European Journal of Cardiovascular Medicine

The brain and heart are two of the most vital organs in the human body, each playing crucial roles in maintaining overall health and function. The brain, serving as the control centre, orchestrates all bodily activities, from basic survival functions to complex cognitive processes. The heart, on the other hand, pumps blood throughout the body, delivering oxygen and essential nutrients while removing waste products. According to the World Health Organization (WHO), cardiovascular diseases are the leading cause of death globally, claiming an estimated 17.9 million lives each year (Hussain et al., 2024). Similarly, neurological disorders significantly impact quality of life, with stroke being a major contributor to disability and mortality worldwide.

The coexistence of symptomatic coronary artery disease (CAD) and significant carotid artery stenosis (CAS) presents a complex clinical challenge, occurring in 3.4% to 22% of patients (Lane et al., 2002; Sulzenko and Pieniazek, 2018). Optimal surgical management of these patients remains controversial, with options including staged carotid endarterectomy (CEA) followed by coronary artery bypass grafting (CABG), the reverse-staged approach (CABG followed by CEA), or simultaneous CEA and CABG. Early studies suggested increased risks with combined procedures, leading to a preference for staged approaches. However, recent data indicate the safety and efficacy of combined CABG and CEA, with some studies reporting a decreased risk of stroke in combined approaches compared to staged procedures. Conversely, a recent meta-analysis highlighted potential increased risks of stroke and death with the combined approach (Yuan et al., 2009; Roffi et al., 2012; Tzoumas et al. 2020).

The advent of off-pump coronary artery bypass (OPCAB) has further complicated the decision-making process. OPCAB avoids extracorporeal circulation, potentially improving surgical outcomes in coronary surgery. Despite its growing popularity and the development of enabling technologies, limited data exist on its use in patients undergoing concurrent CEA and CABG. Additionally, the introduction of carotid stenting as a less invasive alternative to CEA adds another layer of complexity to the management strategy. Significant gaps in the literature persist regarding the optimal approach for managing patients with coexisting CAD and CAS, particularly concerning the use of OPCAB and carotid stenting. To address this, we aims to evaluate the clinical outcomes of combining these procedures. By analysing a series of cases, we seek to provide valuable insights into the safety, efficacy, and potential benefits of simultaneous CEA and OPCAB, contributing to the ongoing debate and guiding clinical practice. This study objectives are to fill the existing gaps in knowledge and provide evidence-based recommendations for the management of patients with concurrent CAD and CAS, ultimately improving patient outcomes and advancing the field of cardiovascular and neurological surgery.

This retrospective case series was conducted at Vinayaka Mission Super speciality hospitals (VIMS) from October 2022 to May 2024. The study aimed to evaluate the impact of optimizing anesthesia for concurrent carotid endarterectomy (CEA) and off-pump coronary artery bypass (OPCAB). Ethical approval for the study was obtained from the Institutional Review Board (IRB). All procedures followed the ethical guidelines for research involving human subjects. The study included patients diagnosed with significant coronary artery disease (CAD) and carotid artery stenosis (CAS) who underwent simultaneous CEA and OPCAB. The inclusion criteria were adult patients with symptomatic CAD and CAS, suitable for surgical intervention, and with accessible medical records and imaging data within the study period. Exclusion criteria included patients with contraindications to surgery or those with alternative conditions such as neoplastic lesions, trauma, or infections at the surgical site. The patients were assigned to undergo combined CEA and OPCAB procedures. This combined approach was chosen based on recent data suggesting improved outcomes compared to staged procedures. The surgeries were performed by a specialized surgical team experienced in both procedures to ensure consistency and reliability of the outcomes.

In patients undergoing concurrent Carotid Endarterectomy (CEA) and Off-Pump Coronary Artery Bypass (OPCAB), the anesthesia protocol was meticulously designed to optimize both cerebral and myocardial protection during the combined surgical procedures. Patients were pre-medicated with 1 mg of midazolam administered intravenously to alleviate anxiety. Standard monitoring devices were applied, including a 5-lead electrocardiogram (ECG), pulse oximetry, and invasive blood pressure monitoring. A central venous catheter was inserted via the right internal jugular vein under ultrasound guidance to facilitate fluid management and administration of medications. Anaesthesia was induced with a combination of midazolam, fentanyl, propofol in titration to ensure a smooth induction and rapid onset of anaesthesia. Muscle relaxation was achieved with rocuronium to facilitate tracheal intubation and provide optimal surgical conditions. Anaesthesia was maintained using a balanced technique involving a continuous infusion of propofol (50 to 150 µg/kg/min) and the volatile anaesthetic sevoflurane (1.5 to 2.5%) to ensure hemodynamic stability and adequate depth of anaesthesia. Inhaled gas nitrous oxide (50%) was used in conjunction with sevoflurane to enhance analgesia and minimize the use of opioids. Continuous monitoring of arterial blood gases, electrolytes, and blood glucose levels was performed to maintain homeostasis. Cerebral oximetry was employed to monitor regional cerebral oxygen saturation and ensure adequate cerebral perfusion during the CEA. Hemodynamic parameters were meticulously managed with intravenous fluids, vasopressors, and inotropes as needed. Patients were monitored in the intensive care unit for at least 24 hours postoperatively to manage any potential complications and ensure stable recovery.

CEA was initiated with an incision anterior to the sternocleidomastoid muscle to expose the common carotid artery, internal carotid artery, and external carotid artery. After systemic heparinization (2 mg/kg), the carotid artery was clamped and a longitudinal arteriotomy was performed. Endarterectomy was conducted, and the arteriotomy was closed either directly or with a saphenous vein patch and skin closure done after confirming good carotid flow on the side of surgery. OPCAB was performed through a median sternotomy following conduit harvesting. Distal anastomoses were performed using an Octopus tissue stabilization system or an Immobilizer stabilization platform. No intracoronary shunts were used. All proximal anastomoses were completed using a side-biting clamp on an atherosclerosis-free segment of the ascending aorta. Patients received standardized anesthesia protocols tailored to manage the dual requirements of CEA and OPCAB. Anaesthetic agents were carefully selected to ensure hemodynamic stability, reduce myocardial oxygen demand, and maintain cerebral perfusion during carotid clamping. Data were collected retrospectively from patient records, including demographic information, surgical details, intraoperative and postoperative outcomes.

Data were analysed using Statistical Package for Social Sciences (SPSS) software version 23 (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics were used to summarize demographic and clinical characteristics. Continuous variables were compared using one-way ANOVA, and a significance level of P<0.05 was set for all statistical tests. The results were interpreted to determine the impact of combined CEA and OPCAB on patient outcomes, focusing on intraoperative stability, postoperative complications, and overall recovery.

Out of the fifteen patients included in this study, only five cases are described here to provide detailed insights and highlight specific clinical scenarios. These cases were selected based on the complexity of their conditions and the varied responses to the anesthesia management protocols used.

Case # 1

A 72-year-old male with a history of hypertension, hyperlipidaemia, and peripheral vascular disease presented with symptoms of exertional chest pain and transient ischemic attacks. The patient experienced progressive angina (Canadian Cardiovascular Society class III) and episodes of transient right-sided weakness and aphasia, which resolved spontaneously. On examination, the patient was alert and oriented with stable vital signs, a body weight of 78 kg, height of 172 cm, and a body mass index (BMI) of 26.4 kg/m². A right carotid bruit was noted, and cardiovascular examination demonstrated normal heart sounds without murmurs. Neurological examination showed no focal deficits. Diagnostic workup included an electrocardiogram (ECG) showing evidence of previous myocardial infarction, transthoracic echocardiography (TTE) revealing left ventricular ejection fraction (LVEF) of 45% with regional wall motion abnormalities, carotid Doppler ultrasound showing 75% stenosis of the right internal carotid artery (ICA) and 60% stenosis of the left ICA, and coronary angiography showing significant triple vessel disease. Given the high risk of stroke and myocardial infarction with staged procedures, the decision was made to proceed with concurrent carotid endarterectomy (CEA) and off-pump coronary artery bypass (OPCAB). A central venous catheter was inserted via the right internal jugular vein under ultrasound guidance. The CEA was performed first, followed by a median sternotomy for the OPCAB. Conduit harvesting included the left internal mammary artery (LIMA) and saphenous vein grafts, with distal anastomoses performed using the Octopus tissue stabilization system. Postoperative management involved ICU monitoring, antiplatelet therapy, statins, beta-blockers, and strict blood pressure control. The patient demonstrated an uneventful recovery, with no new neurological deficits and stable cardiac function, highlighting the successful management of high-risk concurrent carotid and coronary artery diseases using optimized anesthesia protocols for combined CEA and OPCAB.

