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Ann Thorac Surg 2000;69:1798
© 2000 The Society of Thoracic Surgeons

Invited commentary

Invited commentary

Richard M. Engelman, MDa

a Division of Cardiac Surgery, Baystate Medical Center, 759 Chestnut St, Springfield, MA 01107, USA

e-mail: richard.engelman{at}bhs.org

Bilfinger and associates have addressed a serious clinical issue in reviewing their experience with combined carotid endarterectomy and coronary artery bypass grafting (CABG) and comparing it with their experience with CABG alone. They obtained carotid duplex scans on every patient undergoing CABG and thus were able to assess the grade of stenosis in each patient. The authors performed prophylactic carotid endarterectomy whenever the degree of stenosis was 80% or greater and noted a stroke incidence of 4.76% in the 84 patients having a combined procedure compared with only 1.71% in the CABG group (1,987 patients). All of the patients had asymptomatic carotid disease as defined by the authors.

This study documented a significantly increased stroke rate (4.76%) in patients with carotid stenosis of 80% or greater who had a combined procedure (carotid endarterectomy plus CABG) compared with patients having CABG alone (1.71%). In addition, 85% of CABG only strokes were embolic in origin (29 of 38 strokes), and this clearly may not be related to carotid disease. Rather, the presence of carotid disease may simply be a marker of the likelihood of intrathoracic aortic atherosclerosis, the most likely source of cerebral embolization during CABG. It is for this reason that an absolute policy of carotid endarterectomy for patients with carotid stenosis of 80% or greater may not reduce the incidence of cerebrovascular accidents associated with CABG. If stroke is a consequence of the endarterectomy itself, one could theoretically increase the prevalence of cerebrovascular accidents by combining carotid endarterectomy and CABG. A large prospective, randomized study is necessary to address this important issue.


Related Article

Coronary and carotid operations under prospective standardized conditions: incidence and outcome
Thomas V. Bilfinger, Hassan Reda, Fabio Giron, Frank C. Seifert, and John J. Ricotta
Ann. Thorac. Surg. 2000 69: 1792-1798. [Abstract] [Full Text] [PDF]




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