Combined carotid and coronary revascularization: The preferred approach to the severe vasculopath

doi:10.1016/0003-4975(92)90076-G

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Combined carotid and coronary revascularization: The preferred approach to the severe vasculopath

Robert J. Rizzo, MD^_*^,a^,b, Anthony D. Whittemore, MD^a^,b, Gregory S. Couper, MD^a^,b, Magruder C. Donaldson, MD^a^,b, Sary F. Aranki, MD^a^,b, John J. Collins, Jr^a^,b, John A. Mannick, MD^a^,b, Lawrence H. Cohn, MD^a^,b

^a Department of Surgery, Harvard Medical School, and Divisions of Cardiac and Vascular Surgery, Brigham, USA
^b Women's Hospital Boston, Massachusetts, USA

^_* Address reprint requests to Dr Rizzo, Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.

The timing of carotid endarterectomy (CEA) and coronary revascularization(CABG) for concomitant disease is controversial. Results ofcombined CEA/CABG in 127 patients (age range, 46 to 82 years;mean age, 65 years; 61% male) from 1978 to 1991 were reviewed.Ninety-five patients (75%) were in New York Heart Associationfunctional class III or IV, 48 (38%) had left main coronaryartery disease, and 32 (28%) had depressed ejection fraction(<0.50). Forty (32%) had asymptomatic bruits, 61 (48%) transientischemic attacks, and 26 (20%) prior strokes. Seventy-five (59%)had bilateral carotid stenosis, including 20 (16%) with contralateralocclusions. Perioperative mortality was 7 of 127 (5.5%), andall deaths were cardiac related. Myocardial infarctions occurredin 6 of 127 patients (4.7%) and were nonfatal in 3 (2.3%). Permanentstrokes occurred in 7 of 127 (5.5%) and were ipsilateral in5 (3.9%). Perioperative stroke did not occur in the asymptomaticgroup, but the risk was higher in those with prior stroke (19%)or with contralateral carotid occlusion (15%). The stroke riskfor our patients with carotid disease having CABG without CEAis not known, but the literature reports rates as high as 14%.For our patients without known concomitant disease, the riskof permanent stroke was 1.0% ([equation]) for isolated CABGand 1.5% ([equation]) for isolated CEA. The late results afterCEA/CABG revealed a 5-year survival of 70% ± 5%, whichcorrelated with ejection fraction ( $≥$ 0.50, 81% ± 5%; <0.50,45% ± 11%; p < 0.003). Freedom from late permanentipsilateral stroke was 97% ± 2% at 8 years. Freedom fromstroke at 5 years was lower among patients with a previous stroke(71% ± 10%) compared with transiently symptomatic (90%± 4%) and asymptomatic (96% ± 4%) patients (p< 0.03). Combined CEA/CABG is a useful option in this high-riskgroup of patients with extensive atherosclerosis; avoids a subsequenthospitalization, anesthetic, and delay period; and provideslong-term protection from ipsilateral stroke.

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				C. W. Akins and A. C. Moncure Myocardial Revascularization with Carotid Artery Disease Card. Surg. Adult, January 1, 2003; 2(2003): 627 - 637. [Full Text]

				Z. S. Meharwal, A. Mishra, and N. Trehan Safety and efficacy of one stage off-pump coronary artery operation and carotid endarterectomy Ann. Thorac. Surg., March 1, 2002; 73(3): 793 - 797. [Abstract] [Full Text] [PDF]

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				L. L. Mickleborough, P. M. Walker, Y. Takagi, M. Ohashi, J. Ivanov, and M. Tamariz RISK FACTORS FOR STROKE IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFTING J. Thorac. Cardiovasc. Surg., November 1, 1996; 112(5): 1250 - 1259. [Abstract] [Full Text]

				P. O. Daily, R. K. Freeman, W. P. Dembitsky, R. M. Adamson, R. J. Moreno-Cabral, S. Marcus, and J. A. Lamphere COST REDUCTION BY COMBINED CAROTID ENDARTERECTOMY AND CORONARY ARTERY BYPASS GRAFTING J. Thorac. Cardiovasc. Surg., June 1, 1996; 111(6): 1185 - 1193. [Abstract] [Full Text]

				D. E. Maziak, V. Rao, G. T. Christakis, K. J. Buth, J. Sever, S. E. Fremes, and B. S. Goldman Can Patients With Left Main Stenosis Wait for Coronary Artery Bypass Grafting? Ann. Thorac. Surg., February 1, 1996; 61(2): 552 - 557. [Abstract] [Full Text]

				C. W. Akins, A. C. Moncure, W. M. Daggett, R. P. Cambria, A. D. Hilgenberg, D. F. Torchiana, and G. J. Vlahakes Safety and efficacy of concomitant carotid and coronary artery operations Ann. Thorac. Surg., August 1, 1995; 60(2): 311 - 318. [Abstract] [PDF]

				E M. Ohman A Difficult Case: Treat the most unstable vascular distribution identified by carotid and cardiac angiography BMJ, June 3, 1995; 310(6992): 1450a - 1451. [Full Text]

				W. S. Moore, H.J.M. Barnett, H. G. Beebe, E. F. Bernstein, B. J. Brener, T. Brott, L. R. Caplan, A. Day, J. Goldstone, R. W. Hobson II, et al. Guidelines for Carotid Endarterectomy : A Multidisciplinary Consensus Statement From the Ad Hoc Committee, American Heart Association Circulation, January 15, 1995; 91(2): 566 - 579. [Abstract] [Full Text]

				T. Vassilidze, A. C. Cernaianu, T. Gaprindashvili, J. G. Gallucci, J. H. Cilley JR, M. A. Grosso, and A. J. DelRossi Long-Term Results of Simultaneous Carotid Endarterectomy and Coronary Artery Revascularization in Patients with Unstable Angina and Cerebrovascular Insufficiency Vascular and Endovascular Surgery, November 1, 1994; 28(9): 577 - 580. [Abstract] [PDF]