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).