Toward a rational management of concomitant carotid and coronary artery disease.
BACKGROUND
Patients with angina undergoing carotid endarterectomy have a high perioperative mortality. Our aim was to assess the outcome of carotid endarterectomy in patients with concomitant coronary artery disease, in particular, to examine the timing of carotid endarterectomy and CABG.


METHODS
A retrospective study was performed at a tertiary and secondary referral centre for cardiovascular disease. Over a five-year period 71 carotid endarterectomies and 6,590 coronary artery bypasses were performed. Significant (>70%) internal carotid stenoses were found in 35 (0.5%) patients due for CABG. Of these, 23 patients underwent Combined procedures (Carotid and CABG), 9 Reverse staged (CABG then Carotid), and 3 Prior staged carotid endarterectomies (Carotid then CABG). 36 other carotid endarterectomies were in patients evaluated cardiologically, but did not require CABG (Isolated group). Risk factors, 30 day perioperative outcome including hospital inpatient stay and early follow-up are reported.


RESULTS
The Combined group 30-day perioperative mortality rate was 4.3% and permanent stroke rate 8.6%. There were no major complications in Reverse or Prior staged cases. Isolated group mortality was 2.7% with no strokes. Risk factors were more prevalent in the combined group; 56% previous myocardial infarction, 39% hypertension, 35% a history of raised cholesterol and 46% intermittent claudication. All cases were followed up for a mean of 18.4 months, with no carotid stroke related events. Overall hospital stay for staged patients was a mean 19.3 days (SE=2.4) days compared to mean 9.8 days for combined patients (SE=0.97, p<0.001).


CONCLUSIONS
Patients with combined cardiac and carotid disease benefit from assessment of both systems in order to stage CABG and carotid endarterectomy. Risk factors were more prevalent in the combined group; a combined procedure offered a median difference of 8 days less hospital inpatient stay compared to the staged cases. Our experience suggests that carefully planned management of concomitant coronary and carotid disease can achieve better results.
Brow
T D
TD
Department of Surgery, Royal Brompton Hospital, London, UK.
Kakkar
V V
VV
Pepper
J R
JR
Das
S K
SK
D000368:Aged; D016893:Carotid Stenosis / Q000401:mortality / Q000601:surgery*; D002423:Cause of Death; D003131:Combined Modality Therapy; D001026:Coronary Artery Bypass; D003327:Coronary Disease / Q000401:mortality / Q000601:surgery*; D016894:Endarterectomy, Carotid; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality; D015996:Survival Rate