Material and methods
During the period from 01.07.2014 – 01.01.2021, 243 patients with the
coronary and carotid arteries’ combined atherosclerotic lesions were
included in the study. 104 patients (42.8%) underwent simultaneous
combined CABG and CEA, 139 (57.2%) patients received step-by-step
revascularization, of which 102 (73.4%) patients underwent CABG, 37
(26.6%) underwent CEA in the first stage. We determined the surgical
interventions’ scope and stage according to the developed by us
differentiated approach algorithm. It is worth noting that the study
included only patients with the planned nature of surgical
interventions. Emergency patients were excluded from the study.
According to the algorithm, patients with critical lesions of the
carotid and coronary arteries are distinguished. A carotid arteries’
critical lesion means a lesion of more than 80%. Coronary artery damage
is considered critical with more than 75% stenosis. Professor Sukhanov
S. G. used electromagnetic fluometry to study the relationship between
the degree of the internal carotid artery lumen narrowing and volumetric
blood flow. It was found that lumen stenosis up to 75% leads to a
proportional decrease in blood flow. Further stenosis causes a sharp
disproportionate drop in shock volume [7]. Thus, carotid artery
stenosis of 80% or more was chosen by us as a critical value. It is
believed that the greater the coronary artery stenosis degree, the more
likely it is that the lesion is hemodynamically significant. Particular
disagreements are associated with intermediate coronary lesions’
revascularization (with a decrease in the vessel diameter from 50% to
70%) [8]. It is assumed that more than 70% stenosis is
functionally significant. According to studies, most stenoses with
angiographic severity from 50% to 70% are functionally insignificant
according to the study of the blood flow fractional reserve. However,
with more severe lesions (from 71% to 90%), up to 80% of all lesions
cause myocardial ischemia [9]. The more than 75% coronary artery
lesion was chosen by us as a critical value. The main criterion for
choosing the surgical intervention tactics in patients with the coronary
and carotid arteries’ combined atherosclerotic lesions in our algorithm
is the lesion’s anatomical picture. In addition, we evaluated the
clinical coronary heart disease manifestation when choosing the
treatment stage. In the pain-free myocardial ischemia or stable angina
presence of III–IV FC, the patient underwent CABG in the first, and CEA
in the second stage. This group also included patients with FC II
CHF(chronic heart failure) who had a critical isolated proximal lesion
of LAD(left anterior descending) artery or in combination with other
arteries. With a carotid arteries critical lesion, a coronary arteries
lesion up to 75% and CHF at the level of II-III FC, the patient
underwent CEA in the first, CABG in the second stage. We consider the
optimal time between the surgical interventions’ stages to be one month
from the moment the patient is discharged after the first operation. We
took into account the carotid artery lesions’
”symptomality-asymptomicity” as an indication for the carotid arteries
operative reconstruction according to current recommendations, however,
this criterion wasn’t included in the algorithm for choosing treatment
tactics for combined patients. In the critical lesion presence in both
arterial basins, the patient was referred for simultaneous
reconstruction in the coronary and carotid arteries’ basins clinical
manifestations regardless. In this way, we prevent vascular events that
may occur in the perioperative period after intervention on one arterial
bed due to a critical hemodynamic disorder in the non-operated pool.
This algorithm is adopted in the Federal Center for Cardiovascular
Surgery named after S. G. Sukhanov to determine the treatment tactics in
patients with multifocal atherosclerosis. The study design was developed
to confirm its hypothesis’ validity (Figure 1).
We analyzed the preoperative clinical indicators of patients in each
groups. There wasn’t significant difference in the any characteristics
(Table I).