Combined carotid endarterectomy and coronary artery bypass grafting in patients with asymptomatic high-grade stenoses: An analysis of 758 procedures

Heart surgery and simultaneous carotid endarterectomy - 10-years single-center experience

BACKGROUND

Patients with coronary artery heart disease frequently suffer concomitant carotid vascular disease and are at high perioperative risk for neurological adverse events. Several concepts regarding the timing and modality of carotid revascularization are controversially discussed in patients with heart disease. Current guidelines recommendations on myocardial revascularization recommend a concomitant carotid endarterectomy (CEA) in patients with a history of stroke/transient ischemic attack (TIA) or 50-99% grade of the carotid stenosis. Our study aimed to analyze early outcome parameters of patients undergoing coronary artery bypass grafting (CABG), but also including concomitant heart valve surgery and simultaneous CEA.

METHODS

This study retrospectively analyzed a cohort of 111 patients from our institutional database undergoing heart surgery with CABG or heart-valve surgery between 2010 and 2020 with concomitant carotid surgery due to significant carotid stenosis.

RESULTS

Patients undergoing heart and simultaneous carotid surgery were 77 ± 8.0 years of age with a body mass index of 28 ± 1.7 kg/m2 and a mean EuroSCORE II of 6.5 ± 2.3. Most patients (61%) had a smoking history and arterial hypertension (97%). The preoperative mean grade of internal carotid stenosis was 87 ± 4.2%, 13% of patients suffered from internal carotid artery stenosis on both sites. In total, 4.5% of patients had previously undergone internal carotid artery intervention before and 6.3% had a history of stroke with a persistent neurologic disorder in 1.8%, 8.9% of cases had prior TIA. Thirty-day all-cause mortality was 6.3% and postoperative neurologic events occurred with 7.2% TIA and 4.5% of disabling stroke.

CONCLUSION

Within the reported patient population of coronary artery heart disease and significant internal carotid stenosis, a one-time approach with CABG or heart-valve surgery and CEA is safe and feasible as justified by clinical and neurological postoperative outcomes.

Outcomes of simultaneous carotid endarterectomy and coronary artery bypass grafting: A single centre experience

OBJECTIVE

Stroke following a coronary artery bypass surgery is a well-known complication often predisposed by carotid artery disease. Perioperative risk of stroke after on-pump cardiac surgery can overall affect 2% of patients. Patients with 80-99% unilateral carotid artery stenosis carry a 4% risk of stroke. Significant carotid artery stenosis is present in 3-10% of patients who are candidates for coronary artery bypass grafting (CABG). Those patients might be considered for either simultaneous or staged carotid endarterectomy and CABG to reduce the risk of stroke and death. The purpose of this study was to evaluate preoperative and intraoperative risk factors for myocardial infarction (MI), stroke and death and assess complications occurring during the early postoperative period after simultaneous CABG/CAE procedure.

METHODS

A single centre retrospective analysis of 134 patients from 2015 to 2019 who underwent simultaneous CABG/CEA was performed. At the same period, a total of 2827 CABG were performed, of which 4.7% were simultaneous interventions. We excluded staged CEA/CABG procedures, off-pump CABG and urgent CABG patients. All patients included in the study met the criteria for elective CABG for triple-vessel or left main trunk symptomatic coronary artery disease (CAD) with asymptomatic >70% carotid stenosis or symptomatic ipsilateral >50% carotid stenosis regardless of the degree of contralateral carotid artery stenosis. Patient demographics, comorbidities and operative details were reviewed. The primary endpoint was to assess the intraoperative and 30-day risk of stroke and death after simultaneous CEA/CABG procedure.

