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Ann Thorac Surg 1995;60:311-317
© 1995 The Society of Thoracic Surgeons
Cardiac Surgical Unit, Massachusetts General Hospital, Boston, Massachusetts
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Methods. The records of 200 consecutive patients having concurrent carotid endarterectomy and coronary artery bypass grafting from 1979 to 1993 were reviewed, and follow-up was obtained (99% complete). Of the group (77% male; mean age, 67 years), 134 (67%) had unstable angina, 130 (65%) had triple-vessel disease, and 86 (43%) had left main coronary stenosis. Preoperative investigation revealed asymptomatic bruits in 116 (58%), transient ischemia in 65 (32%), strokes in 31 (16%), and bilateral carotid disease in 44 patients (22%). Nonelective operations were required in 66 patients (33%).
Results. Hospital death occurred in 7 patients (3.5%), myocardial infarction in 5 (2.5%), and permanent stroke in 6 (3%). Ten-year actuarial event-free rates were as follows: death, 58%; myocardial infarction, 81%; stroke, 92%; percutaneous angioplasty, 98%; redo coronary artery grafting, 94%; and all morbidity and mortality, 56%. Significant multivariate predictors of hospital death were postoperative stroke, failure to use an internal mammary artery graft, intraoperative intraaortic balloon, and nonelective operation. Significant predictors of postoperative stroke were peripheral vascular disease and unstable angina. Significant predictors of prolonged hospital stay were postoperative stroke, advanced age, and nonelective operation.
Conclusions. Concomitant carotid endarterectomy and coronary bypass grafting can be performed with acceptably low operative risk and good long-term freedom from coronary and neurologic events.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Perioperative stroke after coronary artery bypass grafting is an issue of increasing importance to cardiac surgeons, particularly as the age of coronary bypass patients continues to rise and with it the risk of stroke [1, 2]. Evidence suggests that at least part of this increased stroke risk is related to the uncorrected carotid artery stenosis [3, 4]. Yet controversy continues concerning the most appropriate management for patients with severe coronary artery disease who also have severe carotid stenosis. Approaches vary from totally ignoring carotid stenoses at the time of myocardial revascularization, to performing staged operations with delay of one of the procedures, to combining coronary grafting and carotid endarterectomy during one anesthesia.
This study presents the early and late results of concomitant carotid endarterectomy and coronary artery bypass grafting between 1979 and 1993 at the Massachusetts General Hospital. The study premise was that the risk of adverse cardiac events after isolated carotid endarterectomy in patients with severe coronary artery disease and the risk of adverse neurologic events after isolated coronary bypass grafting in patients with severe carotid disease warrant dealing with both diseases simultaneously.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Perioperative myocardial infarction was defined as either new Q waves or the elevation of the myocardial fraction of creatine kinase in association with persistent ST segment changes or new conduction abnormalities. Urgent operations were defined as operative procedures performed in patients whose accelerated symptoms prompted urgent hospital admission for evaluation and who were judged to be too unstable to discharge before operative intervention. True emergency operations were defined as procedures performed on patients whose cardiovascular instability required operative intervention either outside of normal operating hours or displaced another patient on the surgical schedule.
Virtually all patients in this study were admitted to the hospital because of cardiac symptoms, with their carotid disease diagnosed incidentally. Noninvasive carotid testing was routinely performed for patients with recent neurologic symptoms, history of stroke, audible carotid bruits, evidence of other extensive vascular disease, or advanced age. Noninvasive tests suggesting severe stenosis in either or both carotid arteries led to conventional carotid angiography in 172 patients (86%). Conventional angiography alone was performed because of recent neurologic symptoms in the presence of audible carotid bruits in 27 patients (14%), and 1 patient had magnetic resonance angiography after a positive noninvasive test. Two patients had their carotid endarterectomy performed solely on the basis of noninvasive findings without angiography.
The criteria for determining the severity of a carotid lesion changed over the course of the study. In the early years a severe stenosis was defined as one that reduced the residual lumen to less than 1.5 mm, as calculated from a calibrated metallic bead within the radiation field at conventional angiography. In later years a diameter reduction of greater than 70% was used to define a severe stenosis, or ``signal drop-out'' if magnetic resonance imaging was used in lieu of conventional angiography, as more frequently has become our practice.
Operative Technique
All patients had coronary artery bypass grafting and at least one carotid endarterectomy performed concomitantly. The carotid endarterectomies were all performed by a separate vascular surgical team before cardiopulmonary bypass for the myocardial revascularization. Electroencephalographic monitoring during the carotid endarterectomy was used in 92 patients (46%). The decision to use an intraluminal carotid shunt was left to the individual vascular surgeon; 101 patients (50%) were shunted. After completion of the endarterectomy, the neck incision was left open until heparin reversal after cardiopulmonary bypass.
During performance of the carotid endarterectomy, the cardiac surgical team harvested saphenous vein and occasionally the left internal mammary artery. After completion of the carotid endarterectomy, standard coronary bypass grafting was performed. Myocardial protection was achieved with one of several methods of hyperkalemic cardioplegia in 133 patients (66%) and with hypothermic ventricular fibrillation without aortic occlusion in 67 patients (34%).
Follow-up
Follow-up clinical information about survival and subsequent coronary or neurologic events was obtained between September 1, 1993, and December 31, 1993, through direct communication with the patients by trained research personnel, and was recorded as of August 31, 1993. If subsequent hospitalization, death, or other events had occurred, the patient's physician or appropriate hospital record department was contacted to document the events and hospitalizations.
Of the 200 patients in the study, 193 survived hospitalization. Of the survivors, 1 patient was completely lost to follow-up; thus, follow-up was 99% complete. Mean follow-up was 4.3 years; total follow-up was 856 patient-years.
Statistical Analysis
To describe the long-term results, actuarial curves were obtained by the life-table method. Significant univariate and multivariate predictors of hospital death, postoperative stroke, and prolonged postoperative hospital stay (defined as >20 days) were sought with the use of the BMDP program PLR, which implements a multiple stepwise logistic regression algorithm [5]. Only forward stepping and maximum likelihood estimation were used. Factors tested as predictors of the various events are listed in Appendix 1.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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. The increasing use of the simultaneous procedures over time is due to increased confidence in the efficacy of the combined approach and the increasing age of the patient population, which yields a higher incidence of patients with coexistent disease processes.
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. The incidence of female sex is about 8% more than the average for all coronary bypass patients during the same time frame. In addition the average age of 67 years is about 6 years older than the average age for all myocardial revascularization patients during that time period.
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Important cardiac and neurologic laboratory findings are listed in Table 2. The incidence of left main coronary stenosis (43%) is twice the normal rate for all coronary bypass patients at our institution. Carotid stenosis severity was defined by carotid angiography in 197 patients (98%), only by noninvasive testing in 2 patients, and by magnetic resonance angiography in 1 patient.
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. The number of coronary bypass grafts varied from one to seven (mean, 3.8 grafts/patient). The use of internal mammary artery grafts began in earnest in the middle of this study period, and although only 50% of the total population received at least one mammary graft, 81 of the last 100 patients did. The vast majority of patients required only one concomitant carotid endarterectomy, although 1 patient had simultaneous bilateral carotid endarterectomies. In addition 6 patients had the other carotid endarterectomized preoperatively during the same hospitalization, and 1 patient had a second separate carotid endarterectomy before hospital discharge.
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. Of the seven hospital deaths, four were due to multisystem organ failure, two to perioperative stroke, and one to renal failure. Of the eight hospital strokes, five were ipsilateral hemispheric to the endarterectomy and three were contralateral or in the distribution of vertebral-basilar arteries. Five strokes presented as the patient recovered from anesthesia and were presumed to have occurred intraoperatively. The three remaining strokes presented between 3 and 19 days postoperatively. Of the 8 patients who suffered a perioperative stroke, 6 were left with a permanent deficit (including two deficits that were fatal), and 2 had complete neurologic recovery.
