Carotid endarterectomy can be safely performed with acceptable mortality and morbidity in patients requiring coronary artery bypass grafts

doi:10.1016/S0002-9610(94)80043-X

The American Journal of Surgery

Volume 168, Issue 2, August 1994, Pages 94-96

https://doi.org/10.1016/S0002-9610(94)80043-X Get rights and content

background:

Patients undergoing the placement of coronary artery bypass grafts (CABG) with hemodynamically significant carotid artery lesions pose a difficult problem for both cardiac and vascular surgeons. Despite numerous studies, there has been no consensus of opinion as to the proper management of these patients. In numerous series, the combined mortality and perioperative stroke rates in concomitant carotid endarterectomy and CABG procedures have ranged from 8% to 40%. This has made many surgeons consider staging these procedures.

methods:

Retrospective analysis of patients undergoing combined carotid endarterectomies and CABG from 1980 to 1993 were reviewed. Two hundred six procedures were performed in 189 patients. Seventeen patients had bilateral carotid endarterectomy performed with CABG. The average age of our patient population was 66 years, with 123 being male and 66 being female. Seventy-five percent of the patients were asymptomatic with the remainder having transient ischemic attacks, amaurosis fugax, or prior stroke.

results:

Operative mortality was 2%, with three of four patients dying of cardiac failure and one of a stroke. A temporary neurologic deficit was seen in 2% of patients, and a permanent neurologic deficit was seen in 2 of 206, or 1%. Thirty shunts were used in this series, mostly in patients with contralateral carotid occlusion. All procedures were performed under general anesthesia with full invasive monitoring. One patient was re-explored for bleeding, and one patient had a temporary hypoglossal palsy. A total of 203 cases had the arteriotomies closed primarily, and 3 required patches.

conclusion:

In our experience, simultaneous carotid endarterectomy and CABG can be performed with an acceptable mortality and morbidity and does not appear to put the patient at an increased risk. Staging of these procedures may not be necessary in most cases.

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Cited by (53)

