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Rivista di Chirurgia Cardiaca, Vascolare e Toracica

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The Journal of Cardiovascular Surgery 1999 December;40(6):837-44

lingua: Inglese

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.

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