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Simultaneous carotid endarterectomy and coronary artery bypass grafting: results in specific patient groups
Panagiotis Kougias1, Jeffrey R Kappa, David H Sewell
1Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 1709 Dryden Street, Houston, TX 77030, USA. p_kougias@hotmail.com
Insights
Synchronous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) is a safe procedure for select patients with combined cerebrovascular and coronary artery disease. This combined surgery demonstrated acceptable mortality and stroke rates, justifying its use in carefully selected patient groups.
Area of Science:
- Cardiovascular Surgery
- Cerebrovascular Surgery
- Vascular Disease Management
Background:
- Coexistent carotid and coronary artery disease poses a significant management challenge.
- Synchronous procedures aim to address both conditions simultaneously, potentially improving patient outcomes.
- Evaluating the safety and efficacy of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) is crucial.
Purpose of the Study:
- To assess the safety and outcomes of performing simultaneous CEA and CABG in patients with severe carotid stenosis and coronary artery disease.
- To compare the risks of stroke, myocardial infarction, and mortality in patients undergoing combined procedures versus CABG alone.
Main Methods:
- Retrospective analysis of 8,277 patients undergoing CABG between 1981 and 2003.
- Identification of 277 patients (3.34%) with severe (>70%) carotid stenosis, divided into unilateral, bilateral, or contralateral occlusion subgroups.
- Comparison of outcomes (mortality, stroke, myocardial infarction, hospital stay) between the combined CEA-CABG group and a control group undergoing CABG only.
Main Results:
- Overall combined mortality for CEA-CABG was 3.61% versus 1.7% for CABG alone (P > 0.1).
- Stroke rate in the combined group was 2.8%, with higher rates in specific subgroups (e.g., 13.64% in contralateral occlusion).
- History of stroke and age 70-80 were key predictors of adverse postoperative events.
Conclusions:
- Simultaneous CEA and CABG is a justified procedure for carefully selected patients with concomitant severe carotid and coronary artery disease.
- While overall mortality was similar to CABG alone, specific subgroups experienced higher stroke rates, highlighting the need for careful patient selection.
- The study supports the use of combined surgery, emphasizing the importance of considering patient-specific risk factors like prior stroke and advanced age.
Abstract:
We examined the safety of performing synchronous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) in specific groups of patients with coexistent cerebral and coronary vascular disease. Between 1981 and 2003, 8,277 patients who underwent CABG in our institution had noninvasive screening for carotid disease. Two hundred seventy-seven (3.34%) patients were found to have severe (>70%) carotid stenosis. This patient population was divided into three subgroups: group A had unilateral carotid disease (n = 200), group B had bilateral carotid disease (n = 55), and group C had contralateral carotid occlusion (n = 22). In 29 patients (10.4%), the carotid disease was symptomatic. A simultaneous CABG and CEA was performed in all three subgroups. Patients in group B underwent initially repair of the most dominant lesion, soon followed by contralateral CEA. Patients who underwent only CABG (n = 8,000) served as controls. Overall combined hospital mortality regardless of etiology for the combined group was 3.61% vs. 1.7% for the patients who had CABG only (P > 0.1). The stroke and/or myocardial infarction-associated mortality for the simultaneous CEA-CABG group was 2.52%. There were six deaths in group A (3%), two in group B (3.6%), and two in group C (9.09%). Early stroke complicated the course of four (2%) patients in group A, one (1.8%) patient in group B, and three (13.64%) patients in group C compared to a stroke rate of 1.28% in controls. Overall stroke rate in the combined group was 2.8%. History of previous stroke and age 70-80 were the most important predictors of postoperative stroke and death. In the combined surgery group, the postoperative myocardial infarction rate was 0.72% vs. 0.58% in the control group. The mean length of hospital stay was 9 days for patients who had the combined procedure vs. 8.1 days for patients who had CABG only. Use of the combined procedure for patients with concomitant carotid and coronary artery disease was justified in the patients under study.
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