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Ann Thorac Surg 1997;64:1013-1018
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Management Strategy for Simultaneous Carotid Endarterectomy and Coronary Revascularization

Washington Heart, Section for Thoracic and Cardiovascular Surgery, The Washington Hospital Center, Washington, DC

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. The occurrence of significant carotid artery disease in patients requiring coronary artery bypass grafting (CABG) results in a dilemma regarding the best surgical management. Our philosophy has been to perform simultaneous carotid endarterectomy and CABG. We reviewed the efficacy of this therapy in patients treated at a large community-based hospital.

Methods. During a 6-year period, from 1990 to 1996, 88 patients underwent simultaneous carotid endarterectomy and CABG. All patients underwent preoperative four-vessel arch arteriography and standard coronary angiography. The principal indications for combined procedures were the need for CABG and (1) symptomatic carotid artery disease; (2) internal carotid artery stenosis of 80% or more, with or without contralateral disease; or (3) an ulcerated, unstable internal carotid artery lesion, regardless of degree of stenosis. The average patient age was 68 years, and there was a 3:1 male-to-female predominance. All procedures were performed with the patients under general anesthesia. The carotid endarterectomy was performed first, and an intraluminal shunt was used in all patients.

Results. The average degree of stenosis on the operated side was 86.2%. An average of 3.6 coronary bypasses per patient were performed. Morbidity included four strokes (4.5%). There were no perioperative myocardial infarctions. There were three hospital deaths (3.4%). The combined permanent stroke and mortality rate was 6.8%. Univariate predictors of stroke were an elevated serum creatinine level, a pulmonary complication, and left main coronary artery disease. Univariate predictors of hospital death were stroke, an elevated serum creatinine level, peripheral vascular disease, and left main coronary artery disease. Multivariate predictors of a prolonged hospitalization were stroke, an elevated serum creatinine level, and a pulmonary complication. Eighty-five patients (96.6%) were discharged and alive at 30 days.

Conclusions. In the context of the indications we used to select patients for simultaneous carotid endarterectomy and CABG, the combined permanent stroke and mortality rate was less than 7%. Our management strategy identified patients that were at increased surgical risk as a result of advanced carotid and coronary artery disease. In our practice, simultaneous carotid endarterectomy and CABG is the preferred surgical approach for these high-risk patients and results in a low in-hospital morbidity and mortality using a single anesthetic and hospitalization.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The presence of significant carotid artery disease in patients requiring coronary artery bypass grafting (CABG) poses a dilemma regarding the best surgical management to undertake in this high-risk population. Carotid endarterectomy (CEA) done in patients with severe uncorrected coronary artery disease has been associated with perioperative myocardial infarction rates as high as 17% and operative mortality rates of up to 20%, with myocardial infarctions accounting for as many as 60% of these deaths [1, 2]. There is a 14% risk of perioperative stroke in patients with severe carotid artery disease who undergo CABG, and the stroke rate remains 4% per year for the first 4 years after coronary revascularization [2–4]. Several centers have reported satisfactory results in patients with coexisting carotid and coronary disease who undergo simultaneous CEA and CABG [3–16] or a staged CEA and CABG [4, 17, 18] or in whom hypothermic circulatory arrest is used [19]. Nonetheless, in multiple previous reviews, higher incidences of myocardial infarction, stroke, and death have been noted in those patients with advanced age, unstable angina, or multivessel coronary artery disease with or without left main coronary artery disease, a carotid stenosis of 80% or more, a prior stroke or transient ischemic attack, and a nonelective operation regardless of the operative strategy [3–7, 17–20]. In addition, between 3% and 12% of patients who present with symptoms related to coronary artery disease have been reported to have significant internal carotid artery (ICA) stenosis (more than 70% diameter narrowing), and this is a recognizable source of morbidity and mortality in this high-risk population [4, 6, 21, 22]. Currently there is no multicenter, prospective trial comparing the different operative approaches, and we now rely on the patient selection criteria used at and the results from individual institutions with experience using a particular treatment strategy.

Our cardiovascular surgery practice is at a large tertiary-care referral center and consists of patients from the greater metropolitan Washington, DC, area and the surrounding four states. Most of the patients referred have symptomatic coronary artery disease that requires nonelective operative management and often have coexisting multisystem atherosclerotic disease that requires prompt evaluation. It has been our philosophy to manage patients with coexisting significant carotid artery disease who require coronary revascularization using simultaneous CEA and CABG. We report the early results from our use of simultaneous CEA and CABG between 1990 and 1996 at the Washington Hospital Center. The study premise was that the early outcomes in our patients with carotid artery disease requiring CABG identified to be at risk for adverse neurologic and cardiac events who undergo simultaneous CEA and CABG support our management strategy.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
All patients having concomitant CEA and CABG were identified from a computerized registry of 12,047 adult cardiac procedures performed at the Washington Hospital Center between April 1990 and April 1996. The records of 88 consecutive patients were retrospectively reviewed for demographic information, clinical and angiographic data, operative characteristics, and results.

Nearly all patients in this study were referred to the hospital because of cardiac symptoms. Their carotid artery disease was diagnosed incidentally or on the basis of previous medical records. Noninvasive carotid artery testing was performed in all patients with a history of neurologic symptoms, a previous stroke, a previous CEA, an audible carotid bruit, previously positive oculoplethysmography findings, or evidence of multisystem vascular disease. All patients were identified as having moderate (50% to 80%) to severe (80% to 99%) stenosis or a 100% occlusion of either or both carotid arteries by noninvasive carotid testing and underwent subsequent four-vessel aortic arch angiography. A diameter reduction of more than 70% of the ICA relative to the normal distal ICA shown by angiography was considered to represent severe stenosis.

The absolute indications for simultaneous procedures were the need for CABG and (1) symptomatic carotid artery disease (defined as either a transient ischemic attack or a stroke occurring 4 or more weeks before CABG); (2) ICA stenosis of 80% or more, with or without contralateral disease; or (3) an ulcerated, unstable ICA lesion, regardless of the degree of stenosis. Our selection criteria were not absolute, however, but also took into consideration the findings from careful patient examination and clinical judgment. For example, a patient may have had an asymptomatic, unilateral ICA stenosis of more than 70% but was considered a candidate for a combined procedure if there was an associated ulcerative plaque or contralateral disease identified by the noninvasive carotid imaging study or by carotid arteriography, or if there were numerous preoperative clinical factors that were deemed potential risks for an adverse postoperative neurologic event.

All patients underwent CABG and one CEA performed concomitantly under general anesthesia. The CEAs were performed by the vascular surgeon in our group before cardiopulmonary bypass (CPB) and myocardial revascularization. An intraluminal carotid shunt was used in all patients. After completion of the CEA, the neck incision was left open until heparin reversal after CPB. During CEA, saphenous vein conduits were prepared, though sternotomy was routinely done after CEA. After CEA, standard CABG was performed with CPB in 84 patients (95.5%) and without CPB in 4 (4.5%). In those patients who had CPB, myocardial protection was achieved using antegrade (aortic root) and retrograde (coronary sinus), hyperkalemic, cold blood cardioplegia. In all patients the mean systemic arterial pressure was maintained between 70 and 80 mm Hg. The proximal anastomoses in patients who had CPB were performed primarily using a single aortic cross-clamp technique.

A perioperative myocardial infarction was defined as the occurrence of new Q waves, persistent ST segment changes correlated with an elevated myocardial fraction of creatinine kinase, or a new left bundle-branch block. Strokes were reported as being reversible or permanent, and the deficit was reported as occurring ipsilateral or contralateral to the CEA. An urgent operation was defined as an operative procedure performed in a patient with progressive or nonmedically manageable symptoms that necessitated his or her hospitalization or considered too unstable to permit the patient's discharge from the hospital before an operative intervention. An emergency operation was defined as a procedure performed on a patient because of cardiovascular instability or one that replaced another scheduled operation.

Follow-up clinical information about survival and subsequent coronary or neurologic events was obtained for the period of the hospitalization and up to 30 days postoperatively. Information on long-term survival or events was unavailable and not recorded in the data base. Univariate and multivariate predictors of hospital death, postoperative stroke, and prolonged postoperative stay (defined as 20 days or more) were determined using two-tailed Fisher's exact test, t test, Pearson correlation, and stepwise regression. A p value of less than 0.05 was statistically significant. Factors tested as predictors of the various postoperative events are listed in Appendix 1.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The distribution of important demographic and clinical characteristics in the patients is shown in Table 1. More than 90% of the patients had symptoms related to coronary artery disease, and there was a significant history of known carotid disease in more than 55%. The risk factors for atherosclerotic disease in the patients included age exceeding 70 years (45.5%), smoking history (76.1%), hypertension (69.3%), diabetes (36.4%), and peripheral vascular disease (23.9%).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Although there have been a few reports of a slightly higher incidence of stroke, myocardial infarction, and death in patients undergoing a combined CEA and CABG than in those undergoing only a CEA [7, 16, 18] or CABG [7, 9, 16, 17, 22], there were marked differences in the severity of the arterial pathology and in the risk factors that could account for this. It has been well established by Hertzer [1–4] and others [5–7, 22–25] that patients with significant coexistent carotid and coronary artery disease represent a higher-risk population than those with isolated carotid or coronary atherosclerosis. In particular, D'Agostino [25] and Berens [23] and their colleagues identified predictors of a significant carotid stenosis (80% or greater) in patients evaluated for coronary artery surgery to be a preoperative age of more than 70 years, diabetes, left main coronary artery disease, peripheral vascular disease, female sex, prior vascular operation, prior stroke or transient ischemic attack, and smoking. Recently Schwartz [21], Salisidis [22], Berens [23], and Mickelborough [24] and their colleagues demonstrated that preoperative risk factors for a postoperative neurologic event in patients undergoing cardiopulmonary bypass are a carotid stenosis of 80% or more, carotid occlusion, prior stroke or transient ischemic attack, peripheral vascular disease, postinfarction angina, and prolonged cardiopulmonary bypass times. There is also compelling data demonstrating an increased incidence of stroke in patients undergoing CABG alone who have an asymptomatic carotid stenosis of 80% or more, or who have a carotid occlusion with or without contralateral carotid disease [21, 22, 24]. Many of these described clinical risk factors and angiographic characteristics were present in high percentages of our patient population, and this lends support to our belief that the criteria we have used to select patients for a combined CEA and CABG have been very useful in identifying those at risk for an adverse neurologic outcome.

