6. Risk Neutralization in Cardiac Surgery: Efficacy and Expense of Detection and Treatment of Associated Carotid Disease
John Parker Gott, Vinod H. Thourani, Carolyn E. Wright, W. Morris Brown III, Andrew Adams, William M. McKinnon, Robert A. Guyton
Emory University School of Medicine
Atlanta, Ga.
Background: A screening and treatment protocol has been used since 1991 to extend the benefit of prophylactic carotid endarterectomy (CEA) to cardiac surgical (OHS) patients.
Methods: Elective OHS patients ³65 years old, with left main disease, or suggestive history were eligible for preoperative carotid duplex screening. OHS patients with carotid stenoses > 80 percent were to have angiography then CEA staged or combined with OHS. Carotid CVA was defined as an unihemispheric stroke ipsilateral to > 80 percent carotid stenosis. CVAs that were atheroembolic, cardioarterial, intracranial vascular or in emergent patients were not included. Unscreened patients with CVA after PHS underwent postoperative duplex to assess carotid disease.
Results: There were six carotid CVAs in 5,648 OHS patients. Of 2,598 eligible for screening 1,381 had duplex. Two-sixths Carotid CVAs occurred in eligible, but unscreened patients, one unscreened patients, one unscreened carotid CVA patient (64 years old) just missed the age criterion. Of 1,253 patients with <90 percent stenosis by duplex had carotid CRA. One hundred twenty-eight patients had > 80 percent stenosis. Ninety-three of one hundred twenty-eight had CEA proceeding OHS none of these had carotid CVA. Of the 35 patients with > 80 percent but without prophylactic CEA, (c 2=8.16, p= 0.004 compared with the CEA group, odds ratio 8.0). This strategy costs $500 per screened patient.
Conclusions: Carotid stroke at the time of open-heart operation is infrequent but avoidable. Duplex screening identifies an increased risk group. Prophylactic carotid endarterectomy neutralizes the risk.