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Should we perform carotid endarterectomy synchronously with cardiac surgical procedures?
B A Perler1, J F Burdick, S L Minken
1Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD 21205.
Insights
Carotid endarterectomy (CEA) combined with cardiac surgery shows low neurologic complication rates. However, advanced age and left main coronary artery disease significantly increase mortality risk in these patients.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Surgery
Background:
- Concurrent carotid endarterectomy (CEA) and cardiac surgery is performed for patients with cerebrovascular and coronary artery disease.
- Unstable angina and left main coronary artery disease are common comorbidities in patients undergoing CEA and CABG.
Purpose of the Study:
- To evaluate the safety and outcomes of combined carotid endarterectomy and cardiac surgery.
- To identify risk factors for major neurologic complications and mortality in this patient population.
Main Methods:
- Retrospective review of 63 patients undergoing CEA concurrently with cardiac procedures (CABG, valve replacement) between 1979 and 1987.
- Analysis of patient demographics, indications for surgery, comorbidities, and postoperative outcomes, including neurologic events and mortality.
Main Results:
- Major neurologic complications occurred in 4.8% of patients, with a 3.2% perioperative stroke rate.
- Overall postoperative mortality was 11%, with significantly higher rates in patients aged 65+ (22%), those with left main coronary artery disease (19%), and men (13.3%).
- Risk factors like bilateral carotid disease and previous cerebrovascular symptoms did not increase neurologic risk.
Conclusions:
- Combined CEA and cardiac surgery can be performed with acceptable neurologic risk.
- Patient age, left main coronary artery disease, and sex are significant predictors of mortality.
- A mortality predictive index (MPI) was developed to assess individual patient risk.
Abstract:
From Jan. 1, 1979 through July 31, 1987, 63 patients had carotid endarterectomy (CEA) concurrently with cardiac surgical procedures including coronary artery bypass grafting (CABG) in 61, CABG plus mitral value replacement in one, and aortic valve replacement in one. Among the 62 patients having CABG, unstable angina had been present in 36 (58%), left main coronary artery disease in 21 (34%), and both unstable angina and left main coronary artery disease in 13 (21%). Indications for carotid surgery included previous stroke, amaurosis fugax, or hemispheric transient ischemic attacks (TIAs) in 33 patients (52%); bilaterally significant carotid disease was noted in 48% of the patients. Major neurologic complications occurred in three patients (4.8%), including perioperative stroke in two (3.2%) (fatal in one) and a TIA in a third patient. Bilateral carotid lesions, a contralateral total carotid occlusion, previous cerebrovascular symptoms, and intraaortic balloon pump support did not increase neurologic risk. Seven patients died postoperatively (11%). The mortality rate was 2.8% in patients younger than 65 years vs 22% in patients 65 years or older, 19% in patients with left main coronary artery disease vs 7.3% in patients without, 13.3% in men vs 5.6% in women, 25% in patients with a history of congestive heart failure vs 7.8% in patients without failure, and 6.2% in patients with unilateral carotid disease, 17% in patients with bilateral carotid disease, and 23% in patients with bilateral disease including a contralateral carotid occlusion. A mortality predictive index (MPI) was developed to summarize individual risk for a fatal outcome.(ABSTRACT TRUNCATED AT 250 WORDS)