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Ann Thorac Surg 1999;68:14-20
© 1999 The Society of Thoracic Surgeons
a Division of Cardiovascular Surgery, The Toronto Hospital, Toronto, Ontario, Canada
b Division of Cardiovascular Surgery, University of Toronto, Toronto, Ontario, Canada
c Division of Vascular Surgery, The Toronto Hospital, Toronto, Ontario, Canada
d Institute for Clinical Evaluative Sciences, Sunnybrook and Women’s College Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
Address reprint requests to Dr Fremes, Sunnybrook Health Science Centre, Rm H405, 2075 Bayview Ave, Toronto, Ontario, Canada M4N 3M5
Presented at the Thirty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 25–27, 1999.
Background. Patients with concomitant carotid and coronary artery disease present a surgical dilemma. We compared the stroke and mortality rates for combined coronary artery bypass grafting and carotid endarterectomy in which both procedures were performed under a single anesthetic, versus a staged approach, in which coronary artery bypass grafting and carotid endarterectomy were performed separately.
Methods. A computerized MEDLINE search supplemented with a manual bibliographic review was performed for all peer-reviewed English language publications that contained both combined and staged coronary artery bypass grafting/carotid endarterectomy patient cohorts. Outcomes of interest were stroke, death, and stroke or death; aggregation of outcome rates was performed with the Mantel-Haenszel method.
Results. Sixteen studies were identified with a total of 844 combined patients and 920 staged patients. None of the studies was completely randomized. The combined surgical group had a higher prevalence of unstable angina; the two groups had a similar prevalence of symptomatic carotid disease and severe carotid stenosis. Metaanalysis revealed a significantly increased risk of the composite end point, stroke or death, for patients undergoing combined procedures (relative risk 1.49; 95% confidence interval 1.03–2.15; p = 0.034). There was also a trend toward increased risk during combined procedures for the end points of stroke (relative risk 1.50; 95% confidence interval 0.97–2.32; p = 0.068) and death (relative risk 1.55; 95% confidence interval 0.94–2.53; p = 0.084) considered separately. The crude event rates for stroke were 6.0% versus 3.2% for combined versus staged procedure, 4.7% versus 2.9% for death, and 9.5% versus 5.7% for stroke or death. Two of the 16 individual studies showed a statistically significant increase in the risk of stroke or death for combined procedure (p < 0.05).
Conclusions. Combined coronary artery bypass grafting and carotid endarterectomy may be associated with a higher risk of stroke or death than staged procedures. A randomized trial needs to be performed to determine the optimal management of patients with concomitant carotid and coronary artery disease.
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