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Perioperative morbidity and mortality in combined vs. staged approaches to carotid and coronary revascularization
G Giangola1, J Migaly, T S Riles
1Department of Surgery, New York University Medical Center, NY, USA.
Insights
Simultaneous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) increased stroke risk compared to staged procedures. Staging CABG before CEA is safer for patients needing both surgeries in one hospitalization.
Area of Science:
- Cardiovascular Surgery
- Neurological Surgery
- Vascular Surgery
Background:
- Patients with coronary artery disease and carotid artery stenosis often require both coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA).
- The optimal timing and sequence of these procedures during a single hospitalization remain a critical clinical question.
Purpose of the Study:
- To compare the outcomes of simultaneous versus staged CABG and CEA performed during the same hospitalization.
- To determine the safest sequence for staged procedures when both are necessary.
Main Methods:
- Retrospective review of 57 patients undergoing CEA and CABG within the same hospitalization between 1986 and 1994.
- Patients were divided into two groups: simultaneous procedures (n=28) and staged procedures (n=29).
- Staged procedures were further analyzed based on the order of CEA and CABG.
Main Results:
- Simultaneous CABG and CEA had a higher rate of neurological complications (14.3%) compared to staged procedures (3.4%).
- In staged procedures, CEA preceding CABG resulted in one stroke, five myocardial infarctions, and two deaths.
- CABG preceding CEA in staged procedures had no reported strokes, myocardial infarctions, arrhythmias, or deaths.
Conclusions:
- Simultaneous CABG and CEA are associated with increased neurological morbidity.
- When staged procedures are necessary, performing coronary artery bypass grafting before carotid endarterectomy is associated with better cardiac and neurological outcomes.
- This suggests a preferred sequence of CABG followed by CEA for patients requiring both interventions in a single hospital stay.
Abstract:
Between 1986 and 1994 we identified 57 patients who underwent carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) during the same hospitalization. Simultaneous CABG and CEA was performed in 28 patients (mean age 70.5 years, 58% male). Indications for CABG in these patients were myocardial infarction in two crescendo angina in 19, congestive heart failure in two and left main or triple-vessel coronary artery disease noted during carotid preoperative evaluation in five. Indications for CEA were transient ischemic attack (TIA) in 12, crescendo TIA in six, cerebrovascular accident (CVA) in five, and asymptomatic stenosis in five. There were no postoperative myocardial infarctions or perioperative deaths. Two patients developed atrial fibrillation, and four patients had CVAs (two were ipsilateral to the side of CEA). Twenty-nine patients underwent staged procedures (i.e., not performed concomitantly but during the same hospitalization). Indications for CABG and CEA were comparable to those in the group undergoing simultaneous procedures. In 17 patients CEA was performed before CABG. There was a single CVA, the result of an intracerebral hemorrhage. Five of the 17 patients had a myocardial infarction and two died; one patient had first-degree heart block requiring a pacemaker. Four additional patients developed atrial fibrillation, one of whom required cardioversion. The remaining 12 patients had CABG followed by CEA. There were no CVAs, myocardial infarctions, arrhythmias, or deaths in this subgroup. These data demonstrate that the performance of simultaneous CABG and CEA procedures is associated with increased neurologic morbidity (14.3%), both ipsilateral and contralateral to the side of carotid surgery in contrast to staged CABG and CEA (3.4%). In addition, when staged carotid surgery preceded coronary revascularization in those with severe coronary artery disease, the combined cardiac complication and mortality rate was significantly higher than when coronary revascularization preceded CEA. This evidence suggests that when CABG and CEA must be performed during the same hospitalization, the procedures should be staged with CABG preceding CEA.