RESULTS

Simultaneous CEA/CABG is effective procedure that can be performed in high-risk symptomatic patients with acceptable results. Predictors of postoperative stroke were smoking (P = 0.011), history of MI (P = 0.046), history of CABG (P = 0.013), and history of stroke/TIA (P = 0.005). Significant risk factors for adverse major postoperative complications after simultaneous CEA/CABG procedure were cardiac arrhythmia (AF or AFL) (P = 0.045), previous MI (P < 0.001), and smoking (P = 0.001).

CONCLUSIONS

Synchronous CEA/CABG procedure can be performed with acceptable results in patients having a high risk of stroke, septuagenarians and older.

Major Adverse Cardiac and Cerebrovascular Events in Patients Undergoing Simultaneous Heart Surgery and Carotid Endarterectomy

BACKGROUND

Patients with simultaneous relevant internal carotid artery stenosis and coronary artery heart or valve disease represent a high-risk collective with respect to cerebral or cardiovascular severe events when undergoing surgery. There exist several concepts regarding the timing and modality of carotid revascularization, which are controversially discussed in patients with heart disease. More data regarding outcome predictors and measures are needed to gain a better understanding of the best treatment option of the discussed patient collective.

METHODS

This single-center study retrospectively analyzed n = 111 patients undergoing heart surgery with coronary artery bypass grafting or heart-valve surgery and concomitant carotid surgery due to significant internal carotid artery stenosis. In order to do so, patients were divided into two groups with respect to postoperative major adverse cardiac and cerebrovascular events (MACCE) with thirty-day all-cause mortality, valve related mortality, myocardial infarction, stroke and transitory ischemic attack.

RESULTS

Preoperative patient's characteristic in the no-MACCE and MACCE group were mainly balanced, other than higher rates of chronic obstructive pulmonary disease, chronic kidney disease, instable angina pectoris and prior transitory ischemic attack in the MACCE cohort. The analysis of intraoperative characteristics revealed a higher number of intra-aortic balloon pump implantation, which is in line for a higher number of postoperative supports. Besides MACCE, patients suffered significantly more often from postoperative bleeding events and re-thoracotomy, cardiopulmonary reanimation, new onset postoperative dialysis and prolonged intensive care unit stay related complications.

CONCLUSIONS

Within the reported patient population suffering from MACCE after a simultaneous carotid endarterectomy and heart surgery, a preoperative history of transitory ischemic attack and kidney disease might account for worse outcomes, as severe events were not only neurologically driven but also associated with postoperative cardiovascular complications following heart surgical procedures.

Lessons learned during a 30-year experience with simultaneous carotid endarterectomy and coronary artery bypass grafting

OBJECTIVE

A simultaneous operative approach to patients with significant carotid and coronary disease has been suggested as a safe, lower cost, and more convenient alternative to a staged approach. During the last three decades, spanning the career of our senior author, our group has pursued simultaneous coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) in limited circumstances. We previously reported on our results in series from 1984 to 1994 and 1994 to 1999. Based on these prior results and the current literature, we liberalized our inclusion criteria. We are now reporting on a contemporary cohort of 91 patients operated on from 2006 to 2018.

METHODS

All patients who underwent combined CEA/CABG in 2006 to 2018 were entered into the Vascular Quality Initiative database. We compared the current series of 91 patients (group 3) with the 74 patients (group 2) from 1994 to 1999 and the 100 patients (group 1) from 1984 to 1994 who also underwent combined CEA/CABG. We examined demographic and comorbid factors, presence of cerebrovascular symptoms, degree of contralateral carotid stenosis, perioperative stroke, and death. Statistical comparison was made with χ² analysis.

RESULTS

The groups had similar demographics and comorbidities. Significant differences were noted in the preoperative diagnosis of hyperlipidemia (42%, 51%, 75%; P = .005) and the proportion of patients requiring urgent operations (24%, 47%, 56%; P = .002) during successive time periods. Patients in group 3 were much less likely to have preoperative symptoms from carotid stenosis before operation (55%, 31%, 4.4%; P < .001). Correspondingly, patients in group 3 were more likely to have asymptomatic unilateral carotid stenosis (20%, 55%, 78%; P < .001). The 30-day mortality rate remained stable compared with the first interval (8%, 3%, 2.2%; P = .11). Likewise, the overall stroke rate decreased in the later periods compared with the first series (9%, 1.4%, 2.2%; P = .016). Of the two perioperative strokes recorded for group 3, only one event was ipsilateral to the carotid artery operated on compared with the four ipsilateral strokes of nine total reported in group 1 and no ipsilateral stroke reported in group 2.

CONCLUSIONS

Based on the favorable results of the previously reported series of CEA/CABG from our group, we continued to liberalize selection criteria for the combined procedure to essentially mirror the standard recommendations for CEA in patients without coronary disease. The current series using this treatment algorithm demonstrates the safety of this approach, with stroke and death rates equivalent to those of CABG alone. These excellent results were achieved in the face of increasingly urgent cardiac procedures. The fact that the majority of the perioperative strokes were contralateral to the carotid artery operated on reinforces the safety of our approach but underscores the significant burden of atherosclerosis in these patients.

[Simultaneous brachiocephalic arteries reconstruction and coronary artery bypass grafting]

It is presented the results of simultaneous surgical treatment of 55 patients with brachiocephalic arteries lesion and ischemic heart disease. All patients underwent reconstructive operations on brachiocephalic arteries and CABG. The features of diagnosis and surgical stage are described. The indications for this method are defined. The authors studied russian and world experience; complications of simultaneous operations are presented. It is suggested ways for improvement of results of simultaneous reconstructions.

Simultaneous coronary artery bypass grafting and carotid endarterectomy can be performed with low mortality rates

Introduction

There is controversy over the best approach for patients with concomitant carotid and coronary artery disease. In this study, we report on our experience with simultaneous carotid endarterectomy (CEA) and coronary artery bypass graft (CABG) surgery in our clinic in the light of data in the literature.

Methods

Between January 1996 and January 2009, a total of 110 patients (86 males, 24 females; mean age 65.11 ± 7.81 years; range 44–85 years), who were admitted to the cardiovascular surgery clinic at our hospital, were retrospectively analysed. All patients underwent simultaneous CEA and CABG. Demographic characteristics of the patients and a history of previous myocardial infarction (MI), hypertension, diabetes mellitus, hyperlipidaemia, peripheral arterial disease and smoking were recorded.

Results

One patient (0.9%) with major stroke died due to ventricular fibrillation. Peri-operative neurological complications were observed in seven patients (6%). Complications were persistent in two patients. Four patients (3%) had postoperative major stroke, whereas three patients (2%) had transient hemiparesis. No peri-operative myocardial infarction was observed.

Conclusion

Simultaneous CEA and CABG can be performed with low rates of mortality and morbidity.

Importance of strict patient selection criteria for combined carotid endarterectomy and coronary artery bypass grafting

BACKGROUND

Management of patients with severe concomitant carotid and coronary disease remains controversial. We report our experience of combined carotid endarterectomy (CEA) and coronary artery bypass surgery (CABG) over a fifteen year period using strict patient selection criteria.

METHODS

From 1st January 1995 to December 31st 2009 165 patients underwent combined CABG/CEA procedures at the Mater Hospital. Mean age was 68.2 years (range 43-88) and 127 (77%) were male. Fifty-three (32%) had symptomatic carotid disease. Indications for combined procedures were the presence of symptomatic >70% or asymptomatic >80% internal carotid artery stenosis in a patient requiring urgent CABG because of either unstable angina, recent MI, severe triple vessel disease or severe Left Anterior Descending or Left Main Stem stenosis.

RESULTS

Thirty-day stroke and death rate was 3%. All neurological events were in the hemisphere contralateral to the carotid surgery and symptoms had completely resolved prior to discharge from hospital. One patient required evacuation of a cervical haematoma and there were two transient XII nerve palsies.

