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THE JOURNAL OF CARDIOVASCULAR SURGERY
Rivista di Chirurgia Cardiaca, Vascolare e Toracica
Indexed/Abstracted in: BIOSIS Previews, Current Contents/Clinical Medicine, EMBASE, PubMed/MEDLINE, Science Citation Index Expanded (SciSearch), Scopus
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ORIGINAL ARTICLES VASCULAR PAPERS
The Journal of Cardiovascular Surgery 1999 December;40(6):837-44
Toward a rational management of concomitant carotid and coronary artery disease
Brown T. D., Kakkar V. V., Pepper J. R., Das S. K.
From the Department of Surgery Royal Brompton Hospital, London (UK)
Background. Patients with angina undergoing carotid endarterectomy have a high perioperative mortality. Our aim was to assess the outcome of carotid endarterectomy in patients with concomitant coronary artery disease, in particular, to examine the timing of carotid endarterectomy and CABG.
Methods. A retrospective study was performed at a tertiary and secondary referral centre for cardiovascular disease. Over a five-year period 71 carotid endarterectomies and 6,590 coronary artery bypasses were performed. Significant (>70%) internal carotid stenoses were found in 35 (0.5%) patients due for CABG. Of these, 23 patients underwent Combined procedures (Carotid and CABG), 9 Reverse staged (CABG then Carotid), and 3 Prior staged carotid endarterectomies (Carotid then CABG). 36 other carotid endarterectomies were in patients evaluated cardiologically, but did not require CABG (Isolated group). Risk factors, 30 day perioperative outcome including hospital inpatient stay and early follow-up are reported.
Results. The Combined group 30-day perioperative mortality rate was 4.3% and permanent stroke rate 8.6%. There were no major complications in Reverse or Prior staged cases. Isolated group mortality was 2.7% with no strokes. Risk factors were more prevalent in the combined group; 56% previous myocardial infarction, 39% hypertension, 35% a history of raised cholesterol and 46% intermittent claudication. All cases were followed up for a mean of 18.4 months, with no carotid stroke related events. Overall hospital stay for staged patients was a mean 19.3 days (SE=2.4) days compared to mean 9.8 days for combined patients (SE=0.97, p<0.001).
Conclusions. Patients with combined cardiac and carotid disease benefit from assessment of both systems in order to stage CABG and carotid endarterectomy. Risk factors were more prevalent in the combined group; a combined procedure offered a median difference of 8 days less hospital inpatient stay compared to the staged cases. Our experience suggests that carefully planned management of concomitant coronary and carotid disease can achieve better results.