title: A direct comparison of early and late outcomes with three approaches to carotid revascularization and open heart surgery.
abstract: OBJECTIVE
  The aim of this study was a comparison of risk-adjusted outcomes of 3 approaches to carotid revascularization in the open heart surgery (OHS) population.
  
  
  BACKGROUND
  Without randomized clinical trials, the best approach to managing coexisting severe carotid and coronary disease remains uncertain. Staged carotid endarterectomy (CEA) followed by OHS or combined CEA and OHS are commonly used. A recent alternative is carotid artery stenting (CAS).
  
  
  METHODS
  From 1997 to 2009, 350 patients underwent carotid revascularization within 90 days before OHS at a tertiary center: 45 staged CEA-OHS, 195 combined CEA-OHS, and 110 staged CAS-OHS. The primary composite endpoint was all-cause death, stroke, and myocardial infarction (MI). Staged CAS-OHS patients had higher prevalence of previous stroke (p = 0.03) and underwent more complex OHS. Therefore, the propensity score adjusted multiphase hazard function models with modulated renewal to account for staging, and competing risks were used.
  
  
  RESULTS
  Using propensity analysis, staged CAS-OHS and combined CEA-OHS had similar early hazard phase composite outcomes, whereas staged CEA-OHS incurred the highest risk driven by interstage MI. Subsequently, staged CAS-OHS patients experienced significantly fewer late hazard phase events compared with both staged CEA-OHS (adjusted hazard ratio: 0.33; 95% confidence interval: 0.15 to 0.77; p = 0.01) and combined CEA-OHS (adjusted hazard ratio: 0.35; 95% confidence interval: 0.18 to 0.70; p = 0.003).
  
  
  CONCLUSIONS
  Staged CAS-OHS and combined CEA-OHS are associated with a similar risk of death, stroke, or MI in the short term, with both being better than staged CEA-OHS. However, the outcomes significantly favor staged CAS-OHS after the first year.
authors.affiliation: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: shishem@ccf.org.
authors.forename: Mehdi H
authors.initials: MH
authors.lastname: Shishehbor
authors.affiliation: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Sridhar
authors.initials: S
authors.lastname: Venkatachalam
authors.affiliation: Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Zhiyuan
authors.initials: Z
authors.lastname: Sun
authors.affiliation: Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Jeevanantham
authors.initials: J
authors.lastname: Rajeswaran
authors.affiliation: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Samir R
authors.initials: SR
authors.lastname: Kapadia
authors.affiliation: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Christopher
authors.initials: C
authors.lastname: Bajzer
authors.affiliation: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Heather L
authors.initials: HL
authors.lastname: Gornik
authors.affiliation: Department of Vascular Surgery, Greenville Hospital System, Greenville, South Carolina.
authors.forename: Bruce H
authors.initials: BH
authors.lastname: Gray
authors.affiliation: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: John R
authors.initials: JR
authors.lastname: Bartholomew
authors.affiliation: Department of Vascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Daniel G
authors.initials: DG
authors.lastname: Clair
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Sabik
authors.affiliation: Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
mesh_terms: D006348:Cardiac Surgical Procedures; D016893:Carotid Stenosis / Q000601:surgery*; D003327:Coronary Disease / Q000601:surgery*; D016894:Endarterectomy, Carotid / Q000379:methods*; D006801:Humans; D017410:Practice Guidelines as Topic; D011300:Preoperative Care / Q000379:methods*
keywords: CABG; CAS; CEA; CI; CVIR; Cardiovascular Information Registry; HR; MI; NIS; National Inpatient Sample; OHS; SSDI; Social Security Death Index; carotid artery stenting; carotid endarterectomy; confidence interval; coronary artery bypass grafting; hazard ratio; myocardial infarction; open heart surgery