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Ann Thorac Surg 2004;78:2042-2043
© 2004 The Society of Thoracic Surgeons
Division of Cardiovascular Surgery, Toronto General Hospital, 200 Elizabeth St, Room EN 13–217, Toronto, ON M5G 2C4, Canada
Mishra and colleagues have presented their results in patients undergoing combined carotid endarterectomy (CEA) and coronary bypass grafting over a 6-year period. They compared results in 166 patients undergoing off-pump surgery to 192 conventional on-pump procedures and found similar results for the two groups. The advantages of this study are its relatively large sample size and the excellent operative results. The perioperative stroke rate was 0.3% and the mortality rate was only 1.4%. These results are truly astounding for such high-risk patients, given that a meta-analysis of the literature revealed stroke rates of 6.0% and mortality rates of 4.7% for combined procedures [1]. The main limitations of the study by Mishra and coworkers are that the selection criteria for on-pump versus off-pump surgery was not explicitly stated, and that more than one half of patients had asymptomatic carotid stenosis. The appropriateness of performing CEA in such patients is open to question.
Asymptomatic carotid stenosis is found in a significant proportion of coronary bypass patients and is associated with an increased risk of stroke. Before we recommend combined procedures in all of these patients, however, a careful review of the literature is warranted. The indications for CEA in asymptomatic carotid stenosis are derived from two large trials–the Asymptomatic Carotid Artery Study (ACAS) [2] and the recently published Asymptomatic Carotid Surgery Trial (ACST) [3]. Both of these trials achieved positive results for CEA because of very low perioperative complication rates. The benefit of CEA is nullified if stroke or mortality rates exceed 3%, a result that is very difficult to achieve in patients undergoing combined carotid and cardiac procedures. In addition, the ACAS and ACST trials excluded patients with significant cardiac disease in order to eliminate the confounding effect of extracarotid sources of stroke. This point is particularly salient for coronary bypass patients because the predominant cause of stroke is embolization from ascending aorta arteriosclerosis, not carotid disease [4]. The potential short-term benefit of CEA in cardiac surgery patients is therefore open to question. Indeed, a systematic review of the literature of patients with asymptomatic carotid stenosis revealed that perioperative stroke rates following isolated coronary bypass were no higher than after combined CEA and CABG [5]. If CEA does not lower the early risk of stroke after cardiac surgery, does it lower the long-term risk? Here, too, the evidence from the literature is lacking. Previous studies have demonstrated that the long-term risk of stroke in patients with asymptomatic carotid disease is only 2% per year [2, 3], which is much less than the 13% per year for symptomatic disease. Such modest gains translate into the reality that 67 CEA procedures must be performed to prevent one stroke 2 years postoperatively versus 6 CEAs for patients with symptomatic stenosis.
In summary, Mishra and colleagues have provided excellent results for these high-risk patients. Caution should be used, however, before routinely recommending combined procedures to cardiac surgery patients with asymptomatic carotid stenosis. A careful review of the literature does not support this practice.
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