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Ann Thorac Surg 1997;64:16-22
© 1997 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Is an Integrated Approach Warranted for Concomitant Carotid and Coronary Artery Disease?

Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas

	Abstract

Top Footnotes Abstract Introduction Material and Methods Surgical Procedures Data Analysis Results In-Hospital Events Predictors of Results and... Comment References

 
Background. The management of patients with severe, concomitant coronary and carotid artery occlusive disease is controversial.

Methods. Between 1975 and 1996, 512 patients (mean age, 64.9 years; 70% male) were admitted for coronary revascularization; 316 (61.7%) had asymptomatic, severe carotid disease (stenosis >70%) and 196 (38.3%) had symptomatic carotid disease (159 [31.1%] with transient ischemia and 37 [7.2%] with completed stroke). In group 1, coronary revascularization and carotid endarterectomy were simultaneously performed in 255 patients (49.8%) with unstable angina. In group 2 (staged approach), carotid endarterectomy was performed before coronary revascularization in 257 patients (50.2%) without unstable angina.

Results. Before 1986, the incidence of stroke and death was greater in group 1 (n = 149) than in group 2 (n = 156) (14 [9.4%] versus 4 [2.6%]; p < 0.01). Since 1986, outcomes in group 1 (n = 106) and group 2 (n = 101) have been similar for stroke (2 [1.9%] versus 2 [2.0%]), death (4 [3.8%] versus 3 [3.0%]), and myocardial infarction (4 [3.8%] versus 5 [5.0%]). Significant univariate and multivariate predictors of adverse outcome were primarily heart-related (reoperation, intraaortic balloon use, ejection fraction <0.50, and angina grade 4 for death; age >70 years and congestive heart failure for stroke).

Conclusions. Despite highly selected populations, contemporary surgical results do not indicate that staged treatment of severe, concomitant coronary and carotid artery occlusive disease has an advantage over simultaneous treatment. Advances in myocardial protection and perioperative hemodynamic management may account for the low incidences of stroke and death in these operations.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Surgical Procedures Data Analysis Results In-Hospital Events Predictors of Results and... Comment References

 
See also page 22.

Patients who have concomitant coronary and carotid artery occlusive disease represent a high-risk population whose management remains controversial. As the population ages and more high-risk patients are referred for treatment, surgeons are increasingly faced with the complex decisions that accompany treatment of these patients. The incidence of significant carotid stenosis in patients undergoing cardiac operations in the early 1980s was 3.8% in a study of 4,047 patients [1]. Recent studies, however, have reported that the incidence of hemodynamically significant carotid lesions is between 11% and 20% [2–4]. On the basis of logistic regression analysis, significant carotid stenosis has been identified as the most powerful predictor of perioperative stroke in patients with concomitant disease [4].

An integrated treatment approach involving the timing of carotid endarterectomy (CEA) for patients who have both carotid and coronary artery disease is favored by many surgeons [5]. In this approach, patients with concomitant disease are treated in either a staged (CEA first, followed by coronary revascularization [CABG] at a second operation) or simultaneous (CEA and CABG during the same period of anesthesia) fashion based on the severity of the cardiac findings. This approach evolved in an attempt to minimize the adverse outcomes of stroke and death, which were found to be increased in early, influential studies examining the simultaneous treatment of concomitant disease [6, 7].

This article examines our experience with simultaneous and staged operative treatment of concomitant coronary and carotid artery occlusive disease over a 21-year period. We undertook the study to identify factors associated with adverse outcomes, to examine trends in outcome over time, and to establish the benefits and drawbacks of each approach.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Surgical Procedures Data Analysis Results In-Hospital Events Predictors of Results and... Comment References

 
Patients
We reviewed the individual hospital records and postoperative clinical charts of 512 consecutive patients with concomitant, severe coronary and carotid artery occlusive disease who were treated at this institution between June 1975 and June 1996. From each chart, data were obtained for 51 separate variables. Where necessary, supplemental information was obtained from the patient's private cardiologist and family. Demographic and clinical characteristics of the patients in this report are summarized in Tables 1 and 2.

All patients underwent full invasive radiologic evaluation including cineangiography of coronary vessels and arch aortography with runoff views of carotid and vertebral circulations. Vessel stenosis was determined angiographically by the formula [1 - (diameter at the point of greatest stenosis/diameter at the point of greatest patency)] x 100%. Bilateral carotid stenosis was defined as a narrowing greater than 50% in each vessel. Preocclusive stenosis was defined as a narrowing greater than 90% in a carotid vessel. Severe stenosis was defined as carotid artery narrowing of at least 70% of the vessel diameter.

Patients with carotid artery occlusive disease were classified by status as symptomatic or asymptomatic. Symptomatic patients included those who had focal, transient neurologic symptoms, amaurosis fugax, or a completed stroke. Asymptomatic patients had no evidence of neurologic findings. However, each of these patients had at least 70% stenosis at the carotid bifurcation.

