title: Outcome after combined carotid endarterectomy and coronary artery bypass is related to patient selection.
abstract: OBJECTIVE
  The optimal management of patients with significant coronary and carotid artery disease remains controversial. Since reporting on a series of 100 patients undergoing combined carotid endarterectomy and coronary artery bypass (CEA/CAB) 4 years ago, we have liberalized our selection criteria for combined operation. We sought to compare outcomes of the recent cohort of 74 patients and the previous group.
  
  
  METHODS
  All patients who underwent CEA/CAB since 1984 have been tracked in a database containing identifying information, demographic factors, anatomic information, details of surgery, and short- and long-term follow-up data. We compared the 74 patients (Group 2) undergoing CEA/CAB since 1994 with the previously reported group of 100 patients (Group 1) who underwent CEA/CAB between 1984 and 1994. We examined demographic and comorbidity factors, presence of cerebrovascular symptoms, degree of contralateral carotid stenosis, and perioperative stroke and death. Statistical comparisons were made with the chi(2) test.
  
  
  RESULTS
  The groups had similar age and sex distributions and similar incidences of hypertension, diabetes, congestive heart failure, prior myocardial infarction, and hypercholesterolemia. More patients in Group 1 had preoperative transient cerebral ischemia or monocular blindness (55% vs 31%, P <.002) and preoperative stroke (18% vs 7%, P <.03). More patients in Group 2 had unilateral asymptomatic carotid artery stenosis (55% vs 18%, P <.001). The incidence of all perioperative strokes was higher in Group 1 (9% vs 1.4%, P <.035). There were fewer deaths (3% vs 8%) and ipsilateral strokes (0 vs 4%) in Group 2, though these were not statistically significant.
  
  
  CONCLUSIONS
  We have liberalized our criteria for performing combined CEA/CAB, such that more than 50% of our recent patients have asymptomatic unilateral carotid stenosis. This practice is associated with a lower incidence of all perioperative strokes and a trend toward lower ipsilateral stroke and death. These observations suggest that perioperative stroke after CEA/CAB is related to patient selection and that low-risk patients can undergo CEA/CAB with the benefits of low morbidity, patient convenience, and cost savings from avoiding a second hospitalization and operation.
authors.affiliation: Divisions of Vascular Surgery, and Cardiothoracic Surgery, New England Medical Center, Tufts University School of Medicine, Boston, Mass 02111, USA. jestes@lifespan.org
authors.forename: J M
authors.initials: JM
authors.lastname: Estes
authors.forename: K R
authors.initials: KR
authors.lastname: Khabbaz
authors.forename: M
authors.initials: M
authors.lastname: Barnatan
authors.forename: P
authors.initials: P
authors.lastname: Carpino
authors.forename: W C
authors.initials: WC
authors.lastname: Mackey
mesh_terms: D000368:Aged; D016893:Carotid Stenosis / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery*; D015331:Cohort Studies; D003131:Combined Modality Therapy; D015897:Comorbidity; D001026:Coronary Artery Bypass / Q000379:methods* / Q000401:mortality; D003327:Coronary Disease / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery*; D016894:Endarterectomy, Carotid / Q000379:methods* / Q000401:mortality; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011336:Probability; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome