Nevra GÜLHAN, Levent MAVİOĞLU, Çağatay ERTAN, Ufuk MUNGAN, Aylin MAVİOĞLU, Mehmet Ali ÖZATİK

Semptomatik iki taraflı ciddi karotis arter ve koroner arter hastalığının tedavisi

Amaç: Bu çalışmada semptomatik iki taraflı ciddi karotis arter ve koronerarter hastalığı olan hastalarda yakın aralıklı karotis endarterektomi vesenkronize kardiyak cerrahinin güvenilirliği ve etkinliği araştırıldı.Çalışmaplanı: Çalışmaya kliniğimizde Eylül 2010 - Ocak 2014tarihleri arasında yakın aralıklı karotis endarterektomi ve senkronizekardiyak cerrahi yapılan 12 ardışık hasta (7 erkek, 5 kadın; ort.yaş 70.3±5.1 yıl; dağılım 61-78 yıl) dahil edildi. Hastaların tümünörolojik açıdan semptomatik idi: beş hastada (%41.7) geçici iskemikatak, iki hastada (%16.7) geri dönüşümlü iskemik nörolojik defisit,bir hastada (%8.3) amorozis fugaks, bir hastada (%8.3) sekelli inmeve üç hastada (%25) sekelsiz inme vardı. Ayrıca, tüm hastalarda ikitaraflı ciddi karotis arter darlığı saptandı. Karotis endarterektomi içinendikasyon belirlenirken darlığın derecesi, plağın morfolojisi veyaher ikisi dikkate alındı. Hastaların plak özellikleri ultrasonografikGray-Weale plak tipi nitelemesine göre açıklandı. Kardiyak cerrahilerintümünde kardiyopulmoner perfüzyon kullanıldı. Ortalama takip süresi12.2±9.6 ay (dağılım 0-32 ay) idi.Bul gu lar: Bir hasta düşük kardiyak debi ve çoklu organ yetmezliğinebağlı olarak ameliyat sonrası dördüncü günde kaybedildi. Bir hastada tektaraflı larengeal sinir hasarı gelişti. Ortalama karotis tıkanma zamanı(semptomatik ve asemptomatik tarafta), aortik kros klemp zamanı vekardiyopulmoner perfüzyon zamanı sırasıyla 16.3±3.5 dakika (dağılım8-22 dakika) (semptomatik tarafta), 17.0±3.9 dakika (dağılım 7-23 dakika)(asemptomatik tarafta) ve 63±14 dakika (dağılım 38-84 dakika) ve 79±19dakika (dağılım 50-120 dakika) idi. Yoğun bakımda ortalama kalış süresi3±0.9 gün, hastanede toplam kalış süresi 13.5±2.7 gün idi. Yakın aralıklıcerrahi için ortalama bekleme süresi 5.2±1.3 gün (dağılım 3-7 gün) idi. Takipsüresi boyunca herhangi bir kardiyovasküler olay gözlenmedi.Sonuç: Çalışma sonuçlarımıza göre, semptomatik iki taraflı ciddi karotisarter darlığı ve eşlik eden kardiyak patolojisi olan hastalarda yakın aralıklıkarotis endarterektomi ve senkronize kardiyak cerrahi güvenilir ve etkin biryöntem olabilir.

Manageme nt of sympto matic bilateral sev e re carotid artery and co ro nary arte ry disease

Background: This study aims to investigate the safety and effectiveness of closelysequential carotid endarterectomy and synchronous cardiac surgery in patientswith symptomatic bilateral severe carotid artery and coronary artery disease.Methods: The study included 12 consecutive patients (7 males, 5 females;mean age 70.3±5.1 years; range 61 to 78 years) who were performed closelysequential carotid endarterectomy and synchronous cardiac surgery inour clinic between September 2010 and January 2014. All patients wereneurologically symptomatic: five patients (41.7%) had transient ischemicattack, two patients (16.7%) had reversible ischemic neurologic deficit, onepatient (8.3%) had amaurosis fugax, one patient (8.3%) had stroke with sequel,and three patients (25%) had stroke without sequel. Also, severe bilateralcarotid stenosis was detected in all patients. When indication for carotidendarterectomy was identified, the degree of stenosis, plaque morphologyor both were considered. Patients plaque characteristics were describedaccording to ultrasonographic Gray-Weale plaque type characterization.Cardiopulmonary perfusion was used in all cardiac surgeries. Mean follow-upperiod was 12.2±9.6 months (range 0 to 32 months).Results: One patient died on the postoperative fourth day due to low cardiacoutput state and multi-organ failure. Unilateral laryngeal nerve damageoccurred in one patient. Mean carotid occlusion time (at symptomaticand asymptomatic side), aortic cross-clamping time and cardiopulmonaryperfusion time were 16.3±3.5 minutes (range 8 to 22 minutes) (at symptomaticside), 17.0±3.9 minutes (range 7 to 23 minutes) (at asymptomatic side),63±14 minutes (range 38 to 84 minutes) and 79±19 minutes (range 50 to120 minutes), respectively. Mean duration of stay in cardiac care unit was3±0.9 days and total hospital stay duration was 13.5±2.7 days. Mean waitingduration for closely sequential surgery was 5.2±1.3 days (range 3 to 7 days). Nocardiovascular event was observed during the follow-up period.Conclusion: According to our study results, closely sequential carotidendarterectomy and synchronous cardiac surgery may be a safe and effectivemethod in patients with symptomatic bilateral severe carotid artery stenosisaccompanied with cardiac pathology.

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