Ann Thorac Surg 2002;73:497-498
© 2002 The Society of Thoracic Surgeons
Invited commentary
Cary W. Akins, MDa
a Cardiac Surgical Unit, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
e-mail: cakins{at}partners.org
Perioperative stroke arguably remains the worst complication of surgical myocardial revascularization, being devastating for the patient and family, contributing to significantly elevated early and late mortality rates, and markedly increasing the costs of subsequent care. Unfortunately the overall incidence of perioperative stroke has not diminished significantly because of the aging and worsening risk profile of current patient populations. However, increasing appreciation of the contribution of significant concomitant carotid artery disease to the stroke risk of patients with important coronary artery disease has led many cardiac surgeons to more aggressive surgical approaches directed at treating both disease processes. This report by Zacharias and colleagues of a large contemporaneous experience with the simultaneous management of the two diseases during one anesthetic demonstrates that well-performed concomitant carotid endarterectomy and coronary artery bypass grafting can effectively neutralize unilateral significant carotid artery stenosis as a risk factor for perioperative stroke.
The authors have not only achieved excellent operative mortality and morbidity rates, but they have demonstrated by comparison to the rest of their coronary bypass patients that the concomitant approach has not increased the risk of death or complications. In fact they have reported observed results that are better than would have been predicted if they had ignored the associated carotid artery disease and performed only myocardial revascularization.
Whether similar excellent results could have been achieved with staged carotid endarterectomy and coronary artery bypass grafting may be open to debate. What is not debatable is that the simultaneous operative approach is less costly. Previous attempts to organize large, multiinstitutional, randomized trials of concomitant versus staged operative procedures have met with little success. Given the economic advantage associated with and proved for simultaneous procedures, any future randomized trial would have to demonstrate not only that the early and late outcomes of the two approaches were comparable, but also that they were equally cost-effective.
Until such trials are performed, cardiac surgeons should at least recognize the importance of dealing with the two disease processes in a timely fashion, whether it be simultaneous or staged. To ignore significant carotid disease when performing surgical myocardial revascularization is to potentially commit the patient to a less than optimal result.
Related Article
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Operative and 5-year outcomes of combined carotid and coronary revascularization: review of a large contemporary experience
- Anoar Zacharias, Thomas A. Schwann, Christopher J. Riordan, Paul M. Clark, Bernardo Martinez, Samuel J. Durham, Milo Engoren, and Robert H. Habib
Ann. Thorac. Surg. 2002 73: 491-497.
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