Elsevier

Cardiovascular Surgery

Volume 6, Issue 5, October 1998, Pages 448-452
Cardiovascular Surgery

Combined carotid endarterectomy and coronary artery bypass grafting does not increase the risk of perioperative stroke1

https://doi.org/10.1016/S0967-2109(98)00030-1Get rights and content

Abstract

Patients who present for coronary artery bypass grafting with hemodynamically significant carotid artery lesions pose a difficult problem for both the cardiac and vascular surgeons. There is no consensus as to the proper management of these patients despite numerous studies. Prospective collection of data was performed in patients undergoing combined carotid endarterectomy and coronary artery bypass grafting's from April 1980 to November 1996. A total of 470 simultaneous carotid endarterectomy's and coronary artery bypass grafting's were performed in 420 patients. The average age of the patient was 69 years, with 62% being male, 15% being diabetic and 38% being smokers. Sixty (13%) presented with Transient ischemic attacks, 22 (5%) presented with amaurosis fugax, 16 (3.4%) presented with a prior history of stroke and 372 (70%) were asymptomatic. Operative mortality was 2.4% or 10 patients; 90% of those patients died from cardiac complications postoperatively and one patient died of a stroke. Permanent neurological deficits occurred in five (1%) of the patients, and six (1.7%) of the patients had a transient neurological deficit that improved prior to discharge. In conclusion, in our experience simultaneous carotid endarterectomy with coronary artery bypass grafting can be performed with an acceptable mortality and morbidity and does not appear to put the patient at a higher risk than when either procedure is performed alone.

Introduction

Ten percent of patients presenting for surgical treatment for coronary artery disease have coexistent hemodynamically significant carotid stenosis. Studies have demonstrated that patients with concomitant disease have an increased risk of stroke during the perioperative period if the carotid disease goes untreated [1]. Conversely, patients undergoing carotid endarterectomy with symptomatic coronary artery disease have a perioperative myocardial infarction rate of up to 18% 2, 3, 4. This leaves both the cardiac surgeon and the vascular surgeon with a difficult decision on how best to treat these patients. Some surgeons have opted for staging the procedures with the carotid endarterectomy performed 1–3 days prior to coronary artery bypass grafting, and possibly accepting a higher cardiac morbidity. Others have advocated combined carotid endarterectomy and coronary artery bypass grafting in order to minimize perioperative stroke and cardiac morbidity in this difficult patient population. Unfortunately, results from numerous vascular surgery centers have suggested that despite performing combined procedures, cardiac and cerebral vascular complications are still higher than one would expect for elective carotid endarterectomy or coronary artery bypass grafting alone 1, 5, 6, 7. This has left us with the question `Is this patient population just a group that is at high risk for cardiovascular complications, or is it the combined procedure that puts them at increased risk?'. In this series, the results of treating patients with combined symptomatic coronary artery disease and hemodynamically significant carotid artery disease (symptomatic or asymptomatic) by simultaneous carotid endarterectomy and coronary artery bypass grafting are reviewed. These results are further analyzed according to the risk factors associated with the patients presenting with combined disease.

Section snippets

Patients and methods

The results of patients undergoing combined carotid endarterectomy and coronary artery bypass grafting procedures from April 1980 to November 1996 on the Albany vascular surgery service were reviewed. Patients who presented for coronary artery bypass graftings with a history of transient focal neurological deficits, minor completed cerebral vascular accidents, or asymptomatic bruit on physical examination by the cardiologist or the cardiac surgeon, were further evaluated by carotid duplex

Results

From April 1980 to November 1996, 470 carotid endarterectomies combined with coronary artery bypass graftings were performed in 420 patients. Unilateral procedures were performed in 370 and bilateral procedures were performed in 50. A total of 262 (62%) were male, 65 (15%) were diabetics, 160 (38%) were smokers, and the average age was 69 years (range: 43–88). Sixty (13%) presented with transient ischemic attacks, 22 (5%) presented with amaurosis fugax, 16 (3.4%) presented with a prior history

Discussion

The management of patients with concomitant coronary artery disease and carotid artery stenosis is controversial. In 1972, Bernhard et al. [8]were the first to demonstrate that combined procedures can decrease mortality and morbidity. This was corroborated by later articles from Morris et al. [9], which showed a decrease in cardiac mortality from 14 to 1% with combined procedures, and Pome et al. [10]showed no mortality in 52 patients. Jahangiri et al. [17]demonstrated that combined coronary

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  • Cited by (0)

    1

    Presented at International Society for Cardiovascular Surgery, London, England, September 1997.

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