Ann Thorac Surg 1997;64:22
© 1997 The Society of Thoracic Surgeons
Discussion
Discussion
See also page 16.
DR TIMOTHY L. PANSEGRAU (Charlotte, NC): I enjoyed your presentation and found your results very interesting. Francis Robicsek and I reviewed the data of our group from the Carolina Heart Institute on combined versus staged carotid endarterectomy/coronary artery bypass grafting and found results that were quite different from yours. It has been our practice in patients with severe carotid artery disease and in need of coronary revascularization to perform combined procedures with both the coronary and carotid operations done by the same surgeon. Over the past 6 years, we have performed more than 125 combined operations, and much to our dismay we found an 8% rate of neurologic complications in these patients and a mortality rate of 4%. At the same time, we had a small group of patients with comparable risk factors. These patients had a carotid endarterectomy followed a day or two later by coronary bypass grafting. In the staged group there were no cardiac events before performance of coronary artery bypass grafting nor were there any strokes or deaths. We then went on to compare this with results of routine carotid endarterectomies done by the same surgeons and observed a 0.9% stroke rate. At the same time our patients undergoing coronary artery bypass grafting without the need of a carotid operation had a 1.0% occurrence of neurologic complications. Based on these results we believe that carotid endarterectomy places an ischemic insult on the brain as does cardiopulmonary bypass. When you combine both at the same setting, the effect may be not merely additive but compounded, thus increasing your stroke rate. We certainly agree that a randomized study is necessary to better address this issue. Finally, my question to you is, given a patient with severe coronary artery disease and in need of carotid endarterectomy, what is your current practice based on your results?
DR TAKACH: Thank you, Dr Pansegrau, for your comments and for the opportunity to review your operative results in detail. Various outcomes have been reported by different institutions. Few conclusions can be drawn from your experience with the staged approach that includes only 15 patients. Your permanent stroke rate of 8% after the simultaneous approach is more than 4 times the contemporary total stroke rate in this report and more than twice the mean outcome derived from the summarized data of 11 large series that include 1,842 patients (Fig 2).
The difference in your outcomes and those of other institutions underlines the need to establish optimal techniques and supports our mutual desire for a well-designed, prospective trial. The high incidence of stroke arising from postoperative arrhythmias in your experience (33%) supports our findings regarding both the cause of stroke and the potential mechanisms that may decrease the incidence of stroke in patients with concomitant disease.
Our current approach has been influenced by advances and findings in three areas. First, we are being referred an increasing percentage of elderly and high-risk patients for elective coronary artery bypass grafting. This fact and the documentation of an increased incidence of stroke after coronary artery bypass grafting in the elderly patients have led us to use an aggressive preoperative screening program to detect significant carotid stenosis.
Second, the results of recently completed prospective trials have established the efficacy of carotid endarterectomy in reducing stroke and death in patients with significant carotid stenosis. As a result, we now also consider patients with an asymptomatic (60%) carotid stenosis for simultaneous treatment of concomitant disease.
Finally, the analyses of our results and the results from other large series reported in the literature suggest that simultaneous treatment is a safe approach and have led our institution to favor this method over the staged approach for the treatment of concomitant disease.
Related Article
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Is an Integrated Approach Warranted for Concomitant Carotid and Coronary Artery Disease?
- Thomas J. Takach, George J. Reul, Jr, Denton A. Cooley, J. Michael Duncan, David A. Ott, James J. Livesay, Grady L. Hallman, and O. H. Frazier
Ann. Thorac. Surg. 1997 64: 16-22.
[Abstract]
[Full Text]
