Concomitant caroid endarterectomy and CABG :  Symptoimatic or asymptomatic carotid artery disease may be present in patients undergoing CABG. It is very important to recognize this preoperatively, as haemodynamic fluctuation during CABG may result ill postoperative stroke in the early years of CABG more than GO per cent block of carotid artery, whether symptomatic or not was treated surgically before CABG. If' patient has bilateral lesion of more them (10 percent, the dominated side was tackled first.

Simultaneoils CABG and CAE (carotid artery endarterectomy) had higer rates of stroke and death. Carotid endarterectomy was done 2-5 days before CABG. Some surgeons favour this. However if the coronary artery disease is critical, it is better to do both simultaneously Now even if the cardiac status is stable many surgeons advise one slag operation. With a single anaesthesia and hospitalization, this approach is probably better.

In a combined procedure, the heart is exposed and condults harvested at the same Lime carotid arlery is exposed. The common carotid artery, bifracation, external and internal carotid arteries are exposed. The internal carotid aslery is exposed well above the diseased part. The vessels are looped. The external carotid, distal ends of internal carotid and common carotid are clamped. A vertical incision on the bifracation extending on Lo the internal carotid is made. If back bleeding is not satisfactory on removal of distal internal carotid clamp, an intra luminal shunt has to be placed to protect cerebral circulation.

Endarterectomy is done from internal and common carotid arteries. Loose fragments are removed and irrigated well. At times the intima has to be fixed with 7'01prolene suture inside the internal carotid artery. Arteriotomyis closed with a vein patch or synthetic Goretex patch so as not to narrow the artery. The wound is packed and closure is clone after CABG and reversal of heparin with protamine. The peri-operative stroke and mortality rates exceed that of isolated carotid endarterectomy or CABG.