Staged or Combined Approach for Carotid Endarterectomy in Patients Undergoing Coronary Artery Bypass Grafting: A 5-Year-Long Experience

  • Kursad Oz Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul
  • Ünal Aydın Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul
  • Mugisha Kyaruzi Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul
  • Zeynep Karaman Department of Anaesthesiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul
  • Onur Selçuk Göksel Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul
  • Mehmet Yeniterzi Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul
  • Ihsan Bakir Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul

Abstract

Background: Optimal surgical approach for patients with hemodynamically significant carotid and coronary disease remains controversial. We analyzed our 5-year experience and compared early and long-term outcome following staged and combined carotid and coronary artery bypass.
Methods: 312 consecutive patients undergoing carotid endarterectomy and coronary artery bypass between 2008 and 2013 were prospectively enrolled in the study. Patients were scheduled for a staged (carotid endarterectomy followed by coronary artery bypass within 1 week) procedure (Group S) unless they were unstable in terms of cardiac status (were deemed to a combined procedure; Group C). All patient data including demographics, risk factors, immediate perioperative events, 30-day, and long-term outcome were prospectively recorded and then analyzed. Groups S and C were compared for pre- and perioperative data as well as immediate, 30-day, and long-term survival. A P value less than .05 was considered significant. Survival analysis was made using Kaplan-Meier method and log-rank test.
Results: Group S included 204 patients and Group C included 108 patients. Preoperative demographics and clinical data were similar in the two groups except that preoperative cerebrovascular events were more common in Group C (31.7% versus 22.22%, P = .036) and bilateral carotid disease was more common in Group S. The EuroSCORE was higher in Group C (2.91 versus 2.65, P = .013). Carotid surgery techniques were similar; intraluminal shunting was more frequent in group C than group S (33.33% versus 9.88%, P = .001). Additional cardiac procedures in addition to coronary surgery was predominant in Group C. 30-day neurological adverse event rates, ICU, and hospital stay were significantly higher in Group C. The 30-day mortality was also sigficantly higher in Group C (1.96% versus 4.62%, P = .001).
Conclusion: Staged and combined surgical approaches yield comparable outcomes. A staged approach may provide a more favorable neurological outcome with significantly reduced need for intraluminal shunting. Long-term outcome is, however, similar.

References

Biller J, Feeinber WM, Castaldo JE, Whittemore AD, et al. 1998. Guidelines for Carotid Endarterectomy. A statement for Healtcare Professionals from a Special Writing Group of the Stroke Council, American Heart Association. Circulation 97:501-9.

Borger MA. 2005. Preventing stroke during coronary bypass: are we focusing on the wrong culprit? J Card Surg 20:58-9.

Brener BJ, Hermans H, Eisenbud D, et al. 1996. The management of patients requiring coronary bypass and carotid endarterectomy. In Moore WS, ed. Surgery for Cerebrovascular Disease (2nd Ed). Pennsylvania: W.B. Saunders, 278-87.

Bryne J, Darling RC, Poddy SP, et al. 2006. Combined carotid endarterectomy and coronary artery bypass grafting in patients with asymptomatic high-grade stenoses: An analysis of 758 procedures. J Vasc Surg 44:67-72.

Cinar B, Goksel OS, Karatepe C, et al. 2004. Is routine intravascular shunting necessary for carotid endarterectomy in patients with contralateral occlusion? A review of 5-year experience of carotid endarterectomy with local anaesthesia. Eur J Vasc Endovasc Surg 28:494-9.

Cinar B, Goksel OS, Kut S, et al. 2005. A modified combined approach to operative carotid and coronary artery disease: 82 cases in 8 years. Heart Surg Forum 8:E184-9.

D’Ancona G, Saez de Ibarra JI, Baillot R, et al. 2003. Determinants of stroke after coronary artery bypass grafting. Eur J Cardiothorac Surg 24:552-6.

Ferguson GG, Eliasziw M, Barr HWK, et al. 1999. The North American Symptomatic Carotid Endarterectomy Trial: Surgical results in 1415 patients. Stroke 30:1751-8.

GALA Trial Collaborative Group, Lewis SC, Warlow CP, et al. 2008. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet 372:2132-42.

Goto T, Baba T, Yoshitake A, Shibata Y, Ura M, Sakata R. 2000. Craniocervical and aortic atherosclerosis as neurologic risk factors in coronary surgery. Ann Thorac Surg 69:834-40.

Lutz H-J, Michael R, Gahl B, Savolainen H. 2008. Local versus General Anaesthesia for Carotid Endarterectomy – Improving the Gold Standard ? Eur J Vasc Endovasc Surg 36:145-9.

McKhann GM, Goldsborough MA, Borowicz Jr LM, et al. 1997. Predictors of stroke risk in coronary artery bypass patients. Ann Thorac Surg 63:516-21.

Naylor AR, Mehta Z, Rothwell PM, Bell PR. 2002. Carotid artery disease and stroke during coronary artery bypass: a critical review of the literature. Eur J Vasc Endovasc Surg 23:283-94.

Naylor AR, Cuffe RL, Rothwell PM, Bell PRF. 2003. A systematic review of outcomes following staged and synchronous carotid endarterectomy and coronary artery bypass. Eur J Vasc Endovasc Surg 25:380-9.

North American Symptomatic Carotid Endarterectomy Trial Collaborators. 1991. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 325:445-53.

Ogutu P, Werner R, Oertel F, Beyer M. 2014. Should patients with asymptomatic significant carotid stenosis undergo simultaneous carotid and cardiac surgery? Interact Cardiovasc Thorac Surg 18:511-8.

Steinbach Y, Illig KA, Zhang R, et al. 2002. Hemodinamic benefits of regional anesthesia for carotid endarterectomy. J Vasc Surg 35:333-9.

Published
2016-12-07
Section
Articles