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

Operative and long-term outcomes of combined and staged carotid endarterectomy and coronary bypass

OBJECTIVE

Optimal temporal surgical management of significant carotid stenosis and coronary artery disease remains unknown. Carotid endarterectomy (CEA) and coronary artery bypass (CABG) are performed concurrently (CCAB) or in a staged (CEA-CABG or CABG-CEA) approach. Using the Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network-Medicare-linked dataset, this study compared operative and long-term outcomes after CCAB and staged approaches.

METHODS

The Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network dataset was used to identify CEAs from 2011 to 2018 with combined CABG or CABG within 45 days preceding or after CEA. Patients were stratified based on concurrent or staged approach. Primary outcomes were stroke, myocardial infarction (MI), all-cause mortality, stroke and death as composite (SD) and all as composite within 30 days from the last procedure as well as in the long term. Univariate analysis and risk-adjusted analysis using inverse propensity weighting were performed. Kaplan-Meier curves of stroke, MI, and death were created and compared.

RESULTS

There were 1058 patients included: 643 CCAB and 415 staged (309 CEA-CABG and 106 CABG-CEA). Compared with staged patients, those undergoing CCAB had a higher preoperative rate of congestive heart failure (24.8% vs 18.4%; P = .01) and decreased renal function (14.9% vs 8.5%; P < .01), as well as fewer prior neurological events (23.5% vs 31.4%; P < .01). Patients undergoing CCAB had similar weighted rate of 30-day stroke (4.6% vs 4.1%; P = .72), death (7.0% vs 5.0%; P = .32), and composite outcomes (stroke and death, 9.8% vs 8.5%; P = .56; stroke, death, and MI, 14.7% vs 17.4%; P = .31), but a lower weighted rate of MI (5.5% vs 11.5%; P < .01) vs the staged cohort. Long-term adjusted risks of stroke (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.54-1.36; P = .51) and mortality (HR, 1.02; 95% CI, 0.76-1.36; P=.91) were similar between groups, but higher risk of MI long-term was seen in those staged (HR, 1.49; 95% CI, 1.07-2.08; P = .02).

CONCLUSIONS

In patients undergoing CCAB or staged open revascularization for carotid stenosis and coronary artery disease, the staged approach had an increased risk of postoperative cardiac event, but the short- and long-term rates of stroke and mortality seem to be comparable. Adverse cardiovascular event risk is high between operations when staged and should be a consideration when selecting an approach. Although factors leading to staged sequencing performance need further clarity, CCAB seems to be safe and should be considered an equally reasonable option.

Carotid endarterectomy with concomitant distal endovascular intervention is associated with increased rates of stroke and death

OBJECTIVE

Carotid endarterectomy (CEA) with concomitant distal endovascular intervention (CEA+D) is infrequently necessary but has often been used as a salvage maneuver when complications occur during CEA. The present study aimed to determine whether preoperative risk factors associated with CEA requiring CEA+D exist and to evaluate the outcomes compared with isolated CEA.

METHODS

The Vascular Quality Initiative CEA registry was used to identify patients who had undergone CEA or CEA+D for asymptomatic or symptomatic carotid stenosis from 2013 to 2019. Data regarding distal intervention included whether angioplasty or stenting of the distal internal carotid artery (ICA) and/or bifurcation had been required. However, information regarding the indication or whether the intervention had been planned was not included. The χ² test and analysis of variance were used to evaluate the categorical and continuous perioperative variables. Variables with P < .20 on univariate analysis were included in the multivariable analysis to assess for preoperative predictors of the need for CEA+D and the association with perioperative stroke.

RESULTS

From 2013 to 2019, 327 CEA+D cases were identified and compared with 105,192 isolated CEA cases. The CEA+D patients were more likely to have undergone previous ipsilateral CEA (CEA, 1.8%; CEA+D, 4.9%; P < .01) and contralateral ICA occlusion (CEA, 4.6%; CEA+D, 11.0%; P < .01) but were less likely to have had ipsilateral stenosis ≥70% (CEA, 88.3%; CEA+D, 80.6%; P < .01). The preoperative factors associated with the need for CEA+D on multivariable analysis included previous peripheral vascular intervention, American Society of Anesthesiologists class ≥4, contralateral ICA occlusion, low-volume surgeon, and previous ipsilateral CEA. CEA+D was associated with significantly increased rates of stroke in both asymptomatic (CEA+D, 3.9%; CEA, 0.9%; P < .01) and symptomatic (CEA+D, 9.4%; CEA, 1.9%; P < .01) patients. CEA+D was associated with decreased rates of 30-day survival in both asymptomatic (CEA+D, 98.3%; CEA, 99.4%; P = .02) and symptomatic (CEA+D, 94.8%; CEA, 99.1%; P < .01) cohorts. On multivariable analysis, CEA+D remained significantly associated with stroke (odds ratio, 3.17; 95% confidence interval, 1.80-5.60; P < .01). Other factors significantly associated with perioperative stroke included procedure length >135 minutes, diabetes, hypertension, shunt for indication, symptomatic status, previous ipsilateral CEA, contralateral ICA occlusion, urgent or emergent procedure, intravenous medications for hemodynamic instability, and re-exploration at the initial operation.

CONCLUSIONS

Although markers of more significant cardiovascular disease burden were associated with the use of CEA+D, their power to predict CEA+D use was limited. In cases in which CEA+D was used, CEA+D was associated with significantly greater rates of perioperative stroke and mortality compared with isolated CEA for both asymptomatic and symptomatic patients, which could be useful for framing the expected outcomes after these procedures.

Asymptomatic carotid intraplaque hemorrhage is associated with a high risk of cerebral infarction and death after cardiovascular surgery

BACKGROUND

There is a lack of information on the natural history of asymptomatic carotid artery stenosis (AsymCS) associated with cardiovascular diseases that require surgery. The aim of this study was to investigate risk factors for postoperative ipsilateral ischemic stroke and all-cause mortality after cardiovascular surgery in patients with AsymCS.

METHODS

Among 2158 patients who underwent cardiovascular surgery, 150 patients with AsymCS who didn't undergo carotid revascularization were included. The relationships between preoperative factors, including carotid intraplaque hemorrhage (IPH), and postoperative ipsilateral ischemic stroke and all-cause mortality were analyzed retrospectively.

RESULTS

During the median follow-up of 1087 days of 150 patients with 19 IPH, 12 (8.0%) and 21 (14.0%) encountered ipsilateral infarction and all-cause mortality, respectively. Multivariable Cox regression analyses indicated that IPH was significantly predictive of both ipsilateral infarction (hazard ratio [HR] 21.31, 95% confidence interval [CI], 4.98-91.17; P ≤.001) and all-cause mortality (HR 4.64, 95% CI, 1.61-13.34; P = .004). Another significant factor was peak systolic velocity for ipsilateral infarction with the cutoff velocity of 227 cm/s by the receiver-operating characteristic curve.

CONCLUSIONS

In this cohort of patients with AsymCS undergoing cardiovascular surgery, IPH had a close connection with a high risk of both postoperative ischemic stroke and mortality after cardiovascular surgery.

Combined surgical treatment of symptomatic carotid, coronary and mesenteric occlusive disease

The surgical management of advanced symptomatic atherosclerotic disease in multiple distributions including the coronary circulation presents unique challenges due to the high risk of perioperative ischemic complications in the setting of coronary artery bypass grafting. We present a novel case of the combined surgical management of symptomatic carotid, coronary and mesenteric ischemic disease. The patient underwent carotid endarterectomy followed by combined coronary and mesenteric revascularization using cardiopulmonary bypass during the same hospital admission. He had an uncomplicated post-operative course and was discharged to home on post-operative day 7 after the combined procedure. Ninety-day follow-up was also unremarkable with the patient having no recurrent symptoms of ischemia. This case demonstrates the feasibility and safety of our approach for this rare clinical presentation.

Regional variation in use and outcomes of combined carotid endarterectomy and coronary artery bypass

OBJECTIVE

In treating concomitant carotid and coronary disease, some recommend staged carotid endarterectomy (CEA) and coronary artery bypass grafting, whereas others favor the combined approach (CCAB). Pressure to reduce surgical variation and to improve quality is real, yet little is known about how geographic practice differences affect outcomes. Using the Vascular Quality Initiative (VQI), this study evaluated regional variation in use and outcomes of CCAB.

METHODS

All CCAB procedures in the VQI from 2003 to 2017 were reviewed and stratified into four regions, as defined by the United States Census Bureau. Primary outcomes included perioperative stroke, death, myocardial infarction (MI), and these as composite (SDM). A χ² analysis was performed.

RESULTS

There were 1495 CCAB procedures identified, representing 1.8% of the VQI CEAs. Regions included the following: Midwest (MW), 32%; Northeast (NE), 39%; South (S), 25%; and West (W), 4%. Most were male (70%) and white (92%). There was significant regional variation in proportional volume of CCABs to all CEAs (0.7% [W] to 2.5% [MW]; P < .001). Regional variation in patch use (78% [W] to 93% [MW]; P < .001), shunting (29% [W] to 71% [MW]; P < .001), and electroencephalography monitoring (13% [W] to 52% [NE]; P < .001) was also significant. Overall perioperative stroke was 3.6%; death, 3.0%; and SDM, 6.8%. No regional difference was seen in outcomes of mortality (1.5% [MW] to 4.2% [NE]; P = .05), stroke (2.8% [NE] to 4.4% [MW]; P = .52), and MI (0.6% [MW] to 1.8% [W]; P = .62). When the Bonferroni correction was used, there remained no difference in stroke, MI, or SDM across regions, but mortality became significant. Using the Society for Vascular Surgery guidelines for consideration of CCAB, the minority of patients fell within the symptomatic carotid stenosis (SYMP, 15%; n = 218) or severe (≥70%) asymptomatic bilateral carotid disease (BIL, 18%; n = 267) categories. The most common indication was asymptomatic unilateral severe carotid stenosis (UNI, 37%; n = 552). There were no differences in regional outcomes stratified by indication (SYMP, BIL, UNI). Overall, when SYMP and BIL were compared with UNI, UNI had lower rates of stroke (2.4% vs 4.9%; P = .03) but similar MI (0.7% vs 1.2%; P = .40) and mortality (2.2% vs 2.5%; P = .75).

