913 Brief Communication Management of concomitant coronary and advanced carotid artery disease Bulend Ketenci, MD, M.Rasit Guney, MD, Serdar Cimen, MD, Rafet Gunay, MD, Batuhan Ozay, MD, Recai Turkoglu, MD, Vedat Ozkul, MD, Alper Gorur, MD, Murat Demirtas, MD. T he high-risk potential for neurological dysfunction following coronary artery bypass grafting (CABG) in patients with concomitant carotid stenosis has always been a challenge. Many surgeons advocate combined CABG with carotid endarterectomy (CEA). However, clinical experience with the concomitant approach is conficting. 1 Patients with bilaterally diseased carotid artery have a more challenging group. Sixty-fve patients underwent both CABG and unilateral CEA (group I) or isolated CABG (group II) was enrolled for this study at Siyami Ersek Toracic and Cardiovascular Surgery. Tis retrospective study was initiated with the approval of the institutional review board. All patients had severe bilateral carotid artery disease (CAD) defned as a 50-99% stenosis in conjunction with a >50% stenosis or occlusion in the contralateral carotid artery. Demographic characteristics were comparable between 2 groups. Only a small group of patients (15.5%) had symptomatic carotid artery disease in the whole group. All patients scheduled for CABG underwent carotid color-fow duplex ultrasound examination when a history of transient ischemic attacks, cerebral vascular accidents was present or asymptomatic bruits on physical examination or with an age of >65 years. We excluded patients with previous CABG, concomitant valve replacement, and any other associated procedure or lesions in external carotid artery. We performed CEA procedures either with locoregional anesthesia (6 cases) or general anesthesia (24 cases). Te side with symptoms or greater stenosis was generally performed frst. We used intraoperative caroted shunt in 2 patients and carotid patch in 2. Coronary artery bypass grafting was performed after completion of the carotid operation. Cerebral protection for our patients during cardiopulmonary bypass included hypothermia and high perfusion fows and pressures. Intermittent tepid blood cardioplegic arrest was primarily used for myocardial protection. Proximal anastomoses were performed during partial aortic cross clamp period. Operative and postoperative data are given in Table 1. Tere were 2 deaths (5.7%) and no stroke in group II and 2 deaths (6.6%) and 4 strokes (13.3%) in group I (p=0.87 and p=0.026). Both deaths in group I were cardiac related. One patient died on the 4th postoperative day due to cardiac arrest and the second died due to low cardiac output syndrome on the 8th postoperative day. Two patients in group II died on the 8th and 34th day postoperative due to multiorgan failure and both patients had neurological and cardiac related complications. Tree out of 4 strokes in group I emerged in the early postoperatvie awakening period. Te fourth stroke occurred on the 5th postoperative day. Two of these patients died. In 3 patients, the stroke occurred on the side of the ipsilateral hemisphere of the carotid endarterectomy. Te last patient died without recovering consciousness due to cerebral ischemia. Te other complications were comparable between the 2 groups. Tough routine carotid endarterectomy or coronary revascularization can be performed separately in patients without concomitant carotid and coronary disease with minimal morbidity and mortality, the incidence of permanent stroke increased to 6.7% if the contralateral internal carotid artery was >50% narrowed and 11% in the presence of contralateral internal carotid artery occlusion after CABG. Contribution of cardiopulmonary bypass for the stimulation of micro emboli and the activation of multiple components of the infammatory cascade, resulting in neurological injury and other morbidity has been described previously. 2 On the other hand, beating heart surgery has established a serious ground due to well-documented short and long-term outcomes especially associated with low neurological morbidity rates. We had 21 patients (5 simultaneously operated, and 16 CABG) treated with of-pump myocardial revascularization and only one patient developed hemiplegia that had undergone simultaneous operation. Te early benefcial impact of CEA on neurological outcome still needs to be verifed. Te most recent studies suggested that performing staged or synchronous procedures for stroke prevention especially in asymptomatic patients could gain little or no beneft. 1 Yet patients with bilateral carotid lesions are specifc group of patients not encountered frequently. It has been reported that performing a unilateral carotid endarterectomy while ignoring the contralateral diseased carotid in patients who have signifcant bilateral carotid stenosis may result in increased morbidity and mortality from the uncorrected lesion. 3 In another recently reported document, patients with bilateral carotid artery disease had a 23% incidence of stroke on the untreated contralateral side. 4 Actually these reports do not support concomitant unilateral CEA and CABG operation. We performed isolated CABG in a group of patients in whom bilateral carotid lesion was present and compared early outcomes of this group with concomitantly operated group. In both groups, 2 deaths were present. Although