title: Short-term results of a randomized trial examining timing of carotid endarterectomy in patients with severe asymptomatic unilateral carotid stenosis undergoing coronary artery bypass grafting.
abstract: OBJECTIVE
  This study evaluated the timing of carotid endarterectomy (CEA) in the prevention of stroke in patients with asymptomatic carotid stenosis >70% receiving a coronary artery bypass graft (CABG).
  
  
  METHODS
  From January 2004 to December 2009, 185 patients with unilateral asymptomatic carotid artery stenosis >70%, candidates for CABG, were randomized into two groups. In group A, 94 patients received a CABG with previous or simultaneous CEA. In group B, 91 patients underwent CABG, followed by CEA. All patients underwent preoperative helical computed tomography scans, excluding significant atheroma of the ascending aorta or aortic arch. Baseline characteristics of the patients, type of coronary artery lesion, and preoperative myocardial function were comparable in the two groups. In group A, all patients underwent CEA under general anesthesia with the systematic use of a carotid shunt, and 79 patients had a combined procedure and 15 underwent CEA a few days before CABG. In group B, all patients underwent CEA, 1 to 3 months after CABG, also under general anesthesia and with systematic carotid shunting.
  
  
  RESULTS
  Two patients (one in each group) died of cardiac failure in the postoperative period. Operative mortality was 1.0% in group A and 1.1% in group B (P = .98). No strokes occurred in group A vs seven ipsilateral ischemic strokes in group B, including three immediate postoperative strokes and four late strokes, at 39, 50, 58, and 66 days, after CABG. These late strokes occurred in patients for whom CEA was further delayed due to an incomplete sternal wound healing or because of completion of a cardiac rehabilitation program. The 90-day stroke and death rate was 1.0% (one of 94) in group A and 8.8% (eight of 91) in group B (odds ratio [OR], 0.11; 95% confidence interval [CI], 0.01-0.91; P = .02). Logistic regression analysis showed that only delayed CEA (OR, 14.2; 95% CI, 1.32-152.0; P = .03) and duration of cardiopulmonary bypass (OR, 1.06; 95% CI, 1.02-1.11; P = .004) reliably predicted stroke or death at 90 days.
  
  
  CONCLUSIONS
  This study suggests that previous or simultaneous CEA in patients with unilateral severe asymptomatic carotid stenosis undergoing CABG could prevent stroke better than delayed CEA, without increasing the overall surgical risk.
authors.affiliation: "Francesco Durante" Department of Surgery, University of Rome "La Sapienza," Rome, Italy. giulio.illuminati@uniroma1.it
authors.forename: Giulio
authors.initials: G
authors.lastname: Illuminati
authors.forename: Jean-Baptiste
authors.initials: JB
authors.lastname: Ricco
authors.forename: Francesco
authors.initials: F
authors.lastname: Caliò
authors.forename: Maria Antonietta
authors.initials: MA
authors.lastname: Pacilè
authors.forename: Fabio
authors.initials: F
authors.lastname: Miraldi
authors.forename: Giacomo
authors.initials: G
authors.lastname: Frati
authors.forename: Francesco
authors.initials: F
authors.lastname: Macrina
authors.forename: Michele
authors.initials: M
authors.lastname: Toscano
mesh_terms: D000368:Aged; D058070:Asymptomatic Diseases; D002315:Cardiopulmonary Bypass / Q000009:adverse effects; D016893:Carotid Stenosis / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D016009:Chi-Square Distribution; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality; D003324:Coronary Artery Disease / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D016002:Discriminant Analysis; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality; D005260:Female; D005602:France; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D018579:Patient Selection; D018570:Risk Assessment; D012307:Risk Factors; D012384:Rome; D012720:Severity of Illness Index; D020521:Stroke / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D013997:Time Factors; D036542:Tomography, Spiral Computed; D016896:Treatment Outcome