Synchronous Carotid Endarterectomy Research Articles

PS78. Staged Versus Synchronous Carotid Endarterectomy and Coronary Artery Bypass Grafting: Analysis of 10-year Nationwide Outcomes

The timing of operative interventions for patients with concurrent carotid disease and coronary artery disease has always been controversial. Our aim was to evaluate a nationwide experience in staged or synchronous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) and compare outcome profiles between the two approaches. From Nationwide Inpatient Sample database 1998-2007, we identified 6, 153 (28.9%) patients who underwent staged CEA before or after CABG during the same hospital admission (STAGED) and 16, 639 patients who underwent both on the same day (SYNC). Hierarchic multivariable regression models were used to assess the independent effect of the operative strategy. Risk-adjusted outcomes assessed were mortality, neurologic and overall complications, and charges. The overall mean age (69.5 ± 9.0 years) and Charlson-Deyo scores (4.55 ± 1.5) and were similar for both groups. There were no differences in risk-adjusted mortality (4.2% vs 4.5%) and neurologic complications (3.5% vs 3.9%), between the STAGED and SYNC approach (P > 0.7 for all). STAGED patients had higher overall morbidity (48.4% vs 42.6%) (OR = 1.8; 95% CI = 1.5-2.2; p < 0.001). Subgroup analysis revealed higher risk cardiac (OR = 1.5; 95% CI = 1.4-1.7; p < 0.001), wound (OR = 2.1; 95% CI = 1.8-2.4; p < 0.001), respiratory (OR = 1.2; 95% CI = 1.1-1.3; p = 0.001), and renal complications (OR = 1.15; 95% CI = 1.0-1.3; p < 0.001). STAGED was independently associated with higher hospital charges by $23328 (p < 0.001). Routine home discharges were similar for the two groups (p = 0.05). We identified no significant difference in mortality or neurologic complications between STAGED or SYNC approaches. The STAGED strategy was less commonly utilized and associated with increased risk for overall complications, and higher hospital charges compared to SYNC. Further studies are required to identify the specific reasons for better outcomes associated with the SYNC approach.

Synchronous Carotid Endarterectomy and Off-pump Coronary Bypass: An Updated, Systematic Review of Early Outcomes

Objectives: To update our previous systematic review of outcomes following synchronous carotid endarterectomy (CEA) and off-pump coronary artery bypass grafting (OFF-CABG). Design: A systematic review of operative risks reported in published studies of synchronous CEA plus OFF-CABG procedures. Results: We identified 12 eligible studies, including data on 324 synchronous CEA plus OFF-CABG procedures. Operative mortality was 1.5% (95% confidence interval (CI): 0.3–2.8), the risk of death or ipsilateral stroke was 1.6% (0.4–2.8%), risk of death or any stroke was 2.2% (95% CI: 0.7–3.7) and the risk of death, stroke or myocardial infarction was 3.6% (95% CI: 1.6–5.5). Conclusions: Limited published data on 324 patients suggest that early outcomes after synchronous CEA plus OFFCABG are better than those following staged or synchronous CEA plus CABG where the cardiac procedure was performed on-pump. This may, however, be attributed to publication bias, case selection or the fact that the aorta was not manipulated or cannulated, rather than CEA being primarily responsible for the lower stroke risk. Colleagues with unpublished experience of CEA plus OFF-CABG are encouraged to submit their data to further inform the debate.

A Systematic Review and Meta-analysis of 30-Day Outcomes Following Staged Carotid Artery Stenting and Coronary Bypass

