Wake-up test after carotid endarterectomy for combined carotid-coronary artery surgery: a case series

Objective: In combined carotid-coronary artery surgery, it is important to determine patients’ neurologic status after carotid endarterectomy (CEA). An initial stroke could be exacerbated by cardiopulmonary bypass required for coronary artery bypass graft (CABG) surgery. Various monitoring methods (eg, electroencephalogram) have been used to reduce neurologic deficits during CEA under general anesthesia. However, none of the methods of determining neurologic status of patients are ideal during the time between the end of CEA and the beginning of CABG surgery. In this study, patient’s neurologic status was assessed after CEA with a wake-up test to identify stroke before CABG surgery. Design: A prospective nonrandomized case series. Setting: Single institution, university hospital. Participants: Forty-four patients with carotid artery stenosis and coronary artery disease underwent combined carotid-coronary artery surgery. Interventions: After CEA, propofol and remifentanil anesthesia was discontinued, the wake-up test was performed, and then anesthesia was reinstituted for CABG surgery. Measurements and Results: A total of 48 wake-up tests were performed in 43 patients. Two wake-up tests were performed in each of the 5 patients who underwent bilateral CEA. Postoperative stroke were seen in 2 patients. In the first patient, despite a normal wake-up test, the stroke occurred in the cerebral hemisphere contralateral to the CEA, and the patient recovered within 12 days. In the second patient, there was a positive wake-up test after CEA, and he recovered within 3 days. One patient died postoperatively because of ventricular failure. Conclusions: Although this is a case series, the authors believe that performing a neurologic examination using a wake-up test may make a contribution and increases the safety of combined surgical procedures in patients with coronary and carotid artery disease.