Case # 2

A 68-year-old man (height: 175 cm, body weight: 82 kg) was referred to our hospital for surgical management of severe coronary artery disease and symptomatic carotid artery stenosis. He had a history of hypertension, hyperlipidaemia, and type 2 diabetes mellitus, managed with medication. The patient had experienced transient ischemic attacks (TIAs) and angina pectoris, which prompted further evaluation. Coronary angiography revealed significant stenosis in the left main coronary artery and triple-vessel disease, while carotid Doppler ultrasound showed a 75% stenosis in the right internal carotid artery. Given the severity of both conditions, a combined surgical approach of concurrent Carotid Endarterectomy (CEA) and Off-Pump Coronary Artery Bypass (OPCAB) was planned. The anesthesia team prepared for a complex procedure requiring meticulous management of both cerebral and myocardial perfusion. A pulse oximetry, and invasive blood pressure monitoring, were applied. A central venous catheter was inserted via the right internal jugular vein under ultrasound guidance. The CEA was performed first. An incision was made anterior to the sternocleidomastoid muscle to expose the carotid arteries. After administration of 2 mg/kg of intravenous heparin, the common carotid artery, internal carotid artery, and external carotid artery were clamped, and a longitudinal arteriotomy was performed. An endarterectomy was conducted, and the arteriotomy was closed directly. The neck incision was temporarily left open until the cardiac procedure was completed and heparin was reversed with protamine. Following the CEA, a median sternotomy was performed. The patient was monitored in the intensive care unit for 24 hours postoperatively. The combined surgical approach successfully addressed both the coronary and carotid artery disease. The patient was discharged in stable condition with instructions for regular follow-up to monitor cardiovascular health.

Case # 3

A 65-year-old male (height: 178 cm, body weight: 82 kg) presented to the hospital with a history of progressive exertional angina and transient ischemic attacks (TIAs). The patient had a significant medical history, including hypertension, hyperlipidaemia, and type 2 diabetes mellitus, all managed with medication. Preoperative evaluations revealed severe triple-vessel coronary artery disease and a 70% stenosis in the right internal carotid artery. Given the concurrent coronary and carotid pathologies, a decision was made to perform concurrent Carotid Endarterectomy (CEA) and Off-Pump Coronary Artery Bypass (OPCAB) to optimize surgical outcomes and minimize the risk of perioperative stroke and myocardial infarction. Off-pump coronary artery bypass grafting was conducted using the Octopus tissue stabilization system. All distal anastomoses were performed without intracoronary shunts, and proximal anastomoses were completed using a side-biting clamp on an atherosclerosis-free segment of the ascending aorta. The combined surgical approach was successful, with no perioperative complications such as stroke or myocardial infarction. The patient was extubated in the intensive care unit (ICU) and monitored closely for 48 hours postoperatively. Follow-up imaging confirmed the patency of the coronary grafts and the carotid artery.

Case # 4

A 68-year-old male (height: 175 cm, body weight: 85 kg) presented with a history of progressive angina and transient ischemic attacks (TIAs). Preoperative evaluation revealed severe triple-vessel coronary artery disease and significant stenosis in the left internal carotid artery. Given the dual pathologies, a decision was made to perform concurrent Carotid Endarterectomy (CEA) and Off-Pump Coronary Artery Bypass (OPCAB) to optimize patient outcomes and minimize perioperative risks. The surgical procedure commenced with the CEA. Following the CEA, a median sternotomy was performed, and the left internal mammary artery (LIMA) and saphenous vein grafts were harvested. OPCAB was conducted using the Octopus tissue stabilization system. The patient was extubated in the intensive care unit (ICU) and monitored closely for 48 hours postoperatively. Follow-up imaging confirmed the patency of the coronary grafts and the carotid artery.

