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Combined carotid endarterectomy and coronary artery revascularization: a sobering review
A Bass1, W C Krupski, R B Dilley
1Department of General and Vascular Surgery, Chaim Sheba Medical Center, Tel-Hashomer, Israel.
Insights
Combined carotid endarterectomy and coronary artery bypass grafting leads to high morbidity and mortality. Careful patient selection is crucial, as prophylactic carotid surgery may not reduce stroke risk during bypass.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Surgery
Background:
- Combined carotid artery stenosis and coronary artery disease presents a complex surgical challenge.
- Optimal management strategies for patients requiring both carotid endarterectomy and coronary artery bypass grafting are debated.
Purpose of the Study:
- To analyze the clinical outcomes of patients undergoing combined single-stage carotid endarterectomy and coronary artery bypass grafting.
- To evaluate the morbidity and mortality associated with this combined procedure.
Main Methods:
- Retrospective analysis of 99 patients undergoing combined surgery over 15 years across three hospitals.
- Sequential reconstruction of carotid and coronary circulation by two surgical teams.
Main Results:
- Overall major neurological complication rate was 25%, with an 11% stroke rate ipsilateral to the operated carotid.
- High rates of other major complications including respiratory failure (5%), multisystem failure (8%), and myocardial infarction (8%).
- Overall mortality was 12%, with most deaths related to cardiac operation or stroke.
Conclusions:
- Combined carotid endarterectomy and coronary artery bypass grafting is associated with high morbidity and mortality, even in experienced centers.
- Careful patient assessment for the necessity of both procedures is essential.
- Prophylactic carotid endarterectomy does not appear to significantly reduce neurologic risk in patients undergoing coronary bypass.
Abstract:
The clinical outcome of 99 patients who underwent combined single-stage carotid thromboendarterectomy and coronary artery bypass grafts in three different hospitals over a 15-year period was analyzed. Coronary revascularization was elective in 16 patients, urgent in 46 and emergent in 37 patients. Asymptomatic carotid artery stenosis of greater than or equal to 80% was detected in 79% of patients. Sequential reconstruction of the carotid artery circulation followed by restoration of the coronary circulation was performed in all patients by two separate surgical teams. The population included 79 men and 20 women, with a mean age of 67 +/- 6 years, of whom 53% had a previous myocardial infarction, 59% had hypertension and 49% had a history of smoking. Three or more coronary arteries were revascularized in 90% of patients. The overall major neurological complication rate was 25%, with an 11% stroke rate ipsilateral to the operated carotid. Other major complications included respiratory failure (5%), multisystem failure (8%), and myocardial infarction (8%). The overall mortality was 12%. Ten of the 12 deaths were directly related to the cardiac operation, and 2 died as a result of stroke. We conclude that a combined carotid and coronary artery operation results in a high morbidity and mortality in institutions with excellent records for each operation when performed separately. Whenever possible, these high risk patients should be carefully assessed regarding the need for both procedures, since prophylactic carotid endarterectomy has not been shown to significantly reduce the neurologic risk of coronary bypass.