Atheroembolization in cardiac surgery. The need for preoperative diagnosis.

BACKGROUND: Atheroembolization is a recognized complication of cardiac surgical procedures, and has been implicated in postoperative stroke, renal failure, multiorgan failure, and death. Preoperative identification of patients at risk for developing atheroemboli is essential. The aim of this study was to determine preoperative risk factors for atheroemboli and to assess the postoperative course of the patients who developed atheroembolic syndrome. METHODS: A retrospective record review was conducted. From 1/1990 to 12/1994 5486 patients underwent coronary artery bypass grafting (CABG), valve operations, or other cardiac surgical procedures at Massachusetts General Hospital. Of this population, 107 patients (1.9%) developed atheroembolic syndrome. RESULTS: Patients who develop atheroemboli were older, with an increased incidence (p < 0.01) of hypertension, cerebrovascular disease, and aortoiliac disease. Many had a complicated course after catheterization, with renal insufficiency (35%) and evidence of peripheral emboli (12%). Average Intensive Care Unit stay, hospital stay, and hospital cost of these patients were respectively 16.8 days, 48.4 days, and $88,000, compared to 1.5 days, 9.6 days and $23,000 for a concurrent population undergoing CABG surgery. Of these 107 patients only 2 were discharged home, the others either died (48 patients, or 25% of all cardiac surgical deaths during this period), or went to rehabilitation or chronic hospital facilities. Twenty-seven autopsies were performed and invariably showed a diffusely diseased aorta, with calcification, mural thrombus, and ulceration. CONCLUSIONS: Atheroembolization during cardiac surgical procedures has profound medical and economic consequences. Because of the diffuse nature of aortic disease, measures approaching the disease as a local process are likely to be unsuccessful. Appropriate evaluation would ideally identify patients with extensive aortic atheromatous disease, prior to rather than during surgery.