CONCLUSION

Combined CEA/CABG can be performed safely with acceptable morbidity and mortality in patients selected in accordance with strict criteria in a centre with a large experience of both cardiac and carotid surgery.

Regional use of combined carotid endarterectomy/coronary artery bypass graft and the effect of patient risk

INTRODUCTION

Although carotid artery stenosis and coronary artery disease often coexist, many debate which patients are best served by combined concurrent revascularization (carotid endarterectomy [CEA]/coronary artery bypass graft [CABG]). We studied the use of CEA/CABG in New England and compared indications and outcomes, including stratification by risk, symptoms, and performing center.

METHODS

Using data from the Vascular Study Group of New England from 2003 to 2009, we studied all patients who underwent combined CEA/CABG across six centers in New England. Our main outcome measure was in-hospital stroke or death. We compared outcomes between all patients undergoing combined CEA/CABG to a baseline CEA risk group comprised of patients undergoing isolated CEA at non-CEA/CABG centers. Further, we compared in-hospital stroke and death rates between high and low neurologic risk patients, defining high neurologic risk patients as those who had at least one of the following clinical or anatomic features: (1) symptomatic carotid disease, (2) bilateral carotid stenosis >70%, (3) ipsilateral stenosis >70% and contralateral occlusion, or (4) ipsilateral or bilateral occlusion.

RESULTS

Overall, compared to patients undergoing isolated CEA at non-CEA/CABG centers (n = 1563), patients undergoing CEA/CABG (n = 109) were more likely to have diabetes (44% vs 29%; P = .001), creatinine >1.8 mg/dL (11% vs 5%; P = .007), and congestive heart failure (23% vs 10%; P < .001). Patients undergoing CEA/CABG were also more likely to take preoperative beta-blockers (94% vs 75%; P < .001) and less likely to take preoperative clopidogrel (7% vs 25%; P < .001). Patients undergoing CEA/CABG had higher rates of contralateral carotid occlusion (13% vs 5%; P = .001) and were more likely to undergo an urgent/emergent procedure (30% vs 15%; P < .001). The risk of complications was higher in CEA/CABG compared to isolated CEA, including increased risk of stroke (5.5% vs 1.2%; P < .001), death (5.5% vs 0.3%; P < .001), and return to the operating room for any reason (7.6% vs 1.2%; P < .001). Of 109 patients undergoing CEA/CABG, 61 (56%) were low neurologic risk and 48 (44%) were high neurologic risk but showed no demonstrable difference in stroke (4.9% vs 6.3%; P = .76), death, (4.9 vs 6.3%; P = .76), or return to the operating room (10.2% vs 4.3%; P = .25).

CONCLUSIONS

Although practice patterns in the use of CEA/CABG vary across our region, the risk of complications with CEA/CABG remains significantly higher than in isolated CEA. Future work to improve patient selection in CEA/CABG is needed to improve perioperative results with combined coronary and carotid revascularization.

Patients With Severe Asymptomatic Carotid Artery Stenosis Do Not Have a Higher Risk of Stroke and Mortality After Coronary Artery Bypass Surgery

Background and Purpose—

Stroke development is a major concern in patients undergoing coronary artery bypass grafting (CABG). Whether asymptomatic severe carotid artery stenosis (CAS) contributes to the development of stroke and mortality in such patients remains uncertain.

Methods—

A retrospective analysis of 878 consecutive patients with documented carotid duplex ultrasound who underwent isolated CABG in our institution from January 2003 to December 2009 was performed. Patients with severe CAS (n=117) were compared with those without severe CAS (n=761) to assess the rates of stroke and mortality during hospitalization for CABG. The 30-day mortality rate was also assessed.

Results—

Patients with severe CAS were older and had a higher prevalence of peripheral arterial disease and heart failure. Patients with severe CAS had similar rates of in-hospital stroke (3.4% versus 3.6%; P =1.0) and mortality (3.4% versus 4.2%; P =1.0) compared with patients without severe CAS. The 30-day rate of mortality was also similar between the 2 cohorts (3.4% versus 2.9%; P =0.51).