We must also emphasize that, in the patients in those studies identifying risk factors for a postoperative stroke and in those series of patients who underwent combined CEA and CABG, a postoperative stroke was demonstrated contralateral to the CEA in 20% to 60% and was attributed to multifactorial causes (eg, aortic debris) in up to two thirds of patients who suffered postoperative neurologic events [7, 19, 23, 24]. The four strokes in our study were ipsilateral to the CEA and likely resulted from extracranial disease, especially since 2 of these patients had a contralateral carotid occlusion. In a select subgroup of patients who had a contralateral occlusion and renal insufficiency and had undergone a prior CABG or who had diffuse ascending aortic disease but a single diseased coronary artery, a simultaneous CEA and CABG without cardiopulmonary bypass was performed without sequelae in 4. This particular operative approach perhaps addresses the other confounding multiple risk factors that may have an adverse impact on the neurologic outcome.

Finally, in accordance with reports by Hertzer and associates [1–3], the fact that no patient in our series sustained a perioperative myocardial infarction despite the diffuse nature of the coronary artery disease, the high incidence of left main coronary artery disease, the presence of left ventricular dysfunction in more than 25% of patients, and the need for urgent coronary revascularization support our use of early, rather than staged, CABG in patients who present with coexisting carotid artery disease and symptomatic coronary artery disease. We have therefore not only identified potential risk factors for adverse neurologic outcomes in patients requiring coronary revascularization but also identified a patient population at risk for adverse cardiac events that has benefited from intraoperative management strategies that address both the carotid artery disease and the coronary artery disease.

Although we were unable to demonstrate long-term protection from an ipsilateral stroke, myocardial infarction, or death in our patient population because of the wide geographical referral pattern and inability to record follow-up data, Hertzer [3], Akins [5], and Rizzo [7] and their associates, who performed combined CEA and CABG in patient populations similar to ours, as have reported the following long-term actuarial event-free and survival rates: survival at 5 years, more than 70%; freedom from ipsilateral stroke at 5 or 10 years more than 91%; and 10-year freedom from myocardial infarction, 81%. Daily and associates [16] have also reported the potential cost benefit to be gained from performing simultaneous CEA and CABG by comparing the costs of a combined procedure with the combined costs for isolated procedures. These results are likely to differ among institutions, and because simultaneous CEA and CABG represents less than 0.7% of adult cardiac procedures in our practice, it is unlikely that there is a dramatic cost benefit to either the patient or hospital. The cost to the patient is more likely to be influenced by the occurrence of a postoperative complication and a prolonged hospital stay. We were able to demonstrate low incidences of in-hospital stroke, myocardial infarctions, and death, with a median intensive care unit stay of 1 day, a median hospital stay of 9 days, and a 30-day survival of 96.6%.

In summary, simultaneous CEA and CABG is the preferred surgical approach for a patient with severe combined carotid and coronary artery disease at the Washington Hospital Center. In our practice, patients selected for simultaneous CEA and CABG have identifiable risk factors for adverse neurologic or cardiac outcomes. The simultaneous performance of CEA and CABG in patients with severe coexisting carotid artery disease who require coronary revascularization has proved to be a safe and efficacious operative strategy in these high-risk patients. It also potentially eliminates the cost of a subsequent hospitalization required for a second operation or for a stroke resulting from uncorrected carotid artery disease.

	Appendix

 

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Poster Session of the Thirty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Feb 3–5, 1997.

Address reprint requests to Dr Pfister, Washington Heart, 1706 New Hampshire Ave NW, Washington, DC 20009.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Gregory D. Trachiotis Albert J. Pfister Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Trachiotis, G. D. Articles by Pfister, A. J. Search for Related Content PubMed PubMed Citation Articles by Trachiotis, G. D. Articles by Pfister, A. J.