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Ann Thorac Surg 2002;73:491-497
© 2002 The Society of Thoracic Surgeons
a Department of Cardiovascular Surgery, St. Vincent Mercy Medical Center, Toledo, Ohio, USA
b Department of Vascular Surgery, St. Vincent Mercy Medical Center, Toledo, Ohio, USA
c Department of Anesthesia, St. Vincent Mercy Medical Center, Toledo, Ohio, USA
d Department of Surgery, Medical College of Ohio, Toledo, Ohio, USA
Accepted for publication October 15, 2001.
* Address reprint requests to Dr Habib, Cardiopulmonary Research, St. Vincent Mercy Medical Center, 2213 Cherry St, ACC Bldg, Suite 309, Toledo, OH 43608, USA
e-mail: robert_habib{at}mhsnr.org
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Abstract |
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Methods. We reviewed the operative outcome and 5-year survival results of 189 consecutive patients (69 ± 9 years old, 66 [35%] female patients) who underwent combined CABG/CEA between 1994 and 1999. Survival follow-up was conducted in February 2001 and the incidence of late stroke, carotid surgery, and myocardial infarction was investigated in all surviving patients by mail survey. A phone interview was done by a surgeon of patients with late strokes or repeated CEA.
Results. Operative death occurred in 5 of 189 patients (2.65%) 4 of which were in-hospital deaths. A total of 5 (2 permanent, 3 transient [2.65%]) perioperative strokes were documented in these patients, and 1 of the perioperative strokes patients died in the hospital. In all, 156 of 189 patients (82.5%) were alive at the time of the study and completed surveys were collected from 153 of 156 patients (98%). Of these 153 patients, 4 reported a late stroke (2.6%), 5 suffered a myocardial infarction (3.3%), and 16 (10.5%) underwent subsequent CEA (7 ipsilateral to original CEA). Angioplasty (3 of 153, 2.0%) and redo surgery (1 of 153, 0.66%) occurred infrequently. Median survival follow-up was 51 months (range 12 to 84), and the corresponding 5-year Kaplan-Meier survival was 79.4%. This survival was similar to that of age-matched isolated CABG patients (n = 532) with documented history of cerebrovascular disease but no surgical carotid lesions.
Conclusions. Our results suggest that combined CABG/CEA is safe and may in fact reduce the risk of adverse outcomes in the intermediate term compared with age and risk-matched patients. We speculate the latter may be attributable to a cerebrovascular protective effect of CABG/CEA pending verification by randomized trials. An economic benefit of CABG/CEA may also be inferred from avoiding separate coronary and carotid operations and reduction in the high costs of perioperative stroke.
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Introduction |
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Early studies [4–11] comparing combined and staged surgical approaches to concomitant coronary and carotid disease had mostly suggested increased risks of combined procedures, and were largely responsible for a shift towards staged surgeries in the mid 1980s. In contrast, a number of later studies reported favorable operative outcomes with combined coronary artery bypass grafting/carotid endarterectomy (CABG/CEA) surgical treatments in which CEA preceded CABG during the same anesthesia [12–24]. Importantly, studies exploring the longer term results of the combined operation are scarce [8, 11–13, 25–27], and thus remain a limiting factor in addressing this controversy. Also, the debate over the operative results of the surgical approach was recently clouded by two metaanalyses [28–29]—that collectively considered the data from prior reports—that reached conflicting conclusions about the merits (or demerits) of the two methods.
Relatively improved operative outcomes of combined CABG/CEA surgery perhaps derive at least in part from technical and medical advances achieved over the past decade for cerebral protection. In this study, we reviewed our recent experience (1994 to 1999) with combined CABG/CEA operation in 189 consecutive patients. We specifically report about the operative outcomes in these patients including postoperative neurologic complications, and the longer term follow-up results of this operation including 5-year Kaplan-Meier survival, late strokes, subsequent CEA, and redo cardiac surgery.
