Comparison of Trends and In-Hospital Outcomes of Concurrent Carotid Artery Revascularization and Coronary Artery Bypass Graft Surgery: The United States Experience 2004 to 2012.
The aim of this study was to compare trends and outcomes of 3 approaches to carotid revascularization in the coronary artery bypass graft (CABG) population when performed during the same hospitalization.



The optimal approach to managing coexisting severe carotid and coronary disease remains controversial. Carotid endarterectomy (CEA) or carotid artery stenting (CAS) are used to decrease the risk of stroke in patients with carotid disease undergoing CABG surgery.



The authors conducted a serial, cross-sectional study with time trends of 3 revascularization groups during the same hospital admission: 1) combined CEA+CABG; 2) staged CEA+CABG; and 3) staged CAS+CABG from the Nationwide Inpatient Sample database 2004 to 2012. The primary composite endpoints were in-hospital all-cause death, stroke, and death/stroke.



During the 9-year period, 22,501 concurrent carotid revascularizations and CABG surgeries during the same hospitalization were performed. Of these, 15,402 (68.4%) underwent combined CEA+CABG, 6,297 (28.0%) underwent staged CEA+CABG, and 802 (3.6%) underwent staged CAS+CABG. The overall rate of CEA+CABG decreased by 16.1% (ptrend= 0.03) from 2004 to 2012, whereas the rate of CAS+CABG did not significantly change during these years (ptrend= 0.10). The adjusted risk of death was greater, whereas risk of stroke was lower with both combined CEA+CABG (death odds ratio [OR]: 2.08, 95% confidence interval [CI]: 1.08 to 3.97; p = 0.03; stroke OR: 0.65, 95% CI: 0.42 to 1.01; p = 0.06) and staged CEA+CABG (death OR: 2.40, 95% CI: 1.43 to 4.05; p = 0.001; stroke OR: 0.50, 95% CI: 0.31 to 0.80; p = 0.004) approaches compared with CAS+CABG. The adjusted risk of death or stroke was similar in the 3 groups.



In patients with concomitant carotid and coronary disease undergoing combined revascularization, combined CEA+CABG is utilized most frequently, followed by staged CEA+CABG and staged CAS+CABG strategies. The staged CAS+CABG strategy was associated with lower risk of mortality, but higher risk of stroke. Future studies are needed to examine the risks/benefits of different carotid revascularization strategies for high-risk patients requiring concurrent CABG.
Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York. Electronic address: dnf9001@med.cornell.edu.
Dmitriy N
DN
Feldman
Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina.
Rajesh V
RV
Swaminathan
Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York.
Joshua D
JD
Geleris
Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York.
Peter
P
Okin
Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York.
Robert M
RM
Minutello
Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York.
Udhay
U
Krishnan
Department of Cardiovascular Medicine, Pennsylvania Hospital-University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Daniel J
DJ
McCormick
Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York.
Geoffrey
G
Bergman
Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York.
Harsimran
H
Singh
Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York.
S Chiu
SC
Wong
Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York.
Luke K
LK
Kim
D000368:Aged; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality / Q000639:trends*; D016893:Carotid Stenosis / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D016009:Chi-Square Distribution; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality / Q000639:trends*; D003324:Coronary Artery Disease / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D003430:Cross-Sectional Studies; D016208:Databases, Factual; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality / Q000639:trends*; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010818:Practice Patterns, Physicians' / Q000639:trends*; D017064:Process Assessment, Health Care / Q000639:trends*; D057216:Propensity Score; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D015607:Stents / Q000639:trends; D020521:Stroke / Q000209:etiology / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
carotid artery stenting; carotid endarterectomy; coronary artery bypass grafting