Combined carotid and coronary revascularization: the preferred approach to the severe vasculopath.
The timing of carotid endarterectomy (CEA) and coronary revascularization (CABG) for concomitant disease is controversial. Results of combined CEA/CABG in 127 patients (age range, 46 to 82 years; mean age, 65 years; 61% male) from 1978 to 1991 were reviewed. Ninety-five patients (75%) were in New York Heart Association functional class III or IV, 48 (38%) had left main coronary artery disease, and 32 (28%) had depressed ejection fraction ( < 0.50). Forty (32%) had asymptomatic bruits, 61 (48%) transient ischemic attacks, and 26 (20%) prior strokes. Seventy-five (59%) had bilateral carotid stenosis, including 20 (16%) with contralateral occlusions. Perioperative mortality was 7 of 127 (5.5%), and all deaths were cardiac related. Myocardial infarctions occurred in 6 of 127 patients (4.7%) and were nonfatal in 3 (2.3%). Permanent strokes occurred in 7 of 127 (5.5%) and were ipsilateral in 5 (3.9%). Perioperative stroke did not occur in the asymptomatic group, but the risk was higher in those with prior stroke (19%) or with contralateral carotid occlusion (15%). The stroke risk for our patients with carotid disease having CABG without CEA is not known, but the literature reports rates as high as 14%. For our patients without known concomitant disease, the risk of permanent stroke was 1.0% (31/3012) for isolated CABG and 1.5% (7/482) for isolated CEA. The late results after CEA/CABG revealed a 5-year survival of 70% +/- 5%, which correlated with ejection fraction ( > or = 0.50, 81% +/- 5%; < 0.50, 45% +/- 11%; p < 0.003). Freedom from late permanent ipsilateral stroke was 97% +/- 2% at 8 years. Freedom from stroke at 5 years was lower among patients with a previous stroke (71% +/- 10%) compared with transiently symptomatic (90% +/- 4%) and asymptomatic (96% +/- 4%) patients (p < 0.03). Combined CEA/CABG is a useful option in this high-risk group of patients with extensive atherosclerosis; avoids a subsequent hospitalization, anesthetic, and delay period; and provides long-term protection from ipsilateral stroke.
Rizzo
R J
RJ
Department of Surgery, Harvard Medical School, Boston, Massachusetts.
Whittemore
A D
AD
Couper
G S
GS
Donaldson
M C
MC
Aranki
S F
SF
Collins
J J
JJ
Mannick
J A
JA
Cohn
L H
LH
D000206:Actuarial Analysis; D000368:Aged; D000369:Aged, 80 and over; D001900:Boston / Q000453:epidemiology; D002561:Cerebrovascular Disorders / Q000453:epidemiology / Q000209:etiology / Q000401:mortality; D003131:Combined Modality Therapy; D001026:Coronary Artery Bypass / Q000379:methods / Q000401:mortality / Q000592:standards*; D004569:Electroencephalography; D016894:Endarterectomy, Carotid / Q000379:methods / Q000401:mortality / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology / Q000209:etiology / Q000401:mortality; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology / Q000401:mortality; D012086:Reoperation / Q000706:statistics & numerical data; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume; D016019:Survival Analysis