Stroke after Cardiac surgery and its association with asymptomatic carotid disease: An updated systematic review and meta-analysis
2011, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
In the third systematic review, 141 studies2,5,10,14,15,18,20–22,29,38,77–172 reported stroke rates following synchronous unilateral carotid/cardiac procedures and were eligible for inclusion; of which 3520–22,30,37,46–76 fulfilled the pre-specified inclusion criteria (rates of contralateral stroke documented, extent of contralateral carotid disease documented, outcomes reported separately for contralateral stenosis and occlusion, no bilateral CEAs, >5 cases with bilateral severe disease reported). One hundred and five studies2,10,14,15,18,27–29,37,41,76–172 were excluded following a review of the data; 63 provided no data regarding rates of contralateral stroke,2,10,14,15,26–28,77–135 while eleven did report contralateral stroke rates separately, but did not then correlate these strokes with patterns of contralateral carotid disease.135–145 Four provided rates of contralateral stroke, but did not discriminate between contralateral occlusion and stenosis.53,146–148
(i) Prevalence of stroke in neurologically symptomatic/asymptomatic patients with unilateral/bilateral carotid disease (including occlusion) undergoing cardiac surgery without prophylactic carotid endarterectomy (CEA) or carotid stenting (CAS). (ii) Prevalence of stroke in asymptomatic patients with unilateral/bilateral carotid disease (excluding occlusion) who underwent isolated cardiac surgery. (iii) Prevalence of stroke in the hemisphere ipsilateral to a non-operated asymptomatic stenosis in patients with severe bilateral carotid disease undergoing a synchronous unilateral CEA + cardiac procedure.
Systematic Review and meta-analysis.
Cardiac surgery patients with a symptomatic/asymptomatic 50–99% stenosis or occlusion incurred a 7.4% stroke risk (95%CI 4.8–9.9), increasing to 9.1% (95%CI 4.8–16) in those with 80–99% stenoses or occlusion. After excluding patients with a history of stroke/TIA and those with isolated/bilateral occlusions, the stroke risk fell to 3.8% (95%CI 2.0–4.8) in patients with asymptomatic 50–99% stenoses and 2.0% in those with 70–99% stenoses (95%CI 1.0–5.7). The prevalence of ipsilateral stroke in patients with a unilateral, asymptomatic 50–99% stenosis was 2.0% (1.0–3.8), while the risk of any stroke was only 2.9% (2%–5.7%). These risks did not increase with stenosis severity (70–99%, 80–99%). Patients with bilateral, asymptomatic 50–99% stenoses or a 50–99% stenosis + contralateral occlusion incurred a 6.5% stroke risk following cardiac surgery, while the risk of death/stroke was 9.1% (3.8%–20.6%). Patients with bilateral 80–99% stenoses undergoing a unilateral synchronous cardiac/carotid revascularisation incurred a 5.7% risk of stroke in the hemisphere ipsilateral to the non-operated, contralateral stenosis.
There is no compelling evidence supporting a role for prophylactic CEA/CAS in cardiac surgery patients with unilateral asymptomatic carotid disease. Prophylactic CEA/CAS might still be considered in patients with severe, bilateral asymptomatic carotid disease, but such a strategy would only benefit 1–2% of all cardiac surgery patients.
Combined carotid endarterectomy and coronary artery bypass grafting in patients with asymptomatic high-grade stenoses: An analysis of 758 procedures
2006, Journal of Vascular Surgery
Surgical treatment of hemodynamically significant carotid artery stenoses has been well documented, especially in the asymptomatic patient. However, in those patients presenting with hemodynamically significant asymptomatic carotid artery disease who are to undergo cardiac surgery, optimal treatment remains controversial. In this study, we analyze our experience with patients who underwent synchronous carotid endarterectomy (CEA) and coronary artery bypass graft procedures (CABG) for hemodynamically significant (>70%) asymptomatic carotid artery stenosis and coronary artery disease (CAD).
Demographics and outcomes of all patients undergoing synchronous CEA/CABG for asymptomatic carotid stenosis between April 1980 and January 2005 were reviewed from our vascular registry and patient charts. We included patients who underwent standard patching of their carotid artery and those undergoing eversion CEA. All neurologic events within the first 30 days that persisted >24 hours were considered a stroke. For purposes of comparison, we also reviewed outcomes for patients undergoing synchronous CEA/CABG for symptomatic carotid stenosis.
Asymptomatic carotid artery stenosis (>70%) was the indication in 702 patients (276 women and 426 men) undergoing 758 CEAs. In the asymptomatic group, 22patients, of which 21 succumbed to cardiac dysfunction, and one died from a hemorrhagic stroke. The overall mortality rate was 3.1%. Seven permanent nonfatal neurologic deficits occurred in this series (1 woman, 6 men). The combined stroke mortality was 4.3%. This compares to a 30-day stroke mortality of 6.1% in 132 symptomatic combined CEA/CABG patients. The difference in stroke mortality in women compared with men was not significant.
In this experience, patients presenting with hemodynamically significant (>70%) asymptomatic carotid artery stenosis can undergo synchronous CEA/CABG with low morbidity and mortality.
Case 1 - 2005: Cardiac surgery in congenital afibrinogenemia with thrombo-occlusive disease
2005, Journal of Cardiothoracic and Vascular Anesthesia
A systematic review of outcome following synchronous carotid endarterectomy and coronary artery bypass: Influence of surgical and patient variables
2003, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
Fifteen were excluded.96-110 Reasons included; inability to obtain a copy of the manuscript,96 while nine were subsequently updated with larger numbers. 97-105 If, however, any included data useful for subgroup analyses (i.e. not in the updated paper), these were included in the analysis.