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Material and methods |
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CABG/CEA was performed in patients deemed to have significant carotid disease that justified surgical intervention. These patients were identified from the general nonemergency CABG population according to a predefined paradigm as depicted in Figure 1. CABG patients who were older than 60 years, had a history/symptoms of CVD, had carotid bruits, or had severe ( > 70%) left main coronary artery disease were screened for carotid disease. Carotid screening was done in two steps: (1) noninvasive duplex ultrasonography, followed by (2) angiography in case the initial screen indicated significant disease. Significant disease was defined as stenosis more than 75% of one or both internal carotid arteries. Unilateral CEA was performed on the more severely affected side unless 100% occluded. In symptomatic patients, the presence of ulcerated/unstable plaque even if the carotid stenosis was less than 75% was an indication for CEA.
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Data collection and analysis
All preoperative data including demographics, risk factors, and cardiovascular history in addition to operative and postoperative variables were prospectively entered into the computerized database. Operative outcome variables considered in this study were stroke (permanent or transient), perioperative myocardial infarction, operative mortality (defined as in-hospital death or out-of-hospital within 30 days of surgery), postoperative length of hospitalization as well as pronounced delirium/agitation in the perioperative period. These variables were contrasted for all three patient subgroups. Patients who exhibited any form of the above neurologic symptoms were always assessed by neurology staff.
CABG/CEA patient survey
Surveys were sent to all CABG/CEA patients who were confirmed as alive as of January 2001. The mailed survey interrogated the recurrence and severity of both cardiac and cerebrovascular symptoms including additional carotid or coronary stenting surgery. Local telephone white pages were also used in attempts to reach patients who could not be reached by mail. All patients who reported recurrence of system or additional intervention after their CABG/CEA operation were then interviewed by the surgeon for additional information.
Long-term survival
Long-term patient outcome was investigated by 5-year survival data for all three patient groups. Here, to insure up-to-date survival data, the social security death index database was queried in late February 2001 using patient name and social security number combinations. This corresponds to minimum and maximum follow-up times of 12 months (December 1999 patients) and 84 months (January 1994 patients), respectively. The cardiovascular surgery database was then updated for all deceased patients with the exact date of death and Kaplan-Meier analysis of the data was performed.
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Results |
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As of February 2001, 156 of 189 patients were alive (82.5%) according to the social security death index. Of these patients, 153 (98%) either returned completed surveys by mail or their follow-up data were collected by phone interviews conducted by a physician. Five of 153 patients reported a myocardial infarction (3.27%), 1 patient (0.65%) had redo surgery (CABG and aortic valve replacement) nearly 4 years after the CABG/CEA, and 3 patients underwent interventional procedures (angioplasty/stent; 1.96%). Sixteen patients (10.5%) had a total of 17 subsequent carotid surgeries: 7 ipsilateral (2 in the same patient) and 10 contralateral to their CEA done at the time of the combined operation. Six of these 10 contralateral subsequent CEA procedures were staged as they occurred in patients with known significant ( > 75%) disease at the time of their original combined CABG/CEA operation. Angiography results in the remaining 4 patients showed that three already had measurable disease (30% to 60%) affecting the contralateral side.
Four of the 153 surveyed CABG/CEA patients (2.6%) reported a total of five late strokes and have since fully recovered. Three of these had a single stroke contralateral to their CEA, and 1 patient had two strokes with both affecting the cerebral hemisphere ipsilateral to his CEA.
Assuming up-to-date death index data as of the end of the year 2000 (our search was done in late February 2001), the range of our survival follow-up was between 12 months for December 1999 patients and 84 months for January 1994 patients. The obtained median follow-up was 51 months. Figure 2 depicts the corresponding 5-year Kaplan-Meier survival analysis for the 189 CABG/CEA patient series and it shows a survival of 79.4% at 5 years. This CABG/CEA survival is worse than in the isolated CABG patient cohort in whom no history of cerebrovascular disease or significant carotid lesions were documented (CABG/no CVD; mean age 63 years) over the same time period. This result is rather expected given that CABG/CEA patients are older (mean 69 years), have more comorbidities and risk factors (Table 1), have significant carotid disease, as well as the possible effects of the more complex combined surgery. Alternatively, however, the 5-year survival of CABG/CEA patients is essentially identical to that of a similar age (mean 68 years) isolated CABG patients over the same time period and in whom cerebrovascular disease was documented (CABG/CVD). Note that all CABG/CVD patients underwent carotid duplex ultrasonography/angiography (see Fig 1), and were deemed to be either free of significant carotid disease or rarely may have had complete occlusion (ie, inoperable) of one of their carotid arteries.
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Comment |
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CABG patients with coexistent carotid and coronary disease are at increased risk of adverse cerebral outcomes and hence represent a particularly challenging group of patients. Surgical methods aimed at reducing such risks are therefore desirable [24] and continue to be a topic of significant debate and, currently, surgical treatments of such concomitant disease are not uniform. Numerous authors have presented conflicting findings comparing a combined versus a staged surgery and thus the optimal treatment remains a controversial question. A number of clinical factors potentially contribute to the decision of whether a combined or staged surgical approach to the treatment of concomitant carotid and coronary disease is appropriate. For instance, if carotid surgery is to be undertaken in patients with symptomatic coronary artery disease, the studies have suggested an incidence of postoperative myocardial infarction of approximately 7%, in contrast to an incidence of 1% if the CEA is done in nonsymptomatic patients [6, 26].
Recently published randomized trials of patients with symptomatic carotid artery disease of moderate to high-grade stenosis, demonstrated that carotid endarterectomy will decrease the risk of cerebrovascular accidents as compared with the nonoperated groups [1, 2]. In patients with documented carotid stenosis greater than 80%, the incidence of stroke during CABG increases substantially (15% to 20%) and may be a strong argument to have carotid endarterectomy precede coronary revascularization, if the procedure is not to be done combined [27].
It is suggested that the etiology of cardiovascular accidents in patients undergoing elective CABG is for the most part embolic in nature and not due to local thrombosis secondary to a low-flow state [31]. The correlation of advanced age and the extent of arteriosclerotic disease is proportional and quite significant. Kouchoukas and colleagues [32] demonstrated that embolic strokes will predominate in the setting of significant arteriosclerosis of the ascending aorta and arch, if the situation is not properly diagnosed and corrected by appropriate surgical approaches.
The objective of our investigation was to explore the operative and long term outcome of combined coronary and carotid artery surgery. We found that combined CABG/CEA did not increase the risk of perioperative stroke (1.1% permanent; 1.6% transient) or operative death (2.6%). Indeed, the incidence of these adverse outcomes compare favorably with recent reports of combined CABG and CEA operation [16–24]. Moreover, the observed mortality in this cohort of CABG/CEA patients is in fact lower (observed/expected [O/E] = 0.60) than the expected mortality for isolated CABG per STS CABG risk model. Note, this O/E ratio was also similar to CABG only patients with (O/E = 0.64) or without (O/E = 0.72) documented cerebrovascular disease (Table 3).
The presence of left main trunk stenosis is significantly higher in patients with associated carotid artery disease. In their combined CABG/CEA series, Schwartz and colleagues [7] found a 37% (27 of 73) incidence of left main trunk disease as opposed to 14.2% in the remaining coronary artery bypass population. Furthermore, they reported a high operative mortality of 18.5% (5 of 27) in their left main disease subgroup compared to 4.3% (2 of 46) in patients free of left main disease. A subanalysis of our CABG/CEA series concurs with Schwartz [7] in that left main disease (50 of 189; 27%) occurs at a significantly higher rate than the 17% in the isolated CABG population (p = 0.004). In our series, however, the presence of left main disease did not significantly increase operative mortality after CABG/CEA. Specifically, there were 2 operative deaths in 50 patients with left main artery disease (4%, O/E = 0.85) compared with 3 deaths in 139 patients with no documented left main artery disease (2.2%; O/E = 0.5).