CONCLUSIONS

Significant variation exists across VQI centers in the use of CCAB. Despite differences in volume and practices, regional perioperative outcomes are similar. UNI is the most commonly used indication and has lower stroke rates relative to SYMP and BIL. CCAB is performed well across the United States, but most patients fall outside of Society for Vascular Surgery guidelines.

Characterization of perioperative contralateral stroke after carotid endarterectomy

OBJECTIVE

Contralateral stroke is an infrequent cause of perioperative stroke after carotid endarterectomy (CEA). Whereas the risks of ipsilateral stroke complicating CEA have been discriminated, factors that lead to contralateral stroke are poorly defined. The purpose of this study was to identify the risk of perioperative (30-day) contralateral stroke after CEA as well as predisposing preoperative and operative factors. Its specific effect on long-term survival was interrogated.

METHODS

The Vascular Study Group of New England (VSGNE) was queried from April 1, 2003, to February 29, 2016, for all CEAs. Duplicated patients and those without complete data were excluded. Patients sustaining contralateral stroke after CEA in the 30-day postoperative period were identified. Demographic, preoperative, and operative factors were analyzed to identify discriminators between those with and those without contralateral stroke. Logistic regression modeling was performed to identify factors independently associated with contralateral stroke. The effect of contralateral stroke on 5-year survival was compared with patients with ipsilateral stroke and no stroke using the Kaplan-Meier method. Log-rank testing compared survival curves.

RESULTS

There were 10,837 CEAs performed during the study. Average age was 70.4 ± 9.3 years; 6605 (61%) patients were male, and 40% (n = 4324) were performed for symptoms. Most were current or former smokers (n = 8619 [80%]). Coronary artery disease and congestive heart failure were identified in 31% and 8.6%, respectively. Overall, there were 190 strokes within 30 days of CEA (1.8%); 131 were ipsilateral (1.3%), and 59 (0.5%) patients were identified as having contralateral perioperative stroke. Thirteen patients sustained bilateral stroke (0.1%). Significant univariate associations included urgency (P = .0001), ipsilateral stenosis severity (P = .004), length of operation (P = .0001), CEA with coronary artery bypass graft (P = .0001), CEA with other arterial surgery (P = .01), and CEA with proximal endovascular procedure (P = .03). Contralateral occlusion (P = .06) and degree of contralateral carotid stenosis (P = .14) did not correlate. After logistic regression analysis of significant univariate anatomic and operative factors, length of procedure (odds ratio [OR], 1.08/15 minutes; 95% confidence interval [CI], 1.01-1.15; P = .02), urgency of operation (OR, 2.5; 95% CI, 1.3-4.6; P = .006), and concomitant proximal endovascular intervention (OR, 8.7; 95% CI, 4.5-31.2; P = .001) remained predictors of contralateral stroke after CEA. Occurrence of both ipsilateral (P < .001) and contralateral (P = .023) stroke significantly reduced 5-year survival compared with those without stroke. There was no difference in the negative survival effect based on laterality of stroke (P = .24).

CONCLUSIONS

Contralateral stroke after CEA is rare, affecting 0.5% of patients. Traditional risk reduction medical therapy does not affect occurrence. Degree of contralateral stenosis, including contralateral occlusion, does not predict perioperative contralateral stroke. Urgency of operation, length of operation, and performance of concomitant, ipsilateral endovascular intervention predict contralateral stroke risk with CEA. Contralateral stroke affects long-term survival similar to ipsilateral stroke after CEA.

Perioperative management of combined carotid and coronary artery bypass grafting procedures

The objective of this review is to provide a high level overview on current thinking for treatment of patients with combined carotid and coronary artery disease given that these patients are at higher risk of adverse cardiac events, stroke, and death. This review discusses (1) the current literature addressing perioperative stroke risk in the setting of coronary artery bypass graft, (2) the literature regarding different surgical approaches when both carotid and coronary revascularization are being considered, and (3) the data available to guide optimal management of this complex patient population to minimize complications regardless of the surgical approach taken.