Rapid-staged strategy for concomitant critical carotid and left main coronary disease with left ventricular dysfunction: IABP use

Background. Few reports address the high-risk patient population with concomitant critical carotid and left main coronary disease with left ventricular dysfunction. To decrease the risks involved with the simultaneous and traditional staged surgical approaches, we developed a rapid staging strategy using an intraaortic balloon pump. Methods. Between 1992 and 1996, 20 patients presented with a high-risk 'triad' defined by greater than 70% stenosis of the left main coronary artery, ejection fraction less than 0.30, and greater than 90% stenosis of the internal carotid artery. An intraaortic balloon pump was placed immediately before carotid endarterectomy under angiographic guidance. Less than 24 hours later (mean, 18 hours) coronary artery bypass grafting was performed, and the intraaortic balloon pump was removed the day of coronary artery bypass grafting in all cases (total IABP duration, <36 hours). Results. Eighteen patients (18/20) were extubated on the day of coronary artery bypass grafting (mean, 12 hours). Sixteen patients (16/20) were transferred from the intensive care unit within 48 hours, with total hospital stay ranging from 6 to 12 days (mean, 8 days). There were no 30-day postoperative deaths, myocardial infarctions, or neurologic, vascular, bleeding, or other major complications. At a mean 29.4-month follow-up, there were two noncardiac deaths and no neurologic events. Six-month, 1-year, and 2-year follow-up ultrasounds showed all operative carotid arteries remained patent. Conclusions. A rapid staged procedure with angiographically guided placement of the intraaortic balloon pump was safe and effective in this very high risk patient population. It may be an option to decrease the risks involved with simultaneous operations and increase the efficiency and safety of 'traditional' staged carotid and coronary artery bypass grafting procedures.