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Concomitant severe carotid and coronary artery diseases: a separate management or concomitant approach
Jeffrey Shi Kai Chan1,2, Ahmed Mohamed Abdel Shafi3, Ciaran Grafton-Clarke4
1Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
Insights
Staged carotid endarterectomy (CEA) before coronary artery bypass grafting (CABG) is associated with lower postoperative stroke, operative, and 30-day mortality compared to simultaneous procedures. Further research, such as a randomized controlled trial, is needed to confirm these findings.
Area of Science:
- Cardiovascular Surgery
- Neurosurgery
- Vascular Surgery
Background:
- Patients with asymptomatic carotid artery disease (>80% stenosis) often require coronary artery bypass grafting (CABG).
- The optimal timing for performing carotid endarterectomy (CEA) in relation to CABG remains a subject of clinical debate.
- Both staged and simultaneous approaches carry potential risks and benefits that necessitate careful evaluation.
Purpose of the Study:
- To systematically compare postoperative outcomes between staged CEA followed by CABG and simultaneous CEA and CABG.
- To analyze differences in stroke, myocardial infarction (MI), and mortality rates between the two procedural approaches.
- To provide evidence-based insights for clinical decision-making in patients requiring both CEA and CABG.
Main Methods:
- A comprehensive literature search was conducted across MEDLINE, Scopus, EMBASE, and Ovid up to August 2018.
- Included studies compared staged CEA-CABG versus simultaneous CEA-CABG.
- Primary outcome was postoperative stroke; secondary outcomes included MI and 30-day mortality.
Main Results:
- Analysis of 67,953 patients revealed higher stroke rates (3.64% vs 2.83%), operative mortality (4.32% vs 3.58%), and 30-day mortality (4.40% vs 3.58%) in the simultaneous cohort.
- The staged cohort had a higher rate of previous stroke (2.64% vs 2.32%).
- No significant differences were observed in 1-year mortality, MI rates, or transient neurological deficits; the simultaneous cohort had a shorter length of stay.
Conclusions:
- Staged CEA followed by CABG demonstrates a lower incidence of postoperative stroke, operative mortality, and 30-day mortality.
- The findings suggest a potential benefit of the staged approach in managing patients with concomitant severe carotid stenosis and coronary artery disease.
- A large-scale randomized controlled trial is warranted to definitively establish the superiority of either the staged or simultaneous technique.
Objective:
To systematically compare outcomes between patients with asymptomatic carotid artery diseases (>80% stenosis) that had undergone staged carotid endarterectomy (CEA) before coronary artery bypass grafting (CABG) vs simultaneous CEA and CABG.
Methods:
A comprehensive electronic search of MEDLINE, Scopus, EMBASE, and Ovid from their inception up till August 2018 was performed to identify all studies comparing staged CEA followed by CABG to simultaneous CEA and CABG. Primary outcome measure was postoperative stroke, and secondary measures were myocardial infarction (MI) and 30-day mortality rates.
Results:
A total of 67 953 patients were analyzed from 11 articles. There was higher rate of previous stroke in the staged cohort (2.64% vs 2.32%; odds ratio [OR], 0.81; 95% confidence interval [CI; 0.66, 0.99]; P = .040). There was no difference in previous MI (P = .57) or unstable angina (P = .08) among both cohorts. Postoperatively, there were higher stroke rates (3.64% vs 2.83%; OR, 0.72; 95% CI [0.62-0.89]; P < .0001), operative mortality (4.32% vs 3.58%; OR, 0.90; 95% CI [0.83-0.98]; P = .02), and 30-day mortality (4.40% vs 3.58%; OR, 0.86; 95% CI [0.78-0.96]; P = .006) in the simultaneous cohort. However, length of stay was significantly shorter in the simultaneous cohort (11.9 days vs 12.6 days; weighted mean difference 3.14 [0.77-5.51]; P = .009). There were no significant differences in 1-year mortality (P = .33), MI rates (P = .08), and rates of transient neurological deficits (P = .06).
Conclusion:
The results from this study favors staged CEA with CABG with lower incidence of postoperative stroke, operative, and 30-day mortality. A larger study, ideally a randomized controlled trial, is required to address the superiority of each technique.
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