Two recent metaanalyses of the published literature have been conducted to investigate the risks and benefits of a "staged" versus "combined" carotid and coronary surgery [28, 29]. The first study conducted by an ad hoc committee of the American Heart Association reviewed 56 reports that dealt with combined, staged, or reverse-staged methods [28]. They found a similar risk of perioperative stroke for combined and staged approaches, while the encountered risks of perioperative myocardial infarction and death were significantly greater for staged procedures. The other review [29] included only a subset of 16 studies that included both staged versus combined surgical groups, and concluded that combined surgery increased the risk of both stroke and death.
A few studies have reported the long-term outcome of patients undergoing CABG/CEA surgery [8, 11–13, 25–27]. In this series, we report 5-year survival and other long term outcomes in a large single institution series (n = 189) in whom the combined surgery was performed over a fairly short and recent time period (1994 to 1999). When this study was conducted (February 2001), 156 of 189 (82.5%) were alive, and complete follow-up was obtained in 98% of patients (153 of 156). The Kaplan-Meier survival analysis indicates a 91% and 79.4% survival after 1 and 5 years, respectively (Fig 2). A similar Kaplan-Meier analysis of 532 isolated CABG patients with documented "nonsurgical" cerebrovascular disease over the same time period indicated an almost identical 5-year survival pattern (Fig 2). The long-term survival results in our series indicate that the combined surgery does not negatively affect survival between 1 and 5 years after surgery compared with similar age patients that underwent isolated CABG but have a history of CVD also. In fact, survival over the first 12 months after surgery was slightly yet consistently better for the CABG/CEA patients (see insert in Fig 2).
Diagnostic, therapeutic and technical advances of contemporary cardiac surgery, operative myocardial protection, hemodynamic stability, patient monitoring, and medical management have been important factors contributing to the increased safety of combined coronary and carotid artery surgery [12, 20, 26, 32]. Hertzer and colleagues [12] compared results from 131 combined and 105 staged patients and found a lower stroke (5.3% versus 11.4%) and stroke/death (8.4% versus 13.3%) with combined versus staged surgery. Note, this contrasts with an earlier report (115 combined, 59 staged) by the same group in which both stroke (8.7% versus 5.1%) and stroke/death (13.0% versus 6.8%) were greater with combined surgery [5]. Takach and associates [20] compared the results of staged and combined surgery for two time periods (1975 to 1985 versus 1986 to 1996). They too found a similar trend of increased safety of the combined procedure over the two time periods (stroke: 5.4% down to 1.9%; stroke/death: 8.1% down to 5.7%). Their 1986 to 1996 results show similar rates of stroke, stroke/death, and myocardial infarction for combined and staged surgeries.
The obtained early and 5-year outcomes allow us to conclude that, at least in our experience, the implemented combined surgical approach is safe. Our data indicate that the combined procedure is equally safe in patients with unstable angina or left main disease and that these patients should not be denied the possible benefits of the procedure, provided they are appropriately managed. This interpretation conforms with the conclusion of Brener and associates [28] that a superior outcome may be achieved with the combined operation. An economic benefit may also be inferred by the avoidance of two separate operative procedures and hospitalizations, as well as preventing substantially prolonged hospital stays in patients with perioperative cerebrovascular accidents. While our data may suggest it, the clinical question of the possible benefits of combined compared with staged procedures can best be addressed in trials where patients are randomized to the two treatment strategies. Indeed, one cannot disprove the possibility that the same set of patients may have had similar or even superior results using a staged surgical approach. Other potential approaches such as carotid stenting versus CEA or CEA with off-pump CABG are other potential strategies that warrant future investigation. An important consideration if any such randomized studies are conducted is the potential increased risk of myocardial injury in patients with symptomatic CAD when the CEA precedes CABG or an increased risk of stroke if the staging is reversed. Indeed, some authors have suggested that such studies should be limited to patients with stable angina [6, 26]. Finally, conducting such trials may be complicated by ethical dilemmas on the part of surgeons, whose experiences suggest strongly that one approach or the other has proven to be superior in their hands.
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