138-42.
13.Mackey WC, Khabbaz K, Bojer R, O'Donnell TF Jr. Simultaneous carotid endarterectomy and coronary bypass: perioperative risk and long-term survival. J Vase
14.Hirotani T, Kameda T, Kumamoto T, Shirata S. Stroke after coronary artery bypass grafting in patients with cerebrovascular disease. Ann Thorac Surg 2000; 70: 1571-6.
15.Meharwaal ZS, Mishia A, Trehan N. Safety and efficacy of one stage off-pump coronary artery operation and carotid endarterectomy. Ann Thorac Surg 2002; 73: 793-7.
16.Gargemi JJ, Kran IL, Ross SD, Tribble CG, Kern JA. The safety of combined cardiac and vascular operations: how much is too much? Cardiovasc Surg 2000; 8: 452-6.
17.Nakano H, Daiman M, Hayashi K, Okamura H. Combined off-pump CABG (OPCAB) and abdominal vascular surgery. Kyobu Geka 2001; 54: 1131-7.