Invited Commentary

Abstract

Stroke is the most feared complication of cardiac surgery for many patients and a leading cause of postoperative mortality. Predictors of stroke risk have been identified. Although the pathogenesis is multifactorial, postoperative stroke is often attributed to embolic sources from carotid stenosis, atherosclerosis of the ascending aorta, and atrial fibrillation. Concomitant carotid stenosis and coronary artery disease may be found in many patients with common risk factors. Isolated or staged treatment of either disorder places the patient at an increased risk of a complication from the other condition, whereas combined repair has a higher reported complication rate. Thus, the strategy for surgical repair remains controversial. In the present report, Nabagiez and coauthors [1Nabagiez J.P. Bowman K. Shariff M.A. et al.Twenty-four hour staged carotid endarterectomy followed by off-pump coronary bypass grafting for patients with concomitant carotid and coronary disease.Ann Thorac Surg. 2014; 98: 1613-1619Google Scholar] have described their approach to combined carotid and coronary disease using carotid endarterectomy (CEA) followed within 24 hours with off-pump coronary bypass (CABG). The author’s hypothesis is that staging within 24 hours after CEA reduces the risk of myocardial infarction (MI) and stroke. In their study, 89% of patients met the study’s goal of CABG within 24 hours. Surgical outcomes were commendable, with a post-CEA complication rate of 1% stroke and 1% MI and a CABG outcome with no stroke or MI and 1% mortality. The length of stay (7.5 days) was not prolonged. Although the authors deemed 89% of patients had an urgent status for CABG, only 68% had symptomatic coronary disease with 47% class 3 or 4 angina, and only 6% had symptomatic carotid disease. The authors stated that patients with unstable coronary disease underwent urgent CABG without carotid assessment and were thus excluded from the study. One patient in the study experienced a subendocardial MI after CEA, and 3 patients with neurologic abnormalities had CABG delayed. This strategy may expose higher-risk patients to additional risk of MI from delayed CABG. Most would agree with the authors’ comment that “unstable or severely symptomatic coronary disease should not be considered for a staged strategy and are better served by CABG alone or combined with CEA” and agree that “the symptomatic lesion takes precedence in determining the sequence of procedure when staged.” The excellent outcomes reported herein may be more a reflection of procedural advantages of off-pump CABG and avoidance of aortic atheroma than the timing of the staged procedures. Cardiac surgeons should make stroke prevention a priority by using carotid and aortic screening and modifying surgical strategies in high-risk patients. Twenty-Four Hour Staged Carotid Endarterectomy Followed by Off-Pump Coronary Bypass Grafting for Patients With Concomitant Carotid and Coronary DiseaseThe Annals of Thoracic SurgeryVol. 98Issue 5PreviewCarotid artery stenosis and coronary artery disease share common risk factors and often coexist in the same patient. Currently, no consensus exists regarding the optimal treatment strategy for patients with concomitant severe coronary and carotid disease. We reviewed the results of our experience performing off-pump coronary artery bypass grafting (CABG) within 24 hours of carotid endarterectomy (CEA) in this select patient population. Full-Text PDF