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Staged and combined surgical approach to simultaneous carotid and coronary vascular disease
Insights
For patients with simultaneous carotid and coronary atherosclerosis, staged surgical repair is recommended when feasible. Combined procedures carry a higher risk of stroke, especially with severe cardiac disease.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Surgery
Background:
- Simultaneous carotid and coronary atherosclerosis presents a complex surgical challenge.
- Optimal management strategies for patients with both conditions require careful consideration of risks and benefits.
Purpose of the Study:
- To evaluate the outcomes of staged versus combined surgical procedures for simultaneous carotid and coronary atherosclerosis.
- To assess the incidence of stroke and mortality in patients undergoing these interventions.
Main Methods:
- Retrospective analysis of 174 patients treated between 1969 and 1976.
- Comparison of outcomes between staged carotid endarterectomy followed by myocardial revascularization and combined carotid endarterectomy and myocardial revascularization.
Main Results:
- Staged procedures (n=59) had a low stroke rate (1.5% after carotid endarterectomy) and early mortality (1.7%).
- Combined procedures (n=115) had a higher stroke rate (4.3%) and early mortality (4.3%), particularly in patients with contralateral carotid disease.
- No deaths were attributed to carotid repair in the combined group.
Conclusions:
- Staged surgical correction is generally preferred for simultaneous carotid and coronary atherosclerosis.
- Combined procedures may be considered in selected patients with severe cardiac disease, acknowledging the increased stroke risk.
Abstract:
Between 1969 and 1976, 174 patients were treated surgically for simultaneous carotid and coronary atherosclerosis. In 59 patients, staged carotid endarterectomy was performed a few days to 6 months prior to myocardial revascularization. Severe (more than 60% stenosis) coronary atherosclerosis affected a single vessel in 11 patients (19%), two vessels in 20 patients (34%), and three vessels in 28 patients (47%). Left ventricular contraction was impaired in 30 patients (51%). Nine patients (15%) had previous neurological symptoms, and 50 patients (85%) had asymptomatic carotid stenosis. One patient (1.5%) had a permanent stroke after carotid endarterectomy. There were no permanent strokes after staged myocardial revascularization, and the early mortality rate was 1.7%. Combined carotid endarterectomy and myocardial revascularization were performed in 115 patients with severe cardiac disease. Coronary atherosclerosis affected a single vessel in 10 patients (9%), two vessels in 39 patients (34%), and three vessels in 66 patients (57%). Left ventricular impairment was present in 72 patients (63%). Thirty-five patients (30%) had previous neurological symptoms, and 80 patients (70%) had asymptomatic carotid stenosis. Five patients (4.3%) had permanent strokes after combined revascularization, and four of these patients had occlusion or severe stenosis of the contralateral internal carotid artery. The early mortality rate was 4.3%, but no deaths could be attributed to carotid repair. The results suggest that significant simultaneous carotid and coronary atherosclerosis should be corrected in selected patients by staged operations when feasible. In the presence of severe cardiac disease, a combined precedure may be performed in face of higher risk of intraoperative stroke.