Background: Severe atherosclerotic coronary and carotid arterial disease with indication for surgical intervention presents a high risk of morbidity and mortality. The choice of an adequate therapeutic management option (staged operations versus combined synchronous operation) represents a surgical challenge and should be done in a multidisciplinary team. Delayed cardiotoxicity, induced by chemotherapy and radiation therapy, expressed by atherosclerosis development or acceleration increases the cardiovascular surgical risk of the cancer patient.
Case presentation: We present a 49 year old male patient, overweight, non-smoker, hypertensive, with dyslipidemia and newly diagnosed type 2 diabetes, with a history of Hodgkin lymphoma, treated with chemotherapy (ABVD) and radiotherapy (1998) and Non-Hodgkin lymphoma treated with chemotherapy (R-CHOP and R-CVEP, 2016-2017), in complete remission since December 2017, admitted at the Cardiology Unit with complaints of coronary like, rest and effort chest pain and mild dyspnea, in the last 3 months. An initial electrocardiogram revealed signs of ischemia in the anterior territory; the myocardial necrosis biomarkers were negative. The echocardiogram showed preserved left ventricular systolic function, without any wall motion abnormalities, large degenerative aortic stenosis, without pulmonary hypertension. The coronary angiography revealed trivascular atherosclerotic coronary artery disease with severe coronary artery calcification, with surgical intervention indication. The cervical-cerebral Doppler ultrasound identified bilateral 60-65% internal carotid arteries stenosis and 40% left common carotid artery stenosis, lesions confirmed by CT angiography. Although the cerebral MRI examination did not identify ischemic lesions, the microembolus detection by transcranial Doppler sonography was positive for the right internal carotid artery, indicating the need for revascularization procedure.
Case particularity: Although the cause of atherosclerosis is multifactorial in a hypertensive patient, with dyslipidemia and diabetes, it can also be secondary to complex oncological treatment (chemotherapy and radiation therapy) for two different types of malignant lymphomas. The multidisciplinary approach (cardio-vascular surgeon, cardiologist, neurologist, hematolo-gist, diabetologist) is emphasized in this case, deciding combined synchronous surgical coronary (bypass) and carotid (right internal carotid artery endarterectomy) revascularization, with a favorable evolution.
Conclusions: Cardiovascular toxicity related to onco-logical treatment can present late-onset effects, even after 20 years, worsening the preexistent cardiac patho-logies. Multidisciplinary approach, risk assessment and elaborating screening programs for cancer survivors treated with chemotherapy and radiotherapy are essen-tial; their implementation in the current clinical practi-ce has a great utility for guiding the prevention or early recognition of the cancer treatment related effects with a decrease in the incidence and complications of the cardiovascular diseases.