Carotid atherosclerotic disease is a known independent risk factor of post operative stroke after coronary artery bypass grafting (CABG). The best management of concomitant coronary artery disease and carotid artery disease remains debated. Current strategies include simultaneous carotid endoarterectomy (CEA) and CABG, staged CEA followed by CABG, staged CABG followed by CEA, staged transfemoral carotid artery stenting (TF-CAS) followed by CABG, simultaneous TF-CAS and CABG and transcarotid artery stenting.

We report our experience based on a cohort of 222 patients undergoing combined CEA and CABG surgery who come to our observation from 2004 to 2020. All patients with >70% carotid stenosis and severe multivessel or common truncal coronary artery disease underwent combined CEA and CABG surgery at our institution. 30% of patients had previously remote neurological symptoms or a cerebral CT-scan with ischemic lesions. Patients with carotid stenosis >70%, either asymptomatic or symptomatic, underwent CT-scan without contrast media to assess ischemic brain injury, and in some cases, if necessary, CT-angiography of the neck and intracranial vessels. All procedures were performed under general anesthesia with full invasive monitoring, before onset of cardiopulmonary bypass (CPB). In no cases was CEA performed using loco-regional anesthesia. 72 ( 32,5%) patients underwent off-pump bypass. Neurological assessment was monitored with near infrared refractory spectroscopy and stump pressure measurement . In particular, the intra-operative neuromonitoring was performed by the INVOS™ system (Medtronic, Dublin, Ireland), so as to provide a continuous non-invasive measurement of cerebral oxygen saturation and a reliable indication of changes in cerebral perfusion. Surgical dissection of the carotid arteries was usually completed while cardiac surgeons harvested the saphenous vein. All patients were anticoagulated with heparin 5000 IU before the carotid arteries were cross-clamped. During the CEA, carotid shunting was performed in 200 patients (90%) and all reconstructions were performed with bovine pericardium patch. After CEA, the neck wound was usually left open to identify any suture bleeding during cardiac surgery due to anticoagulation with heparin. The intra-operative anticoagulation status was managed using a thromboelastograph (Haemonetics®, Boston, USA). After CABG and removal of the ECC cannulae, the heparin was reversed with protamine sulphate. The cervical wound was closed at the completion of the cardiac surgery.

The overall perioperative mortality rate was 4.1% (9/222 patients). Two patients (0.9%) had periprocedural ipsilateral transient ischemic attack (TIA) which completely resolved by the second postoperative day. Two patients (0.9%) had an ipsilateral stroke, while 7 patients (3.2%) had a stroke of the contralateral brain hemisphere. Two patients (0.9%) patients were affected by periprocedural coma caused by cerebral hypoperfusion due to perioperative heart failure. There were no statistically significant differences between patients in Extracorporeal Circulation (ECC) and Off-pump patients in the onset of perioperative stroke.

Our experience reported that combined surgical treatment of CEA and CABG, possibly Off-Pump, is a feasible treatment procedure, able to minimize the risk of post-operative stroke and cognitive deficits