Objectives: To determine the overall operative risk of cardiovascular events in patients with combined cardiac and carotid artery disease undergoing staged carotid artery stenting (CAS) and coronary artery bypass grafting (CABG). Design: Systematic review of operative risks reported in all published studies of CAS plus CABG procedures. Results: Eleven eligible, published studies were identified which reported data on 760 CAS plus CABG procedures. The majority of patients (87%) were neurologically asymptomatic and 82% had unilateral carotid stenoses. Overall mortality was 5.5% (95% confidence interval, CI: 3.4–7.6), the risk of suffering an ipsilateral stroke was 3.3% (95% CI: 1.6–5.1) and the risk of suffering ‘any' stroke was 4.2% (95% CI: 2.4–6.1), while the 30-day risk of myocardial infarction (MI) was only 1.8% (95% CI: 0.5–3.0). However, the 30-day death and ipsilateral stroke rate was 7.5% (95% CI: 4.5–10.5) and the 30-day risk of death and any stroke was 9.1% (95% CI: 6.1–12.0), while the 30-day of death/stroke/MI was 9.4% (7.0–11.8). Cumulative risks in studies where patients underwent CABG within 48 h of CAS were not higher than in comparable studies where CABG was delayed by more than 2 weeks. Conclusions: In a cohort of predominantly asymptomatic patients with unilateral carotid disease, the 30-day risk of death/any stroke was 9.1%. These data are comparable to previous systematic reviews evaluating the roles of staged and synchronous carotid endarterectomy (CEA) plus CABG, and suggest that staged CAS plus CABG is an attractive and less invasive alternative to CEA plus CABG. However, it remains questionable whether the observed 9% risks can be justified in any asymptomatic patient with unilateral carotid disease.

Synchronous Carotid Endarterectomy and Off-pump Coronary Bypass: An Updated, Systematic Review of Early Outcomes

To update our previous systematic review of outcomes following synchronous carotid endarterectomy (CEA) and off-pump coronary artery bypass grafting (OFF-CABG). A systematic review of operative risks reported in published studies of synchronous CEA plus OFF-CABG procedures. We identified 12 eligible studies, including data on 324 synchronous CEA plus OFF-CABG procedures. Operative mortality was 1.5% (95% confidence interval (CI): 0.3-2.8), the risk of death or ipsilateral stroke was 1.6% (0.4-2.8%), risk of death or any stroke was 2.2% (95% CI: 0.7-3.7) and the risk of death, stroke or myocardial infarction was 3.6% (95% CI: 1.6-5.5). Limited published data on 324 patients suggest that early outcomes after synchronous CEA plus OFFCABG are better than those following staged or synchronous CEA plus CABG where the cardiac procedure was performed on-pump. This may, however, be attributed to publication bias, case selection or the fact that the aorta was not manipulated or cannulated, rather than CEA being primarily responsible for the lower stroke risk. Colleagues with unpublished experience of CEA plus OFF-CABG are encouraged to submit their data to further inform the debate.

A Systematic Review and Meta-analysis of 30-Day Outcomes Following Staged Carotid Artery Stenting and Coronary Bypass

To determine the overall operative risk of cardiovascular events in patients with combined cardiac and carotid artery disease undergoing staged carotid artery stenting (CAS) and coronary artery bypass grafting (CABG). Systematic review of operative risks reported in all published studies of CAS plus CABG procedures. Eleven eligible, published studies were identified which reported data on 760 CAS plus CABG procedures. The majority of patients (87%) were neurologically asymptomatic and 82% had unilateral carotid stenoses. Overall mortality was 5.5% (95% confidence interval, CI: 3.4-7.6), the risk of suffering an ipsilateral stroke was 3.3% (95% CI: 1.6-5.1) and the risk of suffering 'any' stroke was 4.2% (95% CI: 2.4-6.1), while the 30-day risk of myocardial infarction (MI) was only 1.8% (95% CI: 0.5-3.0). However, the 30-day death and ipsilateral stroke rate was 7.5% (95% CI: 4.5-10.5) and the 30-day risk of death and any stroke was 9.1% (95% CI: 6.1-12.0), while the 30-day of death/stroke/MI was 9.4% (7.0-11.8). Cumulative risks in studies where patients underwent CABG within 48 h of CAS were not higher than in comparable studies where CABG was delayed by more than 2 weeks. In a cohort of predominantly asymptomatic patients with unilateral carotid disease, the 30-day risk of death/any stroke was 9.1%. These data are comparable to previous systematic reviews evaluating the roles of staged and synchronous carotid endarterectomy (CEA) plus CABG, and suggest that staged CAS plus CABG is an attractive and less invasive alternative to CEA plus CABG. However, it remains questionable whether the observed 9% risks can be justified in any asymptomatic patient with unilateral carotid disease.

Combined Carotid Endarterectomy and Coronary Artery Bypass: a Still-Feasible Procedure?