Case # 5

A 70-year-old male patient with a history of coronary artery disease and transient ischemic attacks (TIAs), weighing 82 kg and with a height of 178 cm, was scheduled for concurrent Carotid Endarterectomy (CEA) and Off-Pump Coronary Artery Bypass (OPCAB) due to significant left internal carotid artery stenosis and severe triple-vessel coronary artery disease. The patient was admitted with symptoms of angina and occasional episodes of blurred vision and dizziness, which warranted this combined surgical approach. The surgical procedure began with the CEA followed by OPCAB. Following the CEA, a median sternotomy was performed. The patient was extubated in the intensive care unit (ICU) and monitored closely for 48 hours. No perioperative complications, such as stroke or myocardial infarction, occurred.

Figure 1: Showing various stages of CEA surgical procedure.

Figure 2: Showing off-pump coronary artery bypass surgical procedure.

Demographic Data

Among the fifteen patients in this case series, 12 were male and 3 were female, indicating a possible gender-related predisposition for concurrent carotid endarterectomy (CEA) and off-pump coronary artery bypass (OPCAB). Patients' ages ranged from 54 to 72 years, highlighting that older adults are more likely to require these complex procedures due to the higher prevalence of cardiovascular diseases in this age group. Body weights varied from 68 kg to 98 kg, with heights ranging from 163 cm to 178 cm, reflecting a diversity in body habitus that can influence surgical and anaesthetic management. The body mass index (BMI) of the patients ranged from 24.2 to 28.7, categorizing them as slightly overweight. The side of the carotid procedure was equally distributed, with three patients undergoing the procedure on the right side and two on the left side, underscoring the necessity to tailor surgical approaches based on individual anatomical considerations.

The length of hospital stays for patients undergoing concurrent CEA and OPCAB varied, reflecting the complexity and individual patient responses to the procedures. Patients generally stayed between 7 and 10 days in the hospital. Patients with uncomplicated procedures had shorter stays, typically around 7 days. In contrast, patients with minor postoperative complications, such as transient neurological symptoms, required extended hospitalization up to 10 days. The mean hospital stay was approximately 8.2 days, with a standard deviation indicating variability due to individual patient conditions and recovery rates. These findings underscore the importance of vigilant postoperative care and monitoring to ensure prompt recovery and manage any arising complications effectively.

Associated Anesthesia Complications

Anesthesia-related complications were minimal but noteworthy. Transient hypotension during induction was observed in two patients, managed with fluid administration and vasopressors. No significant cardiovascular events, such as arrhythmias or myocardial infarctions, were reported. Neurological monitoring during the procedure indicated no intraoperative strokes or major neurological deficits. The administration of anesthesia was tailored to maintain hemodynamic stability and optimize cerebral and myocardial perfusion, crucial for patients undergoing these concurrent high-risk procedures. This meticulous approach contributed to the successful management of anesthesia-related challenges, ensuring patient safety and positive surgical outcomes. In concise, the successful management of patients undergoing concurrent CEA and OPCAB requires a comprehensive, multidisciplinary approach. The demographic diversity among the patients and the minor variations in anesthesia and surgical complications highlight the importance of individualized care plans. This case series emphasizes the critical role of careful anaesthetic management and vigilant postoperative monitoring in optimizing patient outcomes for these complex, high-risk procedures.