Patients with coronary insufficiency were classified as having stable or unstable coronary insufficiency. Unstable coronary insufficiency was defined as prolonged (more than 15 minutes) angina, usually with reversible ischemic electrocardiographic changes and partial or no response to maximal medical therapy. Stable coronary insufficiency was defined as angina, usually long-standing, easily controlled with medications.

Operative interventions were classified as elective, urgent, and emergent. Urgent operations were undertaken in patients whose accelerated symptoms required immediate hospital admission for evaluation and who were judged to be too unstable to discharge before operative intervention. Emergent operations were undertaken in patients with accelerated symptoms so unstable that immediate operative intervention was required.

Patients with symptomatic or severe carotid disease and unstable angina were treated with simultaneous CEA and CABG. Those patients who had similar carotid artery disease but stable angina, however, were treated with initial CEA followed by CABG at a later date during the same hospitalization. Patients with asymptomatic carotid disease, carotid stenosis of less than 70%, and coronary insufficiency were treated with CABG alone.

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. Perioperative stroke was defined as new neurologic, focal change on physical examination with or without radiologic confirmation (via computed tomography) of infarction.

	Surgical Procedures

Top Footnotes Abstract Introduction Material and Methods Surgical Procedures Data Analysis Results In-Hospital Events Predictors of Results and... Comment References

 
Coronary revascularization and CEA procedures were done in all patients in either staged or simultaneous fashion. All procedures were performed by the same surgeons and operative team. Patients in the simultaneous procedure group underwent CEA with the chest open but before institution of cardiopulmonary bypass for CABG.

All CEAs were performed under general anesthesia with high-dose barbiturate administration during clamp occlusion. The depth of anesthesia and barbiturate administration were controlled by intraoperative encephalography. Head placement was strictly monitored to prevent compromise of the collateral blood supply. Intraoperative blood pressure and cardiac rhythm were continuously monitored and maintained especially during periods of arterial clamping. Intraoperative carotid shunts were used selectively based on evaluation of collateral blood flow.

Myocardial protection was achieved with one of several methods. Hyperkalemic crystalloid cardioplegia delivered in an antegrade fashion was initially used early in the operative series. Over the course of this series, methods of myocardial protection evolved to include cold blood cardioplegia, retrograde administration of cardioplegic solution via the coronary sinus, and warm blood cardioplegia induction and reperfusion.

	Data Analysis

Top Footnotes Abstract Introduction Material and Methods Surgical Procedures Data Analysis Results In-Hospital Events Predictors of Results and... Comment References

 
Independent and summarized operative outcomes were analyzed between groups and time periods by ^{2 analysis and the two-tailed Fisher's exact test. Significant univariate independent predictors of adverse outcome were determined by Fisher's exact test analysis. Significant multivariate determinants of adverse outcome were obtained by logistic regression analysis. Statistical analysis was performed using SAS software (Statistical Analysis Systems Institute, Cary NC).}

	Results

Top Footnotes Abstract Introduction Material and Methods Surgical Procedures Data Analysis Results In-Hospital Events Predictors of Results and... Comment References

 
Demographic and preoperative clinical findings for all patients are summarized in Tables 1 and 2. In general, the patients in this series were older and had more cardiac and noncardiac risk factors than the patients treated at this institution who need only CEA or CABG. Because we attempted to avoid performing simultaneous procedures except in patients with a higher risk of stroke or death, the patients receiving simultaneous operative treatment had a significantly greater percentage of advanced atherosclerotic and cardiac disease.

	In-Hospital Events

Top Footnotes Abstract Introduction Material and Methods Surgical Procedures Data Analysis Results In-Hospital Events Predictors of Results and... Comment References

 
Before 1986, the incidence of stroke and death was significantly greater in the simultaneous group than in the staged group (p < 0.01). Since 1986, however, outcomes in the staged and simultaneous groups have been similar for stroke (2 [1.9%] versus 2 [2.0%]), death (4 [3.8%] versus 3 [3.0%]), and myocardial infarction (4 [3.8%] versus 5 [5.0%]) (Table 3).

	Predictors of Results and Causal Associations

Top Footnotes Abstract Introduction Material and Methods Surgical Procedures Data Analysis Results In-Hospital Events Predictors of Results and... Comment References

 
Significant predictors of hospital death, postoperative myocardial infarction, and postoperative stroke are listed in Table 4. The independent predictors of adverse outcome were primarily heart related. For death, they were reoperation, intraaortic balloon use, Canadian Cardiovascular Society angina class 4, and ejection fraction less than 0.50. For myocardial infarction, they were reoperation, previous myocardial infarction, intraaortic balloon use, and extended bypass time (>80 minutes). For stroke, they were age greater than 70 years and congestive heart failure. Generalized and advanced atherosclerosis, including peripheral vascular disease and renal insufficiency, were also independent predictors of death. Neither an intraoperative carotid shunt nor patch closure of the carotid vessels was an independent predictor of stroke. The operative approach (simultaneous or staged) was not a predictor for either stroke or death.