To the Editor: The recent article by Randall et al1 is of great interest and involves a large number of patients undergoing carotid artery stent (CAS) and staged myocardial revascularization with a low incidence of periprocedural neurological complication. However, we have some comments and report our own experience. Regarding the AHA guidelines, we do not feel it appropriate to perform carotid/coronary surgery, as Naylor pointed out, with a staged procedure.2 Data on staged procedures taken from his meta-analysis are biased in that the authors do not indicate the number of patients initially enrolled and then submitted to the first procedure (carotid endarterectomy), and the number of patients who leave the study because of neurological or cardiac complications that would contraindicate the programmed staged heart surgery. Furthermore, any procedure, programmed or not, that leaves up to 6 months …

Simultaneous Carotid Endarterectomy and Coronary Artery Bypass Grafting: Results in Specific Patient Groups

We examined the safety of performing synchronous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) in specific groups of patients with coexistent cerebral and coronary vascular disease. Between 1981 and 2003, 8,277 patients who underwent CABG in our institution had noninvasive screening for carotid disease. Two hundred seventy-seven (3.34%) patients were found to have severe (>70%) carotid stenosis. This patient population was divided into three subgroups: group A had unilateral carotid disease (n = 200), group B had bilateral carotid disease (n = 55), and group C had contralateral carotid occlusion (n = 22). In 29 patients (10.4%), the carotid disease was symptomatic. A simultaneous CABG and CEA was performed in all three subgroups. Patients in group B underwent initially repair of the most dominant lesion, soon followed by contralateral CEA. Patients who underwent only CABG (n = 8,000) served as controls. Overall combined hospital mortality regardless of etiology for the combined group was 3.61% vs. 1.7% for the patients who had CABG only (P > 0.1). The stroke and/or myocardial infarction-associated mortality for the simultaneous CEA-CABG group was 2.52%. There were six deaths in group A (3%), two in group B (3.6%), and two in group C (9.09%). Early stroke complicated the course of four (2%) patients in group A, one (1.8%) patient in group B, and three (13.64%) patients in group C compared to a stroke rate of 1.28% in controls. Overall stroke rate in the combined group was 2.8%. History of previous stroke and age 70-80 were the most important predictors of postoperative stroke and death. In the combined surgery group, the postoperative myocardial infarction rate was 0.72% vs. 0.58% in the control group. The mean length of hospital stay was 9 days for patients who had the combined procedure vs. 8.1 days for patients who had CABG only. Use of the combined procedure for patients with concomitant carotid and coronary artery disease was justified in the patients under study.

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

Surgical treatment of hemodynamically significant carotid artery stenoses has been well documented, especially in the asymptomatic patient. However, in those patients presenting with hemodynamically significant asymptomatic carotid artery disease who are to undergo cardiac surgery, optimal treatment remains controversial. In this study, we analyze our experience with patients who underwent synchronous carotid endarterectomy (CEA) and coronary artery bypass graft procedures (CABG) for hemodynamically significant (>70%) asymptomatic carotid artery stenosis and coronary artery disease (CAD). Demographics and outcomes of all patients undergoing synchronous CEA/CABG for asymptomatic carotid stenosis between April 1980 and January 2005 were reviewed from our vascular registry and patient charts. We included patients who underwent standard patching of their carotid artery and those undergoing eversion CEA. All neurologic events within the first 30 days that persisted >24 hours were considered a stroke. For purposes of comparison, we also reviewed outcomes for patients undergoing synchronous CEA/CABG for symptomatic carotid stenosis. Asymptomatic carotid artery stenosis (>70%) was the indication in 702 patients (276 women and 426 men) undergoing 758 CEAs. In the asymptomatic group, 22 patients, of which 21 succumbed to cardiac dysfunction, and one died from a hemorrhagic stroke. The overall mortality rate was 3.1%. Seven permanent nonfatal neurologic deficits occurred in this series (1 woman, 6 men). The combined stroke mortality was 4.3%. This compares to a 30-day stroke mortality of 6.1% in 132 symptomatic combined CEA/CABG patients. The difference in stroke mortality in women compared with men was not significant. In this experience, patients presenting with hemodynamically significant (>70%) asymptomatic carotid artery stenosis can undergo synchronous CEA/CABG with low morbidity and mortality.

