Combined carotid and cardiac surgery: improving the results
Emiliano Chiti1, Nicola Troisi, John Marek
1Department of Vascular Surgery, University of Florence, Florence, Italy.
Insights
Combined carotid endarterectomy and cardiac surgery increases perioperative mortality. Off-pump coronary artery bypass grafting with carotid endarterectomy offers improved outcomes, making it the preferred strategy when feasible.
Area of Science:
- Cardiovascular Surgery
- Neurosurgery
- Surgical Outcomes Research
Background:
- Analysis of a 5-year experience with combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG).
- Comparison of perioperative outcomes between 111 patients undergoing combined procedures and 1,446 patients undergoing isolated CEA.
Purpose of the Study:
- To evaluate the risks and benefits of combined carotid and cardiac surgery.
- To compare outcomes of combined CEA and CABG versus isolated CEA.
- To assess the impact of off-pump CABG on outcomes in combined procedures.
Main Methods:
- Retrospective analysis of 1,557 patients from January 2002 to December 2006.
- Comparison of neurological deficits, cardiac events, and 30-day mortality using chi(2) and Fisher's exact tests.
- Kaplan-Meier survival analysis and log-rank tests for long-term follow-up.
Main Results:
- Combined surgery group showed higher rates of postoperative neurological deficits (2.5% vs. 0.4%) and mortality (3.5% vs. 0.5%).
- No significant difference in stroke incidence, but combined stroke/myocardial infarction/death rate was higher in the combined group (6.3% vs. 1.4%).
- Off-pump CABG in the combined group significantly reduced perioperative stroke/myocardial infarction/death rates (3.3% vs. 10%). 24-month survival was lower in the combined group (91.3% vs. 99.4%).
Conclusions:
- Combined carotid and cardiac surgery is associated with increased perioperative mortality compared to isolated CEA.
- CEA combined with off-pump CABG is the preferred therapeutic strategy when both procedures are necessary.
- Careful patient selection and surgical technique are crucial for managing combined carotid and cardiac disease.
Background:
Aim of this study was to analyze our experience in the last 5 years of combined carotid and cardiac surgery.
Methods:
During a 5-year period (January 2002-December 2006), 111 patients underwent combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) (group 1), while 1,446 patients underwent isolated CEA (group 2). Perioperative outcomes in the two groups were compared using chi(2) and Fisher's exact tests to analyze neurological deficits, cardiac events, and death at 30 days. Results during follow-up were analyzed using Kaplan-Meier survival curves, and both groups were compared using the log-rank test.
Results:
Immediate postoperative neurological deficits occurred more frequently in group 1 patients (2.5 vs. 0.4%, p = 0.002), with a higher incidence of transient ischemic attacks in group 1; however, there was no difference in the incidence of stroke (1% group 1 vs. 0.6% group 2, p = n.s.). Mortality rate was increased in the combined surgery group (3.5 vs. 0.5%, p < 0.001). Combined stroke/myocardial infarction/death rate at 30 days was 6.3% in group 1 compared with 1.4% in group 2, p = 0.001. Perioperative stroke/myocardial infarction/death rate was much improved in the 55% (61/111) of patients undergoing CABG off-pump (3.3 vs. 10%, p = 0.001). Mean follow-up was 18.7 months (range, 1-60). Survival at 24 months was significantly higher in patients of group 2 compared with group 1 (99.4 vs. 91.3% respectively, p < 0.001). At 24 months, there was no significant difference between the two groups in the risk of developing ipsilateral or contralateral neurologic events (3.1% group 1 vs. 1.7% group 2).
Conclusion:
In our experience, combined CEA and cardiac surgery carries a higher risk of perioperative mortality than patients undergoing isolated CEA. Whenever possible, CEA combined with off-pump CABG seems to be the therapeutic strategy of choice.
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