Safety and efficacy of concomitant carotid and coronary artery operations

Controversy exists concerning the best management for patients with concurrent severe carotid and coronary artery disease.

The records of 200 consecutive patients having concurrent carotid endarterectomy and coronary artery bypass grafting from 1979 to 1993 were reviewed, and follow-up was obtained (99% complete). Of the group (77% male; mean age, 67 years), 134 (67%) had unstable angina, 130 (65%) had triple-vessel disease, and 86 (43%) had left main coronary stenosis. Preoperative investigation revealed asymptomatic bruits in 116 (58%), transient ischemia in 65 (32%), strokes in 31 (16%), and bilateral carotid disease in 44 patients (22%). Nonelective operations were required in 66 patients (33%).

Hospital death occurred in 7 patients (3.5%), myocardial infarction in 5 (2.5%), and permanent stroke in 6 (3%). Ten-year actuarial event-free rates were as follows: death, 58%; myocardial infarction, 81%; stroke, 92%; percutaneous angioplasty, 98%; redo coronary artery grafting, 94%; and all morbidity and mortality, 56%. Significant multivariate predictors of hospital death were postoperative stroke, failure to use an internal mammary artery graft, intraoperative intraaortic balloon, and nonelective operation. Significant predictors of postoperative stroke were peripheral vascular disease and unstable angina. Significant predictors of prolonged hospital stay were postoperative stroke, advanced age, and nonelective operation.

Concomitant carotid endarterectomy and coronary bypass grafting can be performed with acceptably low operative risk and good long-term freedom from coronary and neurologic events.