Carotid Artery Stenting Before CABG: A Better Alternative to Treat Concomitant Coronary and Carotid Artery Disease

To the Editor: We read with great interest the article published recently “Is There Any Benefit From Staged Carotid and Coronary Revascularization Using Carotid Stents?” by Randall et al.1 In our institution, we have a clinical research protocol regarding the management of patients with concomitant coronary and carotid artery disease.2 To date we have treated 37 patients who have had concomitant surgical coronary artery disease and significant carotid artery disease with staged-combined …

Cerebral protection during open retrograde angioplasty/stenting of common carotid and innominate artery stenoses

This was a retrospective study of the effectiveness of open, retrograde angioplasty/stenting of supra-aortic arterial stenoses combined with transcranial Doppler-directed dextran therapy in preventing perioperative embolization. Eight patients underwent angioplasty/stenting of the proximal common carotid (synchronous carotid endarterectomy (CEA) in six), while four underwent angioplasty/stenting of the innominate artery (synchronous CEA in one). Open exposure of the carotid bifurcation enabled temporary carotid clamping to protect the brain from procedural embolization. Dextran was administered to patients with a high rate of embolization on transcranial Doppler after the operation. No emboli were recorded in the cerebral circulation during the actual angioplasty procedure when the internal carotid artery was clamped. After operation three patients developed high-rate embolization and received dextran. No strokes or deaths occurred within 30 days of treatment. One patient developed symptoms and a recurrent stenosis greater than 50 per cent during follow-up and was treated by redo angioplasty. Retrograde angioplasty/stenting with or without synchronous CEA offers an alternative approach to treating patients with supra-aortic inflow disease.

A systematic review of outcome following synchronous carotid endarterectomy and coronary artery bypass: Influence of surgical and patient variables

Objectives: outcomes after synchronous carotid endarterectomy (CEA) plus coronary artery bypass (CABG) relative to surgical and patient based variables. Design: systematic review of 94 published series (7863 synchronous procedures). Results: 11.5% of patients died or suffered a stroke/myocardial infarction in the peri-operative period (95% CI 10.1-12.9). The risk of death/stroke appeared to significantly diminish in studies published between 1993-2002, compared with 1972-1992 (7.2% (95% CI 6.5-9.1) versus 10.7% (95% CI 8.9-12.5), p = 0.03). However, increasing operative experience was not associated with significantly lower risks of death/stroke; (1-49 cases (9.6% (95% CI 7.5-11.8); 50-99 cases (9.1% (95% CI 6.4-11.8); 100+ cases (8.4% (95% CI 6.9-10.1) (p = 0.64)). Patients with severe bilateral carotid disease were significantly more likely to suffer death and/or stroke compared to patients with unilateral disease (odds ratio 2.5, 95% CI 1.4-5.0, p = 0.001). Similarly, patients with a prior history of stroke/transient ischaemic attack (TIA) were significantly more likely to suffer a further stroke than asymptomatic patients (odds ratio 1.8, 95% CI 1.1-2.8, p = 0.008). There was no difference in the risk of death/stroke relative to the timing of CEA (pre- versus on-cardiopulmonary bypass), but recent small studies indicate that improved outcomes might be achieved by performing CABG ‘off-bypass’. Conclusions: synchronous CEA + CABG is associated with a not insignificant cardiovascular risk. No comparable information is available for similar patients undergoing CABG without prophylactic CEA.Eur J Vasc Endovasc Surg 26, 230-241 (2003)

Synchronous Carotid Endarterectomy and Retrograde Endovascular Treatment of Brachiocephalic or Common Carotid Artery Stenosis

Objectives. To retrospectively evaluate the safety and the long-term results of retrograde brachiocephalic and common carotid angioplasty and stenting (AS) performed for >70% stenosis synchronously with the carotid endarterectomy (CEA).Patients. Sixteen patients operated between April 1999 and March 2002Results. 14/16 procedures were successful. There was no neurological morbidity or mortality. Per-operative angiography showed the optimal stent positioning and patency of both proximal and distal arteries in all patients. In the follow-up, all patients showed patency of the treated vessels without restenosis and the absence of any cerebrovascular symptoms.Conclusion. Intra-operative retrograde AS combined with CEA is an effective, safe and durable alternative to conventional surgery when a tandem significant proximal lesion is identified in a patient with an high grade carotid stenosis.

