ORIGINAL ARTICLES  VASCULAR PAPERS 

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

Copyright © 2000 EDIZIONI MINERVA MEDICA

language: English

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.