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The Annals of Thoracic Surgery, Vol 54, 1099-1108, Copyright © 1992 by The Society of Thoracic Surgeons
RJ Rizzo, AD Whittemore, GS Couper, MC Donaldson, SF Aranki, JJ Collins Jr, JA Mannick and LH Cohn
The timing of carotid endarterectomy (CEA) and coronary revascularization
(CABG) for concomitant disease is controversial. Results of combined
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 Association functional class III or IV, 48 (38%) had left
main coronary artery disease, and 32 (28%) had depressed ejection fraction
( < 0.50). Forty (32%) had asymptomatic bruits, 61 (48%) transient
ischemic attacks, and 26 (20%) prior strokes. Seventy-five (59%) had
bilateral carotid stenosis, including 20 (16%) with contralateral
occlusions. Perioperative mortality was 7 of 127 (5.5%), and all deaths
were cardiac related. Myocardial infarctions occurred in 6 of 127 patients
(4.7%) and were nonfatal in 3 (2.3%). Permanent strokes occurred in 7 of
127 (5.5%) and were ipsilateral in 5 (3.9%). Perioperative stroke did not
occur in the asymptomatic group, but the risk was higher in those with
prior stroke (19%) or with contralateral carotid occlusion (15%). The
stroke risk for our patients with carotid disease having CABG without CEA
is not known, but the literature reports rates as high as 14%. For our
patients without known concomitant disease, the risk of permanent stroke
was 1.0% (31/3012) for isolated CABG and 1.5% (7/482) for isolated CEA. The
late results after CEA/CABG revealed a 5-year survival of 70% +/- 5%, which
correlated with ejection fraction ( > or = 0.50, 81% +/- 5%; < 0.50,
45% +/- 11%; p < 0.003). Freedom from late permanent ipsilateral stroke
was 97% +/- 2% at 8 years. Freedom from stroke 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-risk group of
patients with extensive atherosclerosis; avoids a subsequent
hospitalization, anesthetic, and delay period; and provides long-term
protection from ipsilateral stroke.
ARTICLES
Combined carotid and coronary revascularization: the preferred approach to the severe vasculopath
Department of Surgery, Harvard Medical School, Boston, Massachusetts.
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