	Comment

Top Footnotes Abstract Introduction Material and Methods Surgical Procedures Data Analysis Results In-Hospital Events Predictors of Results and... Comment References

Therapeutic and technical advances in the areas of myocardial protection, patient monitoring, and medical management directly influence operative management and may contribute to the low incidence of stroke and death in our contemporary surgical results. As it may be inappropriate to compare the dollar cost of patient hospitalizations in 1975 with those in 1996, it may likewise be inappropriate to compare operative outcomes from those years.

Treatment options for the management of patients with concomitant disease include performing only CEA or CABG, sequentially staging CEA and CABG, or synchronously performing CEA and CABG. Both staged (Fig 1) and simultaneous (Fig 2) operative approaches provide superior results when compared with historical data reporting the results of isolated CEA or isolated CABG performed in patients with concomitant disease. Isolated CEA undertaken in patients with known, uncorrected coronary artery disease has been associated with operative mortality rates as high as 20% [8, 9], primarily the result of myocardial infarction. Isolated CABG performed in patients with known, significant carotid artery stenosis produced a mean stroke rate of 4.1% in 344 asymptomatic patients and 8.2% in 97 symptomatic patients in a total of 14 series reviewed by Rizzo and associates in 1992 [10].

View larger version (29K): [in this window] [in a new window]   Fig 1. . Results after staged and simultaneous operative approaches from the same institution. (THI = Texas Heart Institute results [this study].)

View larger version (32K): [in this window] [in a new window]   Fig 2. . Results after simultaneous operative approach from institutions reporting outcomes in more than 100 patients. (THI = Texas Heart Institute results [this study].)

The known benefits of the simultaneous approach include decreased exposure to anesthesia, shorter hospital stay, and significant cost savings [15]. However, early influential studies by Hertzer and colleagues [6] and Dunn [7] reported elevated stroke and mortality rates following this approach. In contrast, nine other large series [10, 13, 16–21] including this study have not reported the elevated stroke and mortality rates found in those early studies (see Fig 2). The contemporary results of this study suggest that the simultaneous approach is as safe as the staged approach.

An ad hoc committee of the American Heart Association performed a metaanalysis on 56 English-language reports (19 of which had 50 or more patients) that dealt with simultaneous, staged, or "reversed-staged" (CEA after CABG) methods for surgical treatment of concomitant coronary and carotid artery disease [22]. The results of that study were similar to the findings in our report. In the metaanalysis, the perioperative stroke rate was similar if CEA and CABG were combined or if CEA preceded CABG. In addition, the frequencies of myocardial infarction (p = 0.01) and death (p = 0.02) were greater when CEA preceded CABG.

Our salutary results in this study must be interpreted in the context of our overall institutional results. The mortality, myocardial infarction, and stroke rates for the combined or staged approaches at our institution are higher than those rates for isolated CABG or CEA undertaken for the treatment of isolated coronary or isolated carotid disease (Table 6) [23]. These results reflect the higher risk and poorer medical condition of the patients with concomitant coronary and carotid disease.

In summary, we conclude that an integrated approach using both staged and simultaneous operations for the treatment of concomitant coronary and carotid artery occlusive disease is unwarranted. Despite highly selected populations, contemporary surgical results in this study do not indicate that staged treatment of severe, concomitant coronary and carotid artery occlusive disease has an advantage over simultaneous treatment. A staged approach may increase hospital stay, cost of hospitalization, and the risk of development of acute ischemia and myocardial infarction after CEA and before CABG. Advances in myocardial protection and perioperative hemodynamic management may account for the low incidence of stroke and death in patients who underwent simultaneous operative treatment in this report. These findings are based on retrospective analysis, and the optimal strategy for management of patients with concomitant coronary and carotid disease will ultimately need to be established by a well-designed prospective, randomized trial.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Surgical Procedures Data Analysis Results In-Hospital Events Predictors of Results and... Comment References

 
Presented at the Forty-third Annual Meeting of the Southern Thoracic Surgical Association, Cancun, Mexico, Nov 7–9, 1996.

Address reprint requests to Dr Cooley, Department of Cardiovascular Surgery, Texas Heart Institute, PO Box 20345, Houston, TX 77225-0345.

	References

Top Footnotes Abstract Introduction Material and Methods Surgical Procedures Data Analysis Results In-Hospital Events Predictors of Results and... Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Thomas J. Takach George J. Reul, Jr Denton A. Cooley J. Michael Duncan James J. Livesay Grady L. Hallman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Takach, T. J. Articles by Frazier, O. H. Search for Related Content PubMed PubMed Citation Articles by Takach, T. J. Articles by Frazier, O. H. Related Collections Related Article