Coexisting Coronary and Carotid Artery Disease: What We Did, What Happened
Mehmet Raşit Güney1, Erhan Güler2, Erkan Albay1
1Department of Cardiovascular Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey.
Insights
Surgical outcomes for combined coronary and carotid artery disease show similar early survival rates. However, prioritizing coronary artery bypass grafting (CABG) alone led to increased neurological events long-term.
Area of Science:
- Cardiovascular Surgery
- Neurosurgery
- Vascular Surgery
Background:
- Coexisting coronary and carotid artery disease presents a complex surgical challenge with no established consensus on optimal management strategies.
- High-risk patient populations require careful evaluation of surgical methods and long-term consequences.
Purpose of the Study:
- To retrospectively evaluate and compare the surgical results and long-term outcomes of different management strategies for patients with combined coronary and carotid artery disease.
- To identify the most effective surgical approach based on perioperative, early, and late postoperative data.
Main Methods:
- Retrospective analysis of 196 patients treated between 2005 and 2015 for combined coronary and carotid artery disease.
- Comparison of three surgical groups: staged procedures (carotid endarterectomy (CEA) or coronary artery bypass grafting (CABG) priority), simultaneous CABG and CEA, and CABG only for asymptomatic carotid lesions.
- Uni-/multivariate analyses were used to evaluate perioperative, early, and late postoperative data, including all-cause mortality, cardiovascular events, and fatal neurological events.
Main Results:
- Perioperative and early (30-day) postoperative parameters showed no significant differences between the three surgical groups.
- Long-term follow-up (average 94.9 months) revealed similar event-free actuarial survival rates when fatal neurological events were excluded (P=0.740).
- However, when all events were included, actuarial survival rates differed significantly (P=0.027), with a marked increase in neurological events observed between 34 and 66 months, particularly in the CABG-only group.
Conclusions:
- Perioperative and early survival rates are comparable across staged, simultaneous, and CABG-only surgical approaches for combined coronary and carotid artery disease.
- The strategy of performing only coronary artery bypass grafting (CABG) for patients with significant carotid stenosis was associated with a higher incidence of neurological events in the long term.
- Clinical decision-making should prioritize the 'most threatened organ' when selecting the surgical methodology for this high-risk patient cohort.
Introduction:
There is no complete consensus on the three surgical methods and long-term consequences for coexisting coronary and carotid artery disease. We retrospectively evaluated the surgical results in this high-risk group in our clinic for a decade.
Methods:
Between 2005 and 2015, 196 patients were treated for combined carotid and coronary artery disease. A total of 50 patients were operated on with the staged method, 40 of which had carotid endarterectomy (CEA) priority, and 10 had coronary artery bypass grafting (CABG) priority. CABG and CEA were simultaneously performed in 82 patients; and in 64 asymptomatic patients with unilateral carotid artery lesions and stenosis over 70%, only CABG was done (64 patients). Results were evaluated by uni-/multivariate analyses for perioperative, early, and late postoperative data.
Results:
In the staged group, interval between the operations was 2.82±0.74 months. Perioperative and early postoperative (30 days) parameters did not differ between groups (P-value < 0.05). Postoperative follow-up time was averaged 94.9±38.3 months. Postoperative events were examined in three groups as (A) deaths (all cause), (B) cardiovascular events (non-fatal myocardial infarction, recurrent angina, congestive heart failure, palpitation), and (C) fatal neurological events (amaurosis fugax, transient ischemic attack, and stroke). When group C events were excluded, event-free actuarial survival rates were similar in all three methods (P=0.740). Actuarial survival rate was significantly different when all events were included (P=0.027). Neurological events increased markedly between months 34 and 66 (P=0.004).
Conclusion:
Perioperative and early postoperative event-free survival rates were similar in all three methods. By the beginning of the 34th month, the only CABG group has been negatively separated due to neurological events. In the choice of methodology, "most threatened organ priority'' was considered as clinical parameter.
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