Concomitant carotid endarterectomy and cardiac surgery does not decrease postoperative stroke rates
Derek Klarin1, Virendra I Patel2, Shuaiqi Zhang3
1Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla.
Insights
Combining carotid endarterectomy (CEA) with coronary artery bypass grafting (CABG) did not significantly reduce stroke risk compared to CABG alone. This combined approach may increase morbidity and length of stay in on-pump procedures.
Area of Science:
- Cardiovascular Surgery
- Neurosurgery
- Vascular Surgery
Background:
- The optimal timing for revascularization in patients with both carotid artery stenosis and coronary artery disease is debated.
- Evaluating the outcomes of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) is crucial for clinical decision-making.
Purpose of the Study:
- To assess the association between combined CEA and CABG versus CABG alone with postoperative outcomes.
- To analyze data from the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database.
Main Methods:
- Patients undergoing CABG with >80% carotid stenosis from 2011-2016 were identified.
- Propensity score matching was used to compare outcomes between combined CABG-CEA and CABG-only groups, stratified by on-pump vs. off-pump procedures.
- Primary endpoints included 30-day mortality, in-hospital stroke, and transient ischemic attack; secondary endpoints included STS morbidity composite events and length of stay.
Main Results:
- In on-pump procedures, combined CABG-CEA showed no difference in stroke rates but had higher STS morbidity composite events and longer hospital stays compared to CABG-only.
- Off-pump CABG-CEA also demonstrated no significant difference in stroke rates compared to off-pump CABG-only.
- No significant difference in 30-day mortality was observed for either on-pump or off-pump combined procedures.
Conclusions:
- A combined CABG-CEA approach does not appear to offer significant stroke reduction benefits over CABG alone.
- The combined approach may be associated with increased morbidity and longer hospital stays in on-pump settings.
- Further research comparing combined procedures with staged approaches is warranted.
Objective:
The timing of operative revascularization for patients with concomitant carotid artery stenosis and coronary artery disease remains controversial. We examined the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database to evaluate the association of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) with postoperative outcomes.
Methods:
All patients undergoing CABG with known carotid stenosis of >80% were identified from 2011 to 2016. Individuals were stratified by use of cardiopulmonary bypass and whether a concomitant CEA was performed at the time of CABG. Multivariate logistic regression was used to model the probability of combined CABG and CEA. The resulting propensity scores were used to match individuals on the basis of clinical and operative characteristics to evaluate primary (30-day mortality and in-hospital transient ischemic attack and stroke) and secondary (STS morbidity composite events and length of stay) end points, with P < .05 required to declare statistical significance.
Results:
After propensity score matching, 994 off-pump CABG patients (497 CABG only and 497 CABG-CEA) and 5952 on-pump CABG patients (2976 CABG only and 2976 CABG-CEA) were identified. For patients who received on-pump operations, those undergoing CABG-CEA had no observed difference in rate of in-hospital stroke (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.72-1.21; P = .6), higher incidence of STS morbidity composite events (OR, 1.15, 95% CI, 1.01-1.31; P = .03), longer length of stay (7.0 [interquartile range, 5.0-9.0] days vs 6.0 [interquartile range, 5.0-9.0] days; P < .005), and no observed difference in 30-day mortality (OR, 1.28; 95% CI, 0.97-1.69; P = .08) compared with those undergoing CABG only. For off-pump procedures, CABG-CEA patients had no observed difference in rate of in-hospital stroke (OR, 0.80; 95% CI, 0.37-1.69; P = .56) compared with those undergoing CABG only.
Conclusions:
Whereas the differences are relatively small, these data suggest that a combined CABG-CEA approach is unlikely to provide significant stroke reduction benefit compared with CABG only. However, comparison with staged approaches merits further investigation.
More Related Videos
Related Concept Videos
01:28Cardiomyopathy VII: Pre and Post Operative Nursing Management
01:22Aneurysm IV: Nursing Management
01:28Cardiac Catheterization I: Pre-Procedure Overview
01:28Imaging Studies for Cardiovascular System V: CT
01:26Cardiac Catheterization IV: Nursing Management
01:26Aneurysm III: Interprofessional Care