Abstract
Introduction: In patients with carotid artery stenosis, combined coronary and carotid surgery has been widely used despite lack of evidence from randomized trials. Moreover, there are no data on long-term outcome following carotid revascularization versus best medical treatment. Hypothesis: May simultaneous coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) prevent the long-term risk of stroke? Methods: In the Coronary Artery Bypass graft surgery in patients with Asymptomatic Carotid Stenosis (CABACS) trial, patients with coronary disease and high-grade carotid stenosis (NASCET >=70%) were randomized to receive combined simultaneous CABG+CEA or CABG alone. Primary endpoint was the composite rate of non-fatal stroke or death within 30 days after surgery, with both treatments assumed to be equally safe and efficacious. Secondary endpoints included any stroke, stroke or vascular death and death of any cause, and follow-up was five years. While our previous report focused on primary outcome, here we evaluate the long-term results of the trial. Results: The trial was terminated prematurely after recruitment of 129 patients in 17 centers in Germany and the Czech Republic. The rate of stroke or death at 30 days was not significantly different following combined CABG+CEA and CABG alone (18.5% (95% confidence interval [95% CI]: 0.099-0.300) versus 9.7% (95% CI: 0.036-0.199), p=0.203). By 5 years, stroke or death rate was 40.6% (95% CI: 0.285-0.536) following CABG+CEA and 35.0% (95% CI: 0.231-0.484) following CABG alone (p=0.581). Strokes of any kind tended to occur more frequently after CABG+CEA (5 years: 29.4% vs. 18.8%, p=0.245), while death rate was similar in both treatment arms (25.4% vs 23.3% (p=0.837). Subgroup analysis revealed no significant effect of center on outcomes. Conclusions: Long-term risk of stroke or death was higher after combined CABG+CEA, mainly due to increased perioperative event rates. Because of minor power, further trials are warranted to confirm our results.
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