Morbidity and mortality associated with carotid endarterectomy: effect of adjunctive coronary revascularization

The occurrence of significant carotid disease in patients requiring coronary revascularization results in the dilemma of whether simultaneous or staged operations should be performed. To determine appropriate therapy we reviewed this experience at Emory University Hospital. During a 10-year period from 1983 to 1992, 110 patients underwent carotid endarterectomy during the same hospitalization or simultaneously with coronary artery bypass; 907 patients underwent carotid endarterectomy alone during the same period. The combined 30-day postoperative stroke and death rate was 18.2% for the 110 patients undergoing concomitant procedures. When comparing morbidity and mortality rates for those having simultaneous carotid endarterectomy and coronary artery bypass with those having delayed coronary artery bypass, the latter group was found to have a 6.6% combined risk of postoperative stroke or death within 30 days, whereas those undergoing simultaneous procedures had a 26.2% rate. In the control group of 907 patients undergoing carotid endarterectomy alone during the same period, the combined 30-day mortality and stroke morbidity rate was 2.1%. Although the patient population undergoing simultaneous carotid and coronary revascularization may have more severe disease, we believe that combining the procedures during the same operative setting results in an increased perioperative stroke and death rate. Consequently only extremely high-risk patients are selected for simultaneous procedures; otherwise our experience suggests that delaying coronary artery bypass by several days will reduce overall postoperative mortality and stroke morbidity.