Cost reduction by combined carotid endarterectomy and coronary artery bypass grafting

Abstract

A significant cost reduction is likely if patients who require coronary artery bypass grafting with significant carotid stenosis have simultaneous carotid endarterectomy and bypass grafting, provided risk is not increased. To investigate this issue, we retrospectively identified cases from February 1977 to May 1994 with first-time isolated carotid endarterectomy, coronary bypass, or combined procedures. In the isolated carotid endarterectomy population, median age was 69 years and 58% (85/146) were male, as compared with 68 years and 68% (68/100) male in the combined group; median age of the coronary bypass cohort was 65 years and 76% (381/500) male. A significantly higher percentage of patients in the coronary bypass versus combined group were in New York Heart Association functional class IV. In the combined group there was a significantly higher incidence of older age, diabetes, hypertension, hyperlipidemia, renal failure, and congestive heart failure. There was no difference among the three groups with respect to hospital mortality (0%, 3.4%, and 4.0%, respectively) and permanent stroke (0.7%, 1.2%, and 0%, respectively). Hospital costs were $4,896, $10,959 and $11,089, respectively, with a savings of $4,766 (30%), and Medicare hospital reimbursement was $8,575, $23,071, and $23,071, respectively, with a savings of $10,077 (25.3%). Thus, in appropriate patients, a combined procedure is cost effective, eliminating a second surgical procedure and the cost of the postoperative stay (3.7 +/- 2.4 days) associated with isolated carotid endarterectomy. Risk of permanent stroke or death is not increased.

<b>Simultaneous Carotid Endarterectomy and Coronary Revascularization is Safe Using Either On-Pump or Off-Pump Technique</b>

“…[6][7][8] Combined one-stage CABG and CEA has advantages over the two-stage procedures, including shorter hospital stays, decreased exposure to anesthesia, and decreased costs. 9) Although an earlier study by Hertzer and colleagues 4) reported elevated stroke and mortality rates after the combined approach, many other large series have not reported the higher strokes and mortality rates found in earlier studies. 10,11) On the other hand, there is an increased risk of myocardial infarction and death with no difference in stroke rates among patients undergoing staged procedures as reported by the European Carotid Surgery Trial and Brener and colleagues.…”

“…In addition, they reported the combined one-stage CABG and CEA has advantages over the twostage procedure, including a shorter hospital stay, decreased exposure to anesthesia, and decreased costs. 9) We believe that the rational approach for all patients who present with severe combined arterial disease is to perform one-stage combined CAE and CABG. In this context, one-stage operations can be done either simultaneously or staged procedures conducted.…”

Procedimento combinado entre operação de revascularização do miocárdio e endarterectomia de carótida: análise dos resultados

“…Mean hospitalization following combined surgery may range from 10.3 to sixteen days, 26,36 and mean ICU stay, from 3.6 to four days 13,18 . Respiratory complications occurred in up to 12% of the patients 14 , acute renal failure in 6% 14,36 , bleeding requiring surgical reintervention in 5% 36 ; wound infection and hematoma in 4% 10,36 ; low cardiac output syndrome (LCOS) from 0.6% to 4% 8,36 , arrhythmias in up to 33%, and atrial fi brillation from 0 to 34% 15 .…”

“…In some series, CABG was preceded by CE under the same anesthesia without extracorporeal circulation (ECC) 7,9,12,17,26,36 . Still, Khaitan et al 13 have reported good results with the combined procedure using ECC.…”

“…ECC time is an important risk predictor for postoperative complications, ranging from 72 to 129 minutes. 13,18 Aortic clamping time ranges from 32 to 44 minutes 10,14 , and number of grafts may vary from 2.9 to 4 per patient 8,36 .…”