Conclusions—

Severe CAS alone is not a risk factor for stroke or mortality in patients undergoing CABG. The decision to perform carotid imaging and subsequent revascularization in association with CABG must be individualized and based on clinical judgment.

Asymptomatic carotid disease and cardiac surgery consensus

The Carotid Disease and Cardiac Surgery Consensus Meeting was convened as a multidisciplinary gathering to consider the management of patients undergoing cardiac surgery who are found to have asymptomatic carotid artery disease. There are no randomized trials concerning whether carotid interventions are of value in this situation and the natural history is unclear. Bilateral carotid artery disease (≥70% stenosis) should be regarded clinically relevant when considering hemodynamic and short-term surgical stroke risk. However, this may be because the presence of significant carotid disease is also a marker for aortic arch and intracerebral disease. A natural history study is urgently needed to determine the incidence, predictive factors, and natural history of asymptomatic carotid disease in patients undergoing contemporary cardiac surgical interventions to inform the design of any future randomized trial.

Combined Carotid Endarterectomy and Coronary Artery Bypass Grafting Versus Coronary Artery Bypass Grafting Alone: A Retrospective Review of Outcomes at Our Institution

Background: It remains controversial whether patients with concomitant carotid and coronary disease should undergo operative repair separately or in combination. Methods: Patients with documented cerebrovascular disease undergoing coronary artery bypass grafting (CABG) alone were matched by propensity scoring with patients undergoing combined carotid endarterectomy (CEA)/CABG procedures and compared for the occurrence of stroke, myocardial infarction (MI), and mortality. Results: Of the 4943 patients undergoing CABG, 908 had known cerebrovascular disease. Among these, 134 underwent concomitant CEA, and these were propensity matched with 134 patients undergoing CABG only. No differences were observed in the perioperative risks of stroke (4% vs 3%, odds ratio [OR] 1.5, 95% confidence interval [CI] 0.4-5.5), MI (0.7% vs 0.7%, not significant [NS]), or combined cardiovascular events (6% vs 10%, OR 0.5, 95% CI [0.2-1.3]), although mortality (1% vs 8%, OR 0.2, 95% CI [0.04-0.8] was higher with CABG only. Discussion: Addition of CEA to CABG did not significantly alter the risk of perioperative stroke relative to propensity-matched patients undergoing CABG alone.

Current outcomes of simultaneous carotid endarterectomy and coronary artery bypass graft surgery in North America

OBJECTIVE

Management of patients with concomitant carotid and coronary artery disease has been controversial. Divergent strategies have been employed, including simultaneous carotid endarterectomy and coronary bypass (SCC) versus various staged procedures. Although no strict comparison group is available, this study defines current outcomes of SCC, compared qualitatively to two reference categories.

METHODS

Utilizing the STS database from 2003 to 2007, patients who had SCC were compared with patients with cerebrovascular disease who had coronary bypass (CABG) with prior carotid endarterectomy (CEA), and those with carotid Doppler stenosis >75% and no carotid intervention. Logistic regression analysis adjusted for differences in baseline characteristics and operative mortality (OM), and a composite of neurological complications (NC) was assessed.

RESULTS

Of 745,769 patients who underwent isolated CABG with/without CEA, 108,212 (14%) had cerebrovascular disease. Of this group, 5,732 (5%) underwent SCC. The SCC group had more males and lower preoperative risk factors. After statistical adjustment for all baseline differences, SCC had clinically and statistically higher OM and NC compared with any of the reference groups, with 20-40% higher event risk.

CONCLUSIONS

Although no quantitative control group exists for comparison, SCC as recently performed in North America has a high risk compared with any of the reference groups. Suboptimal results associated with the SCC strategy suggest a need for quality improvement and research on the optimal management of patients with simultaneous carotid and coronary disease.

