ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Harold C. Urschel, Jr
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Urschel, H. C.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Urschel, H. C., Jr
Related Collections
Right arrowRelated Article

Ann Thorac Surg 1999;68:21
© 1999 The Society of Thoracic Surgeons

Invited Commentaries

Harold C. Urschel, Jr, MDa

a 1201 Barnett Tower, 3600 Gaston Ave, Dallas, TX 75246, USA,

Invited commentary

This complete review of literature regarding coronary artery bypass and carotid endarterectomy shows that there is a higher risk in the combined group than for the staged group. This would be expected because of the criteria for patient selection. The authors frequently mention that there are "no criteria for selection." This is not the case. In our paper, as in most reviewed, the indications for selection to the combined surgery group are patients with severe symptoms and anatomical narrowing in both the coronary and carotid systems. The combined group would thus have a higher mortality, but less than if staged (not discussed by the authors, but confirmed in the one partially randomized group reported by Dr Hertzler with a higher mortality in the staged group).

The other factor not addressed is the technical expertise and coordination necessary for successful combined surgery. If two services (cardiac and vascular) are involved, it is usually much more inconvenient and slower than if the same service performs both system surgeries expediently.

The authors mention the risk of thrombosis from fibrinolytics used in C-P bypass combined patients, but failed to emphasize the higher risk of hemorrhagic stroke from the much larger anticoagulant dosage in the same group.

According to the previous Editor of the New England Journal of Medicine Arnold Relman, "you should follow the evidence." However in this case, the evidence analyzed by the paper does not reveal what is the "common sense" practical conclusion. Staging is obviously the safest, unless both carotid and coronary systems are severely compromised, in which case, staging is more risky.


Related Article

Coronary bypass and carotid endarterectomy: does a combined approach increase risk? A metaanalysis
Michael A. Borger, Stephen E. Fremes, Richard D. Weisel, Gideon Cohen, Vivek Rao, Thomas F. Lindsay, and C. David Naylor
Ann. Thorac. Surg. 1999 68: 14-20. [Abstract] [Full Text] [PDF]




This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Harold C. Urschel, Jr
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Urschel, H. C.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Urschel, H. C., Jr
Related Collections
Right arrowRelated Article

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS