Screening for neuro "clearance" before CABG PEARLS

based on a lecture at ISC 2016 Los Angelos

by Michael Mullen  U Penn

1.  Patient risk factors for perioperative stroke:  (odds ratio):  prior stroke (3.55), PVD, DM AND HTN (EACH around 1.3),  female (1.6).  If divided into early and late stroke, risk factors (odds ratios) for early stroke are prior stroke (11.6), female (6.9), ascending aorta atherosclerosis (2.0), time on bypass (1.1).  Delayed stroke : history of stroke (27.6), diabetes (2.8), female (2.4), low CO and AF (1.7_)  ascending aorta atherosclerosis (1.4)

2. Timing of surgery and risk of stroke after a prior stroke:  (odds ratio). No prior stroke (1.), any prior stroke, any mechanism (4.0);  < 3 monthds prior (14); 3-6 mo prior (4.9); 6-12 mo prior , 3.0; > 12 months prior(2.5).  Sweet spot is 9 months

3.  Carotid screening:  1. not recommended for noncasrdiac surgery   2.  For cardiac surgery scren high risk patients:  >65, left main disease, peripheral vascular disease, history of prior stroke or TIA, carotid bruit based on guidelines ACCF/AHA for CABG (2011) by Hillis et al,  and by Brott et al, on Extracranial caroitd disease.  Published in Circulation.

4.  Risk of stroke with carotid disease: metanalysis(2011) Li et al, JAMA Neurology, 2009.  Low stroke risk in unilateral, asymptomatic carotid stenosis suggests revascularization is not necessary.  Odds ratio for stroke in such patients is (2.0).  However, suggest maintaining arterial perfusion pressure in such patients.

5. In patients with bilateral 50-99 % stenosis, unilateral 50-99 + contralateral occlusion, asymptomatic, odds ratio is (6.5).   Among these patients its reasonable to consider revascularizing one side.

6.  How to sequence procedures: Staged CEA-CABG, combined CEA-CABG

or staged CAS- CABG.  Main risk of staged CEA-CABG is MI, of combined CEA-CABG is stroke.  If CABG is urgent, do a combined CEA-CABG.  If not urgent do staghed CAS-CABG.