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lists the operative results with combined carotid and coronary operation in series published in the past 10 years containing more than 100 patients and compares those results with the present series.
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. Ten-year freedom from follow-up coronary events is displayed in Figure 2; freedom from follow-up neurologic events is graphed in Figure 3; and freedom from total death, stroke, and myocardial infarction is seen in Figure 4.
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Predictors of Results
Significant predictors of hospital death, postoperative stroke, and prolonged postoperative hospital stay are listed in Table 7. The deleterious impact of both nonelective (urgent or emergent) operation and the occurrence of a postoperative stroke is clearly documented.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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To justify this conclusion, we must demonstrate that the combined approach is safe and effective, and that it is necessary. Therefore, we must establish that carotid endarterectomy and coronary artery bypass grafting are each appropriate treatments for carotid and coronary disease, that both diseases pose an important adverse risk during operations that address only one of the lesions, and finally that the combined operation yields the best early and late results.
The initial premise that needs to be proved is that carotid endarterectomy and coronary artery bypass grafting are the best treatment modalities for patients with significant carotid or coronary disease. The first issue is the efficacy of carotid endarterectomy for patients with symptomatic carotid stenoses. In 1986 Hertzer and colleagues [13] from the Cleveland Clinic were able to document significant freedom from late neurologic events when symptomatic patients having carotid endarterectomy were compared with medically treated patients. The recent North American Symptomatic Carotid Endarterectomy Trial [14] verified a statistically significant advantage for endarterectomy patients compared with medical patients in terms of freedom from any stroke, any ipsilateral stroke, and any stroke or death. The results were even more striking when there was clear demonstration of plaque ulceration in the carotid lesion [15]. Similar results have been reported from the European Carotid Surgery Trial [16].
Next we must assess the results of carotid endarterectomy for patients with asymptomatic carotid lesions. In 1986 Hertzer and associates [17] reported significant freedom from late neurologic events in surgical versus medical patients with asymptomatic stenoses. In 1993 the Veterans Affairs Cooperative Study Group [18] reported significant reduction in the overall incidence of ipsilateral neurologic events after carotid endarterectomy in asymptomatic patients with stenoses that reduced the arterial lumen diameter by 50% or more. Most recently the National Institutes of Health abruptly ended a randomized comparison of carotid endarterectomy and medical treatment for patients with asymptomatic carotid lesions because of an overwhelming advantage for the surgical group [19].
Coronary artery bypass grafting has been demonstrated to have long-term survival and symptom-free advantages over medical treatment for most patients with coronary artery disease [20], especially when the left internal mammary artery is used to revascularize anterior coronary arteries [21]. In addition all the major studies comparing coronary artery bypass grafting and percutaneous transluminal coronary angioplasty to date document a significant advantage for surgical patients in terms of event-free survival [22–25].
Thus, carotid endarterectomy is appropriate treatment for patients with severe carotid stenosis, whether the patients are symptomatic or asymptomatic. In addition coronary artery bypass grafting has clear advantages in event-free survival over both medical therapy and percutaneous transluminal coronary angioplasty for most patients with severe coronary artery disease. The second major premise that must be addressed is whether the presence of severe disease in one arterial system poses an important threat to the patient with combined diseases if an operation addresses only the disease in the other system.
The major contribution of coronary artery disease to the short-term risks of carotid endarterectomy has been well established [26]. Also, Hertzer and co-workers [27, 28] have documented that the greatest long-term risk to all carotid patients is the risk of myocardial infarction, the principal cause of death in this population. Further, in one Cleveland Clinic study of 209 carotid endarterectomy patients with clinically suspected coronary artery disease followed up to 11 years, survival was much improved for patients having coronary artery bypass grafting compared with medical therapy [27].
The high incidence of coronary artery disease in carotid endarterectomy patients has been well documented, with only 7% of patients in one study having normal coronary arteries after prospective coronary angiography in 506 patients with carotid stenosis [29]. Clearly, coronary artery disease, an extremely common coexistent disease process, poses important short-term and long-term risks to patients with carotid artery stenosis.