Objectives: outcomes after synchronous carotid endarterectomy (CEA) plus coronary artery bypass (CABG) relative to surgical and patient based variables. Design: systematic review of 94 published series (7863 synchronous procedures). Results: 11.5% of patients died or suffered a stroke/myocardial infarction in the peri-operative period (95% CI 10.1-12.9). The risk of death/stroke appeared to significantly diminish in studies published between 1993-2002, compared with 1972-1992 (7.2% (95% CI 6.5-9.1) versus 10.7% (95% CI 8.9-12.5), p = 0.03). However, increasing operative experience was not associated with significantly lower risks of death/stroke; (1-49 cases (9.6% (95% CI 7.5-11.8); 50-99 cases (9.1% (95% CI 6.4-11.8); 100+ cases (8.4% (95% CI 6.9-10.1) (p = 0.64)). Patients with severe bilateral carotid disease were significantly more likely to suffer death and/or stroke compared to patients with unilateral disease (odds ratio 2.5, 95% CI 1.4-5.0, p = 0.001). Similarly, patients with a prior history of stroke/transient ischaemic attack (TIA) were significantly more likely to suffer a further stroke than asymptomatic patients (odds ratio 1.8, 95% CI 1.1-2.8, p = 0.008). There was no difference in the risk of death/stroke relative to the timing of CEA (pre- versus on-cardiopulmonary bypass), but recent small studies indicate that improved outcomes might be achieved by performing CABG ‘off-bypass’. Conclusions: synchronous CEA + CABG is associated with a not insignificant cardiovascular risk. No comparable information is available for similar patients undergoing CABG without prophylactic CEA.
Eur J Vasc Endovasc Surg 26, 230-241 (2003)
A systematic review of outcomes following staged and synchronous carotid endarterectomy and coronary artery bypass
2003, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
Patients undergoing cardiac valvular reconstructions or carotid reconstructions other than endarterectomy (e.g. aorto-carotid bypass) were excluded. One hundred and twelve series were identified for inclusion.2-113 Fifteen were subsequently excluded.99-113
Objectives: to determine the overall cardiovascular risk for patients with combined cardiac and carotid artery disease undergoing synchronous coronary artery bypass (CABG) and carotid endarterectomy (CEA), staged CEA then CABG and reverse staged CABG then CEA. Design: systematic review of 97 published studies following 8972 staged or synchronous operations. Results: mortality was highest in patients undergoing synchronous CEA + CABG (4.6%, 95% CI 4.1-5.2). Reverse staged procedures (CABG − CEA) were associated with the highest risk of ipsilateral stroke (5.8%, 95% CI 0.0-14.3) and any stroke (6.3%, 95% CI 1.0-11.7). Peri-operative myocardial infarction (MI) was lowest following the reverse staged procedure (0.9%, 95% CI 0.5-1.4) and highest in patients undergoing staged CEA − CABG (6.5%, 95% CI 3.2-9.7). The risk of death ± any stroke was highest in patients undergoing synchronous CEA + CABG (8.7%, 95% CI 7.7-9.8) and lowest following staged CEA − CABG (6.1%, 95% CI 2.9-9.3). The risk of death/stroke or MI was 11.5% (95% CI 10.1-12.9) following synchronous procedures versus 10.2% (95% CI 7.4-13.1) after staged CEA then CABG. Conclusions: 10-12% of patients undergoing staged or synchronous procedures suffered death or major cardiovascular morbidity (stroke, MI) within 30 days of surgery. Overall, there was no significant difference in outcomes for staged and synchronous procedures and no comparable data for patients with combined cardiac and carotid disease not undergoing staged or synchronous surgery.
Eur J Vasc Endovasc Surg 25, 380-389 (2003)
Multistate population-based outcomes of combined carotid endarterectomy and coronary artery bypass
2003, Journal of Vascular Surgery
Objectives: The management of combined carotid and coronary disease is controversial, and the outcomes of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) have not been determined on a community-wide basis. This study was undertaken to evaluate the community-wide outcomes of combined CEA and CABG and to evaluate the risk for adverse events. Methods: A complete medical record review of 10,561 CEA procedures randomly selected from Medicare patients undergoing CEA in 10 states was performed. In this sample, 226 procedures were performed in combination with CABG in the same operative event. Results: Recent ipsilateral stroke or transient ischemic attack was the indication for the CEA in only 12% of patients undergoing CEA/CABG, and 56% were asymptomatic with respect to the carotid lesion. The combined stroke and death rate was 17.7% (25 nonfatal strokes, two fatal strokes, and 13 nonstroke deaths). Eighty percent of the nonfatal strokes were disabling. Proximal aortic arch atherosclerosis and symptomatic carotid stenosis were associated with stroke (P <.05). Female gender, emergent operation, redo CABG, blood pressure on pump, total pump time, presence of left main disease, and number of diseased coronaries were associated with mortality (P <.05). The strokes appeared to be associated with the operative event, but diagnosis was delayed and postevent carotid patency was not documented. Most strokes were not limited to the hemisphere ipsilateral to the CEA. Conclusion: The community-wide outcomes of combined CEA/CABG in the Medicare population are inferior to those reported in many single-institution reviews. Diagnosis of postoperative stroke is often delayed, and most strokes are not limited to the hemisphere ipsilateral to the CEA operative site. (J Vasc Surg 2003;37:32-9.)

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^*: Presented at the 22nd Annual Meeting of the Society for Clinical Vascular Surgery, Tucson, Arizona, March 2–6, 1994.

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Scientific PaperCarotid endarterectomy can be safely performed with acceptable mortality and morbidity in patients requiring coronary artery bypass grafts*

background:

methods:

results:

conclusion:

J Vasc Surg

J Vasc Surg

J Vasc Surg

J Vasc Surg

J Vasc Surg

J Vasc Surg

J Vasc Surg

J Thorac Cardiovasc Surg

The risk of stroke in patients with asymptomatic carotid stenosis undergoing cardiac surgery. A follow-up study

J Vasc Surg

Current concepts in coronary artery surgery: a critical analysis of 1287 patients

Ann Thorac Surg

Scientific Paper
Carotid endarterectomy can be safely performed with acceptable mortality and morbidity in patients requiring coronary artery bypass grafts*