WITHDRAWN: A Systematic Review of Outcome Following Synchronous Carotid Endarterectomy and Coronary Artery Bypass: Influence of Surgical and Patient Variables

WITHDRAWN: A Systematic Review of Outcome Following Synchronous Carotid Endarterectomy and Coronary Artery Bypass: Influence of Surgical and Patient Variables

A systematic review of outcomes following staged and synchronous carotid endarterectomy and coronary artery bypass

Objectives: to determine the overall cardiovascular risk for patients with combined cardiac and carotid artery disease undergoing synchronous coronary artery bypass (CABG) and carotid endarterectomy (CEA), staged CEA then CABG and reverse staged CABG then CEA. Design: systematic review of 97 published studies following 8972 staged or synchronous operations. Results: mortality was highest in patients undergoing synchronous CEA + CABG (4.6%, 95% CI 4.1-5.2). Reverse staged procedures (CABG − CEA) were associated with the highest risk of ipsilateral stroke (5.8%, 95% CI 0.0-14.3) and any stroke (6.3%, 95% CI 1.0-11.7). Peri-operative myocardial infarction (MI) was lowest following the reverse staged procedure (0.9%, 95% CI 0.5-1.4) and highest in patients undergoing staged CEA − CABG (6.5%, 95% CI 3.2-9.7). The risk of death ± any stroke was highest in patients undergoing synchronous CEA + CABG (8.7%, 95% CI 7.7-9.8) and lowest following staged CEA − CABG (6.1%, 95% CI 2.9-9.3). The risk of death/stroke or MI was 11.5% (95% CI 10.1-12.9) following synchronous procedures versus 10.2% (95% CI 7.4-13.1) after staged CEA then CABG. Conclusions: 10-12% of patients undergoing staged or synchronous procedures suffered death or major cardiovascular morbidity (stroke, MI) within 30 days of surgery. Overall, there was no significant difference in outcomes for staged and synchronous procedures and no comparable data for patients with combined cardiac and carotid disease not undergoing staged or synchronous surgery.Eur J Vasc Endovasc Surg 25, 380-389 (2003)

Should we perform carotid endarterectomy synchronously with cardiac surgical procedures?

From Jan. 1, 1979 through July 31, 1987, 63 patients had carotid endarterectomy (CEA) concurrently with cardiac surgical procedures including coronary artery bypass grafting (CABG) in 61, CABG plus mitral value replacement in one, and aortic valve replacement in one. Among the 62 patients having CABG, unstable angina had been present in 36 (58%), left main coronary artery disease in 21 (34%), and both unstable angina and left main coronary artery disease in 13 (21%). Indications for carotid surgery included previous stroke, amaurosis fugax, or hemispheric transient ischemic attacks (TIAs) in 33 patients (52%); bilaterally significant carotid disease was noted in 48% of the patients. Major neurologic complications occurred in three patients (4.8%), including perioperative stroke in two (3.2%) (fatal in one) and a TIA in a third patient. Bilateral carotid lesions, a contralateral total carotid occlusion, previous cerebrovascular symptoms, and intraaortic balloon pump support did not increase neurologic risk. Seven patients died postoperatively (11%). The mortality rate was 2.8% in patients younger than 65 years vs 22% in patients 65 years or older, 19% in patients with left main coronary artery disease vs 7.3% in patients without, 13.3% in men vs 5.6% in women, 25% in patients with a history of congestive heart failure vs 7.8% in patients without failure, and 6.2% in patients with unilateral carotid disease, 17% in patients with bilateral carotid disease, and 23% in patients with bilateral disease including a contralateral carotid occlusion. A mortality predictive index (MPI) was developed to summarize individual risk for a fatal outcome. Survivors had a mean MPI of 1.98 vs 3.30 for those who died. The mortality rate was 2.4% in patients with an MPI of 0 to 2 vs 29% for those with an index of 3 to 5. In elderly cardiac surgical patients and those with an MPI of 3 or greater, the risks of operation may outweigh the potential benefits of synchronous CEA.