Treatment strategy for combined carotid artery stenosis and coronary artery disease: staged or simultaneous surgical procedure?

Patients with combined carotid and coronary arterial diseases pose a high risk of cerebrovascular events, and the treatment of choice with either a simultaneous or a staged surgical procedure remains controversial. The literature of combined carotid and coronary arterial diseases of a recent decade in English was retrieved. Totally 41,901 patients undergoing simultaneous or staged carotid and coronary procedures from 53 reports were included. As a result, carotid endarterectomy plus coronary artery bypass remained the most commonly used procedure for the intervention of combined carotid artery stenosis and coronary artery disease, and was associated with higher incidences of perioperative transient ischemic attack, stroke and hospital mortality, but with less perioperative myocardial infarction comparing with the staged procedures. Patients with a simultaneous carotid endarterectomy and coronary artery bypass were generally related more to an advanced atherosclerotic coronary artery disease, so that a pure comparison between the two strategies was not always possible. To compare the efficacy of different surgical methods for combined carotid and coronary arterial diseases is of pronounced importance. The new hybrid approach consisting of the simultaneous carotid artery stenting and subsequent on-pump coronary artery bypass can be a safe approach, with the aim to reduce the surgical trauma as compared to surgical procedures, and to reduce the risk of myocardial infarction in the interval period required for the staged operations. Thus, for patients with combined carotid artery stenosis and coronary artery disease, the simultaneous surgical procedure, rather than the staged procedure, is recommended.

Mathematical Modeling in Cardiac Surgery: Helping Clinical Trials Answer the Question

Mathematical modeling, based on fundamental principles from engineering may help clinical trial design, aiding in answering problems that remain in cardiac surgery, such as management of carotid artery stenosis in patients undergoing cardiopulmonary bypass (CPB), hematocrit during CPB, adequacy of oxygen delivery during CPB, adequacy of blood pressure management during CPB, filtration during bypass for renal failure, bypass circuit pacification, carbon dioxide wound insufflation and neurological events, and pulsatile to nonpulsatile flow during CPB. In addition, mathematical modeling may help explain deficiencies of previous work that have failed to clarify what to do.

Análise crítica das indicações e resultados do tratamento cirúrgico da doença carotídea

O tratamento da doença carotídea tem ganhado enfoque nos últimos anos, principalmente com o advento da técnica endovascular, que defende o emprego da angioplastia e stent de carótida (CAS), principalmente em pacientes considerados de "alto risco" para a endarterectomia carotídea (ECA). Através da revisão bibliográfica, analisamos os resultados do tratamento da lesão carotídea em ambas as técnicas, realizando comentários embasados na experiência pessoal e nos dados da literatura, sobretudo nos pacientes de alto risco. Até o presente momento, não há evidência e justificativa para o emprego da CAS em larga escala nos pacientes com doença carotídea, inclusive nas situações de alto risco, tais como nos octogenários. No entanto, acreditamos que a CAS possa ser um coadjuvante no tratamento de pequeno número de pacientes com lesão carotídea (até 4% dos casos), como na presença de pescoço hostil, radioterapia prévia e alguns casos de estenose carotídea alta. Quando realizada com os cuidados técnicos necessários, a ECA ainda continua a melhor opção terapêutica aos doentes com lesão carotídea.

Combined coronary artery bypass grafting and phaeochromocytoma excision

We report two patients who had successful combined coronary artery bypass grafting and excision of phaeochromocytoma. These cases represent the first reports of combined coronary artery bypass grafting and laparoscopic adrenalectomy for phaeochromocytoma and of combined coronary artery bypass grafting and excision of extra-adrenal phaeochromocytoma. With careful peri- and intra-operative management, especially in regard to haemostasis, combined operations for coronary artery disease and phaeochromocytoma are both feasible and safe.