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Concomitant carotid and coronary artery reconstruction
Insights
Concomitant carotid endarterectomy and coronary artery bypass surgery (CECAB) offers similar outcomes to coronary artery bypass surgery (CAB) alone for patients with carotid stenosis. This combined approach demonstrates low mortality and improved angina symptoms, supporting its use in appropriate patients.
Area of Science:
- Cardiovascular Surgery
- Cerebrovascular Surgery
- Interventional Cardiology
Background:
- Patients undergoing coronary artery bypass surgery (CAB) often present with co-existing carotid artery disease.
- The optimal management strategy for patients requiring both procedures remains a subject of investigation.
- Carotid stenosis can significantly increase the risk of perioperative stroke in patients undergoing cardiac surgery.
Purpose of the Study:
- To evaluate the safety and efficacy of concomitant carotid endarterectomy (CE) and coronary artery bypass surgery (CAB) compared to CAB alone.
- To assess perioperative outcomes, long-term survival, and symptom improvement in patients undergoing combined versus isolated CAB procedures.
Main Methods:
- A retrospective analysis of 68 patients who underwent concomitant carotid endarterectomy and coronary artery bypass surgery (CECAB) from 1974-1981.
- Comparison with a matched control group of 84 patients who underwent coronary artery bypass surgery (CAB) alone during the same period.
- Data collected included patient demographics, preoperative conditions, surgical procedures, perioperative complications, and long-term follow-up.
Main Results:
- No hospital mortality was observed in the CECAB group.
- Perioperative myocardial infarction (MI) occurred in 2.0% and stroke with residual deficit in 1.3% in the CECAB group.
- Cumulative survival was 98.5% at two years, with 92% reporting improvement or elimination of anginal symptoms.
- No significant differences were found between the CECAB and CAB alone groups in terms of sex, angina, ventricular function, coronary anatomy, perioperative stroke or MI, mortality, or postoperative activity.
- Older age and less complete coronary revascularization were noted in the CECAB group.
Conclusions:
- Concomitant carotid endarterectomy and coronary artery bypass surgery can be performed with acceptable risk and comparable results to coronary artery bypass surgery alone.
- The study supports the simultaneous correction of significant carotid stenosis in patients undergoing coronary artery bypass surgery.
- This combined approach effectively addresses both coronary and cerebrovascular disease, improving patient outcomes.
Abstract:
Data are presented on 68 patients who underwent concomitant carotid endarterectomy (CE) and coronary artery bypass surgery (CAB) at Emory University Hospital from January 1974 to February 1981. This group is then compared with a randomly selected, matched population without known carotid disease who underwent CAB alone. Asymptomatic bruit was the reason for investigation in 40 patients (59%); another 23 patients (34%) experienced transient cerebral ischemic attacks (TIAs); and five patients (7%) had TIA and prior stroke. Carotid stenoses (>75% luminal narrowing) were demonstrated as follows: isolated left, 24 patients; isolated right, 27 patients; and bilateral lesions, 16 patients. One patient had innominate artery stenosis. Associated total occlusion of one or both vertebral arteries was demonstrated in six patients. Ninety-seven per cent of patients had disabling angina pectoris prior to operation; the angina was unstable in 57%, 15% had congestive heart failure, and 54% had had at least one prior myocardial infarction (MI). Single-vessel coronary disease was present in 12.5% of patients, double in 37.5%, triple in 41.1%, and left main stenosis in 9%; 43% of patients had abnormal ventricular contractility. CE was performed on 67 patients (36 left and 31 right); aortocarotid bypass was performed on one. The CE procedures were performed immediately prior to the sternotomy for CAB under the same anesthesia. CAB consisted of single bypass in eight patients (11.8%); double in 16 patients (23.5%); triple in 22 patients (32.4%); and quadruple or more in 22 patients (32.4%) (mean = 2.9 grafts per patient). There was no hospital mortality. Perioperative MI occurred in 2.0% and stroke with residual deficit in 1.3%. Cumulative survival is 98.5% at two years. Sixty-three patients (92%) reported improvement or elimination of anginal symptoms after operation. Rehospitalization for stroke was necessary in 3.7% patients. Postoperative activity levels are; self-care only, 3.9%; normal daily activity only, 17.6%; moderate exercise capability, 45%; and vigorous exercise capability, 33%. Comparison was made with a group of 84 randomly selected patients who underwent CAB alone during the same time interval. Data revealed no significant difference between the groups regarding sex, angina subset, ventricular function, coronary anatomy, vessels grafted, perioperative stroke or MI, mortality, or postoperative activity capability. Older age (59.8 vs. 55.6, p < 0.01) and less complete coronary revascularization possible (66 vs. 84%, p < 0.05) in the CECAB group were the only significant differences. Carotid stenosis co-existing in patients requiring CAB should be concomitantly corrected with the same risk and results expected from CAB alone.