The risk of perioperative stroke after coronary artery bypass grafting has become an issue of increasing importance to cardiac surgeons, especially as the average age of coronary bypass patients continues to rise and with it the incidence of stroke. Gardner and associates [1] noted in their coronary bypass population an incidence of stroke of 0.2% for patients less than 45 years of age, which rose progressively to 8.0% for patients over age 75. Tuman and colleagues [2] reported a stroke rate of 0.9% for patients less than 65 years old compared with 8.9% for patients more than 75 years of age, with the curve of stroke incidence in their patients rising exponentially after age 65. To put this risk in perspective, in the coronary bypass patients in our institution average age is currently about 67 years with 20% of patients being more than 75 years of age.
Given that stroke is an important complication of coronary artery bypass grafting and that the incidence is rising, we must demonstrate that at least part of this stroke risk is related to carotid artery disease. In 1988 Reed and co-workers [3] documented that the presence of carotid bruits increased the risk of stroke 3.9-fold after coronary artery bypass grafting. Faggioli and associates [4] preoperatively evaluated 539 coronary bypass patients with no symptoms of carotid ischemia using noninvasive methods and found that 8.7% of patients had carotid stenosis greater than 75% (11.3% for patients >60 years and 3.8% for patients <60 years). In their report the odds ratio for stroke after coronary grafting was 9.9 in the presence of a documented carotid stenosis greater than 75%. In patients more than 60 years of age with greater than 75% carotid stenosis the stroke rate was 15%, compared with 0.6% in patients of the same age but with no evidence of carotid disease. Also, of the 19 patients with greater than 75% carotid stenosis who had prophylactic endarterectomy, none suffered perioperative strokes compared with 4 (14.3%) of the 28 patients who had greater than 75% carotid stenosis but who did not have endarterectomy. Brenner and colleagues [30] evaluated 4,047 cardiac surgical patients and reported a 9.2% rate of stroke or transient ischemic attacks in patients with asymptomatic carotid stenoses compared with 1.3% for patients with no carotid stenosis (p < 0.001).
Why significant carotid stenoses yield such an increased incidence of stroke during myocardial revascularization operations, particularly when the patients are so vigorously heparinized, is not completely understood. The occurrence of intraoperative strokes may be related to the loss of pulsatile perfusion on cardiopulmonary bypass. Strokes that occur postoperatively, as three of the eight strokes in our series did, may be related to what is thought to be a prothrombotic milieu in the early days after cardiopulmonary bypass.
If one then accepts that severe carotid stenosis increases the stroke risk after myocardial revascularization, the next issue is the appropriate timing of carotid endarterectomy in relation to coronary grafting. In 1989 Hertzer and associates [9] prospectively randomized 129 unstable coronary bypass patients with unilateral, asymptomatic carotid lesions to either combined carotid and coronary operation (71 patients) or coronary grafting followed by delayed endarterectomy (58 patients). The risk of stroke was 2.8% for the combined operations and 14.4% (6.9% at the time of coronary grafting and 7.5% at the time of delayed carotid operation) for the staged procedures (p < 0.05). Of the 24 patients in the study whose coronary disease could be stabilized to permit initial carotid endarterectomy before bypass grafting, 1 patient (4.2%) suffered a stroke.
Therefore, current evidence suggests that coronary artery bypass grafting and carotid endarterectomy are appropriate interventions for severe carotid and coronary disease, that coexistent severe disease in one arterial system adversely influences the results of isolated operations on the other system, and that the best results are obtained with concomitant, not separate, operations.
We believe our in-hospital results with concomitant carotid and coronary operations compare favorably to those of other groups (see Table 5
). Further, our long-term results, particularly the excellent freedom from late neurologic events, support the durability of the combined operative approach. In summary we believe that previously published reports and our current results support the contention that concomitant carotid endarterectomy and coronary artery bypass grafting is the preferred approach to patients with severe coexistent disease.
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Acknowledgments |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Address reprint requests to Dr Akins, Department of Surgery, Massachusetts General Hospital, White 503, Boston, MA 02114.
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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