Comparison of Early Outcomes with Three Approaches for Combined Coronary Revascularization and Carotid Endarterectomy

Abstract

ObjectiveThis study aims to compare three different surgical approaches for combined coronary and carotid artery stenosis as a single stage procedure and to assess effect of operative strategy on mortality and neurological complications.MethodsThis retrospective study involves 136 patients who had synchronous coronary artery revascularization and carotid endarterectomy in our institution, between January 2002 and December 2012. Patients were divided into 3 groups according to the surgical technique used. Group I included 70 patients who had carotid endarterectomy, followed by coronary revascularization with on-pump technique, group II included 29 patients who had carotid endarterectomy, followed by coronary revascularization with off-pump technique, group III included 37 patients who had coronary revascularization with on-pump technique followed by carotid endarterectomy under aortic cross-clamp and systemic hypothermia (22-27ºC). Postoperative outcomes were evaluated.ResultsOverall early mortality and stroke rate was 5.1% for both. There were 3 (4.3%) deaths in group I, 2 (6.9%) deaths in group II and 2 (5.4%) deaths in group III. Stroke was observed in 5 (7.1%) patients in group I and 2 (6.9%) in group II. Stroke was not observed in group III. No statistically significant difference was observed for mortality and stroke rates among the groups.ConclusionWe identified no significant difference in mortality or neurologic complications among three approaches for synchronous surgery for coronary and carotid disease. Therefore it is impossible to conclude that a single principle might be adapted into standard practice. Patient specific risk factors and clinical conditions might be important in determining the surgical tecnnique.

Surgical treatment for coronary artery disease with concomitant carotid stenosis: one-center experience

“…A.A. Dönmez и соавт. [11] получили аналогичные результаты, отметив, что при одновременном КШ и КЭАЭ в условиях работающего сердца риски развития ОНМК, ОИМ и летальности не возрастают. Данные нашего исследования коррелируют с выводами работ [10,11].…”

How Can We Treat Asymptomatic Carotid Disease in Patients with a Planned CABG?

“…Guibaud et al (40) also stated hypothermia below 28°C provides better cerebral protection especially for patients with bilateral carotid lesions. In contrast to this benefit, hypothermia during CEA had found to increase risk of MI (OR=3.5, CI=0.8-15.5) due to increased cross clamp and cardiopulmonary bypass times (37) .…”

“…In the literature, reported rate of mortality is between 0-4.5% and rate of stroke is between 0-3.1% for combined CEA and off-pump CABG (34)(35)(36)(37)(38)(39) . Eren et al (35) reported no stroke and 3.7% mortality for patients who had CEA and simultaneous off-pump CABG.…”

“…Nabagiez et al (36) suggested that twenty-four hour staged CEA followed by off-pump CABG minimizes post-CEA myocardial infarction while minimizing cerebrovascular accident post-CABG in patients with concomitant severe coronary and carotid artery disease. In order to comparison of early outcomes with three different approaches for combined CEA-CABG, Dönmez et al (37) reported that no any further benefit with off-pump technique compared to onpump technique, except for shorter intensive care unit and hospitalization times.…”

A Strategy for the Treatment of Patientswith Coronary Artery Disease and the Presence of Significant Carotid Artery Stenosis: Analysis of the "Staged" and "Concomitant" Approaches

“…One approach is the performance of carotid endarterectomy and CABG as a stepwise procedure, carotid endarterectomy, and CABG ("staged" procedure), with endarterectomy being performed prior to the establishment of extracorporeal circulation (18)(19)(20)(21). Most surgeons recommend this type of operative approach, especially for patients who have stable angina pectoris and who are hemodynamically stable (5).…”