Combined carotid endarterectomy and coronary artery bypass grafting does not increase the risk of perioperative stroke1
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
References (22)
- et al.
Surgical staging for simultaneous coronary and carotid disease: a study including prospective randomization
Journal of Vascular Surgery
(1989) - et al.
Carotid artery duplex scanning in preoperative assessment for coronary artery revascularization: the association between peripheral vascular disease, carotid artery stenosis, and stroke
Journal of Vascular Surgery
(1995) - et al.
Myocardial revascularization and carotid endarterectomy: a combined approach
Annals of Thoracic Surgery
(1977) - et al.
Simultaneous carotid endarterectomy and coronary bypass: perioperative risk and long-term survival
Journal of Vascular Surgery
(1996) - et al.
Combined myocardial revascularization and carotid endarterectomy
Journal of Thoracic and Cardiovascular Surgery
(1983) - et al.
Cost reduction by combined carotid endarterectomy and coronary artery bypass grafting
Journal of Thoracic and Cardiovascular Surgery
(1996) - et al.
Improved results of carotid endarterectomy in patients with symptomatic coronary disease. An analysis of 1546 consecutive carotid operations
Stroke
(1997) - et al.
Fatal myocardial infarction following carotid endarterectomy. Three hundred thirty-five patients following 6–11 years after operation
Annals of Surgery
(1981) - et al.
Simultaneous myocardial revascularization and carotid endarterectomy
Circulation
(1982) - et al.
Carotid artery stenosis: associated with surgery for coronary artery disease
Archives of Surgery
(1972)
Management of coexistent carotid and coronary atherosclerosis
Cleveland Clinic Quarterly
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Presented at International Society for Cardiovascular Surgery, London, England, September 1997.