This case series provides valuable insights into optimizing anesthesia for concurrent carotid endarterectomy (CEA) and off-pump coronary artery bypass (OPCAB) procedures. Among the fifteen patients studied, all were male except for three females, suggesting a potential gender predisposition for these combined surgeries. Patients' ages ranged from 54 to 72 years, reflecting the increased likelihood of complex cardiovascular diseases in older adults. Body weights varied from 68 kg to 98 kg, and heights ranged from 163 cm to 178 cm, indicating a diverse range of body habitus that necessitates tailored anaesthetic and surgical management. The BMI of the patients ranged from 24.2 to 28.7, categorizing them as slightly overweight. The carotid procedures were evenly distributed between the right and left sides, underscoring the need for individualized surgical approaches based on anatomical considerations. Hospital stays varied from 7 to 10 days, with minimal anesthesia-related complications. Anesthesia management for concurrent CEA and OPCAB requires a high level of expertise and precision. In this study, CEA was performed on 14 patients with 65-75% unilateral carotid stenosis and one patient with a 95% carotid blockage. Maintaining cerebral perfusion was critical, with the mean arterial pressure kept above 70 mmHg. Patients with low ejection fractions (30-35%) often developed hypotension after induction, necessitating careful administration of anesthesia and sometimes requiring pre-induction inotropic support. To mitigate the risk of stroke due to hypotension, embolization of carotid plaques, or cerebral hyperemia post-CEA, magnesium sulfate (2 grams) and thiopentone sodium (10-20 mg/kg/hr) were used, monitored by a bispectral index (BIS) score of 20-40. These findings underscore the necessity for individualized anesthesia management and meticulous postoperative monitoring to ensure favourable outcomes in high-risk surgical patients. Our results align with findings from Meharwal et al., (2002); Beauford et al. (2003) and Garg et al., (2015), who reported successful outcomes in patients undergoing combined off-pump coronary revascularization and CEA, emphasizing the importance of careful surgical planning and execution. Yildirim et al., (2005) and Xu et al. (2017) also demonstrated favourable early results in simultaneous CEA and OPCAB procedures, supporting the feasibility and safety of this combined approach. Similarly, Youssuf et al. (2001) and Fareed et al. (2009) highlighted the potential benefits of off-pump myocardial revascularization combined with CEA, noting minimal perioperative complications, which is consistent with our findings. Conversely, Ricotta et al., (2005); Abdurakhmanov et al. (2018) and Ramponi et al., (2023) reported initial experiences indicating slightly higher complication rates, which might be attributed to their initial phase of procedural adaptation. Chen et al. (2009) and Yang et al., (2016) observed that careful patient selection and optimized anesthesia protocols were crucial for successful outcomes in combined CEA and OPCAB, reinforcing our emphasis on individualized care plans.

The minimal anesthesia-related complications observed in our study can be attributed to the meticulous management of hemodynamic stability and optimized cerebral and myocardial perfusion. The use of advanced monitoring techniques and individualized anaesthetic regimens likely contributed to the successful outcomes. Additionally, the simultaneous approach of performing CEA first, followed by OPCAB, minimized the potential risks associated with separate procedures, as it ensured continuous management of both cerebral and cardiac perfusion. This case series demonstrates the critical importance of a multidisciplinary approach in managing complex cardiovascular and cerebrovascular pathologies. Our findings suggest that concurrent CEA and OPCAB can be performed safely with optimized anesthesia protocols, potentially reducing the overall risk of perioperative complications and improving patient outcomes. The emphasis on individualized care plans and meticulous intraoperative monitoring can serve as a guideline for clinicians managing similar high-risk surgical patients. Future research should focus on larger, prospective studies to validate these findings and further refine anesthesia protocols for combined CEA and OPCAB procedures. Additionally, exploring the long-term outcomes of patients undergoing this combined approach would provide valuable insights into the overall benefits and risks associated with simultaneous surgical management of carotid and coronary artery diseases.

This case series underscores the critical importance of optimizing anesthesia protocols for concurrent carotid endarterectomy (CEA) and off-pump coronary artery bypass (OPCAB). Individualized anesthesia management and meticulous postoperative monitoring were pivotal in ensuring favorable outcomes, with minimal complications observed among the studied patients. These findings highlight the necessity of a multidisciplinary approach in managing high-risk surgical patients, contributing valuable insights to the existing literature. Future research should aim to validate these results through larger studies, further refining anesthesia strategies to enhance patient safety and surgical success in combined CEA and OPCAB procedures.

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