title: Regional use of combined carotid endarterectomy/coronary artery bypass graft and the effect of patient risk.
abstract: BACKGROUND
  Although carotid artery stenosis and coronary artery disease often coexist, many debate which patients are best served by combined concurrent revascularization (carotid endarterectomy [CEA]/coronary artery bypass graft [CABG]). We studied the use of CEA/CABG in New England and compared indications and outcomes, including stratification by risk, symptoms, and performing center.
  
  
  METHODS
  Using data from the Vascular Study Group of New England from 2003 to 2009, we studied all patients who underwent combined CEA/CABG across six centers in New England. Our main outcome measure was in-hospital stroke or death. We compared outcomes between all patients undergoing combined CEA/CABG to a baseline CEA risk group comprised of patients undergoing isolated CEA at non-CEA/CABG centers. Further, we compared in-hospital stroke and death rates between high and low neurologic risk patients, defining high neurologic risk patients as those who had at least one of the following clinical or anatomic features: (1) symptomatic carotid disease, (2) bilateral carotid stenosis >70%, (3) ipsilateral stenosis >70% and contralateral occlusion, or (4) ipsilateral or bilateral occlusion.
  
  
  RESULTS
  Overall, compared to patients undergoing isolated CEA at non-CEA/CABG centers (n = 1563), patients undergoing CEA/CABG (n = 109) were more likely to have diabetes (44% vs 29%; P = .001), creatinine >1.8 mg/dL (11% vs 5%; P = .007), and congestive heart failure (23% vs 10%; P < .001). Patients undergoing CEA/CABG were also more likely to take preoperative beta-blockers (94% vs 75%; P < .001) and less likely to take preoperative clopidogrel (7% vs 25%; P < .001). Patients undergoing CEA/CABG had higher rates of contralateral carotid occlusion (13% vs 5%; P = .001) and were more likely to undergo an urgent/emergent procedure (30% vs 15%; P < .001). The risk of complications was higher in CEA/CABG compared to isolated CEA, including increased risk of stroke (5.5% vs 1.2%; P < .001), death (5.5% vs 0.3%; P < .001), and return to the operating room for any reason (7.6% vs 1.2%; P < .001). Of 109 patients undergoing CEA/CABG, 61 (56%) were low neurologic risk and 48 (44%) were high neurologic risk but showed no demonstrable difference in stroke (4.9% vs 6.3%; P = .76), death, (4.9 vs 6.3%; P = .76), or return to the operating room (10.2% vs 4.3%; P = .25).
  
  
  CONCLUSIONS
  Although practice patterns in the use of CEA/CABG vary across our region, the risk of complications with CEA/CABG remains significantly higher than in isolated CEA. Future work to improve patient selection in CEA/CABG is needed to improve perioperative results with combined coronary and carotid revascularization.
authors.affiliation: Department of Surgery, New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY 10065, USA. doj9016@gmail.com
authors.forename: Douglas W
authors.initials: DW
authors.lastname: Jones
authors.forename: David H
authors.initials: DH
authors.lastname: Stone
authors.forename: Mark F
authors.initials: MF
authors.lastname: Conrad
authors.forename: Yvon R
authors.initials: YR
authors.lastname: Baribeau
authors.forename: Benjamin M
authors.initials: BM
authors.lastname: Westbrook
authors.forename: Donald S
authors.initials: DS
authors.lastname: Likosky
authors.forename: Jack L
authors.initials: JL
authors.lastname: Cronenwett
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016893:Carotid Stenosis / Q000150:complications / Q000401:mortality / Q000601:surgery*; D016009:Chi-Square Distribution; D015897:Comorbidity; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data*; D023921:Coronary Stenosis / Q000150:complications / Q000401:mortality / Q000601:surgery*; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence; D017052:Hospital Mortality; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009511:New England; D010043:Outcome and Process Assessment, Health Care; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012111:Residence Characteristics; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome