title: Is an integrated approach warranted for concomitant carotid and coronary artery disease?
abstract: BACKGROUND
  The management of patients with severe, concomitant coronary and carotid artery occlusive disease is controversial.
  
  
  METHODS
  Between 1975 and 1996, 512 patients (mean age, 64.9 years; 70% male) were admitted for coronary revascularization; 316 (61.7%) had asymptomatic, severe carotid disease (stenosis > 70%) and 196 (38.3%) had symptomatic carotid disease (159 [31.1%] with transient ischemia and 37 [7.2%] with completed stroke). In group 1, coronary revascularization and carotid endarterectomy were simultaneously performed in 255 patients (49.8%) with unstable angina. In group 2 (staged approach), carotid endarterectomy was performed before coronary revascularization in 257 patients (50.2%) without unstable angina.
  
  
  RESULTS
  Before 1986, the incidence of stroke and death was greater in group 1 (n = 149) than in group 2 (n = 156) (14 [9.4%] versus 4 [2.6%]; p < 0.01). Since 1986, outcomes in group 1 (n = 106) and group 2 (n = 101) have been similar for stroke (2 [1.9%] versus 2 [2.0%]), death (4 [3.8%] versus 3 [3.0%]), and myocardial infarction (4 [3.8%] versus 5 [5.0%]). Significant univariate and multivariate predictors of adverse outcome were primarily heart-related (reoperation, intraaortic balloon use, ejection fraction < 0.50, and angina grade 4 for death; age > 70 years and congestive heart failure for stroke).
  
  
  CONCLUSIONS
  Despite highly selected populations, contemporary surgical results do not indicate that staged treatment of severe, concomitant coronary and carotid artery occlusive disease has an advantage over simultaneous treatment. Advances in myocardial protection and perioperative hemodynamic management may account for the low incidences of stroke and death in these operations.
authors.affiliation: Department of Cardiovascular Surgery, Texas Heart Institute, Houston 77225-0345, USA.
authors.forename: T J
authors.initials: TJ
authors.lastname: Takach
authors.forename: G J
authors.initials: GJ
authors.lastname: Reul
authors.forename: D A
authors.initials: DA
authors.lastname: Cooley
authors.forename: J M
authors.initials: JM
authors.lastname: Duncan
authors.forename: D A
authors.initials: DA
authors.lastname: Ott
authors.forename: J J
authors.initials: JJ
authors.lastname: Livesay
authors.forename: G L
authors.initials: GL
authors.lastname: Hallman
authors.forename: O H
authors.initials: OH
authors.lastname: Frazier
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016893:Carotid Stenosis / Q000150:complications / Q000601:surgery*; D015897:Comorbidity; D001026:Coronary Artery Bypass; D003327:Coronary Disease / Q000150:complications / Q000601:surgery*; D016894:Endarterectomy, Carotid; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome