LAUSR

OBJECTIVE Demographics are shifting towards an increasingly older population in the United States, thus it is imperative that patients with a complex cardiovascular history are approached in a systematic fashion. Currently, there is no clear protocol on how best to manage elderly patients who present with both severe coronary artery disease and symptomatic carotid stenosis. For cardiac patients with severe, asymptomatic, high-grade carotid artery stenosis there may be even more of a conundrum . Though most centers would tend to manage the asymptomatic carotid stenosis expectantly, it is well known that patients with severe, uncorrected internal carotid artery disease are at an increased risk of experiencing a cerebrovascular accident during coronary artery bypass grafting (CABG). One approach that has been recognized in other settings as a cost-effective strategy to stabilize high-risk elderly patients preoperatively is the use of an intraaortic balloon pump (IABP). To better understand the best approach to take in these patients with concomitant disease, we analyzed the outcomes of four patients who underwent placement of an intraaortic balloon pump prior to carotid endarterectomy (CEA) as a bridge to CABG. METHODS Between 2017 and 2019, four patients presented with multi-vessel symptomatic coronary artery disease and greater than 90% stenosis of at least one internal carotid artery and underwent either staged or simultaneous CEA and CABG. There was placement of an intra-aortic balloon pump in all patients prior to the CEA. Time to CABG ranged from a simultaneous procedure to 23 days post CEA. RESULTS The only death within 30-days post-operation involved the patient who had CEA and CABG performed simultaneously. None of the surviving patients experienced a myocardial infarction. Two of the four patients experienced acute kidney injury after surgery and one patient developed atrial fibrillation postoperatively. None of the patients experienced a postoperative neurological complication. Additionally, there were no access site complications associated with IABP placement. CONCLUSIONS A staged procedure with placement of an IABP can be successfully used in carefully selected patients presenting with concomitant severe carotid and coronary artery disease who will undergo surgical management of their disease. The stabilization provided by IABP was potentially protective against adverse post-operative events and appeared to allow for flexibility in the time between CEA to CABG for patients. Additional studies are necessary to further understand the impact of such an approach.