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Ann Thorac Surg 1998;66:1480-1482
© 1998 The Society of Thoracic Surgeons
a Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
Address reprint requests to Dr Johnson, Cardiac Surgery Laboratory, Beth Israel Hospital, 330 Brookline Ave, Dana 905, Boston, MA 02215
Presented at Outcomes ’98, "The Key West Meeting," Key West, FL, May 27–31, 1998.
Patients with both carotid and coronary disease may be treated operatively by combined or sequential (staged) coronary (coronary artery bypass grafting [CABG]) and carotid operations (carotid endarterectomy [CEA]). It is difficult to construct a positive argument for the staged approach. Although results with the combined approach are well documented, there are not many reports including serial data for patients having sequential CABG and CEA, or CEA followed by CABG. In fact, for most of us the argument for the staged procedure is primarily one against the combined procedure. There is ample evidence that CABG can decrease the incidence of myocardial infarction after CEA, and that issue will not be specifically addressed in this brief presentation. The ability of CEA to decrease the risk of cerebrovascular accidents (CVA) with CABG, whether performed concomitantly or subsequently, is much less certain.
Previous studies
No published series of consecutive CABG patients suggest a lower incidence of CVA when CEA is combined with CABG when compared with the incidence of CVA with isolated CABG or isolated CEA [1–3]. These data can be used to suggest the risk of the combined procedure is not prohibitive, or these data can be used to demonstrate that the risk of the combined procedure is excessive. In the two most recently published series comparing staged CEA and CABG with the combined procedure the overall incidence of CVA was lower in the staged groups [4, 5].
Selection of patients
Combined procedures are undoubtedly performed in all cardiac surgical centers. Certainly an economic argument can be made for its use in patients who simultaneously have indications for both procedures [6]. Although there are many reports of the use of the combined procedure, it is not common for the author-proponents to include sufficient data to determine the percentage of their CABG patients who are selected for CEA + CABG. It is the percentage of all CABG patients so treated that separates the combination advocates from the detractors. Patient selection is the critical factor in this clinical determination, and it is the confounding factor in the various published results. It is likely the intent to select patients with the highest risk of CVA for combined procedures. Many factors, other than carotid disease, have been identified as predictors of CVA with CABG, including age, female sex, prior stroke or transient ischemic attack, left main coronary artery disease, poor left ventricular function, diabetes, smoking history, severe peripheral vascular disease, carotid bruit, ascending aortic atheromata, and time on bypass. Only one of these is specifically amenable to potential relief by concomitant or prophylactic CEA [7, 8].
Screening for carotid disease
The use of noninvasive carotid screening in patients with no central nervous system symptoms requiring CABG may be a very important factor in the selection of patients for a combined CABG + CEA. These studies may detect anatomy predisposing to CVA, but studies of consecutive series of patients do not convincingly demonstrate that noninvasive carotid screening results in a lower incidence of CVA in patients so selected [1]. No doubt the inability to demonstrate a benefit for noninvasive carotid screening is the result of retrospective comparisons of a higher risk cohort and the fact that CVAs occur in such patients for reasons other than the carotid disease identified [7].
A minimalist approach to the combined procedure
At our institution we have taken a minimalistic approach to noninvasive carotid screening in patients before CABG. Patients who reach us with unevaluated symptoms consistent with CVD undergo diagnostic evaluation, but we do not screen or request evaluations of asymptomatic patients. Our approach to patients referred for CABG can be crudely illustrated by the simple two-by-two decision matrix shown in Table 1.
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Risk reduction in patients with known carotid disease
Among the 3,014 solitary CABG operations noted above, there was a subgroup of 203 patients with known carotid disease before CABG (29 of whom had CEA + CABG). We retrospectively applied a multiinstitutional Bayesian prediction method to estimate the risk of CVA in this subgroup of patients. Comparing the mean estimated CVA risk of those who had CEA with those who did not, we found no significant difference (no CEA = 12.5% versus with CEA = 13.8%; p = 0.579). A CVA actually occurred in only 8/174 (4.6%) of those without CEA and in 2/29 (6.9%) of CEA + CABG patients. Acknowledging that the risk prediction model employed does not include concomitant central nervous system and coronary artery disease symptoms or anatomic predictors, it is still notable that the combined procedure did not yield a more favorable variance of observed CVAs from expected CVAs (-0.64 versus -0.5).
Conclusion
As yet there are no demonstrated objective criteria by which patients who need CABG can be selected for CEA + CABG as a means of lessening the risk of CVA associated with CABG. Notwithstanding the obvious economic advantages, given the available data, a surgeon’s use of CEA + CABG to reduce the risk of post-CABG CVA must be based on her or his individualclinical intuition and not an established benefit for a high-risk subgroup.
References
This article has been cited by other articles:
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  R Hofmann, A Kypta, C Steinwender, K Kerschner, M Grund, and F Leisch Coronary angiography in patients undergoing carotid artery stenting shows a high incidence of significant coronary artery disease Heart, November 1, 2005; 91(11): 1438 - 1441. [Abstract] [Full Text] [PDF]
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