Adjuvant PTA for cervical internal carotid artery stenosis prior to Coronary Artery Bypass Grafting (CABG): Report of four cases involving sequential "partial balloon PTA→CABG→CEA" treatment

Abstract

Stroke is the most common complication in those patients with symptomatic coronary artery disease requiring coronary artery bypass grafting (CABG). Severe stenosis of the internal carotid artery (ICA) may induce stroke following intraoperative hypotension, even if bypass surgery is performed with off-pump coronary artery bypass (OPCAB). Carotid artery stent placement is beneficial, however, this technique displays disadvantages of postprocedural hypotension attributable to stretching of the carotid sinus, which may exacerbate severe myocardial ischemia. We report four cases of ICA stenosis treated initially with intentional partial PTA (adjuvant PTA) in an attempt to reduce the risk of post-procedural stroke following CABG. Subsequently, CABG was conducted as quickly as possible to improve cardiac function, followed by radical CEA after recovery from the invasive CABG. Patients, all males aged from 71 to 79 years (mean 73.3), were admitted with stable angina pectoris and diagnosed with coronary disease necessitating early treatment with CABG. Subsequently, ICA stenosis was detected by preoperative screening. Cerebral angiography revealed severe ICA stenosis and near-occlusion in three patients ; mean stenosis rate was 93.0% (range 77-99%). Adjuvant PTA was performed successfully with a low profile (3.0-3.5 mm) balloon catheter employing a distal protection system with no incidence of hypotension or myocardial ischemia. Following PTA, mean stenosis rate was improved from 93.0% to 58.8% (range 50-70%). All patients underwent OPCAB at mean 7.0 days post PTA and with CEA at mean 10.8 weeks post PTA ; neither major stroke nor myocardial infarction occurred. In a series of the periprocedural period, the permanent morbidity and mortality rate was 0%. In the patient priory to CABG associated with severe ICA stenosis, a sequential regime comprised of "adjuvant PTA→CABG→CEA" is useful for prevention of periprocedural ischemic complications.