Lessons learned during a 30-year experience with simultaneous carotid endarterectomy and coronary artery bypass grafting

Minisandram, Aarathi; Shah, Anand Y.; Yao, Mengdi; Beasley, Kathryne A.; Son, Andrew; Iafrati, Mark D.; Salehi, Payam; Mackey, William C.

doi:10.1016/j.jvs.2020.06.107

Cited by 4 publications

(4 citation statements)

References 17 publications

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“…The authors stated that there were no differences in postoperative stroke rates or thirty-day all-cause mortality when comparing both groups, with respect to on- and off-pump surgery [ 24 ]. On the other hand, Minisandran et al reported on favorable 30-year experiences with simultaneous CEA in combination with coronary artery bypass grafting and further advocate this approach [ 25 ]. In a landmark study from 1996, Roach et al reported a proximal high-grade aortic atherosclerosis as an independent stroke predictor [ 26 ], as athero-arterial embolism from the ascending aorta is believed to be a source of embolic stroke related to aortic manipulation or clamping of the aorta ascendens [ 27 ].…”

Section: Discussionmentioning

confidence: 99%

Major Adverse Cardiac and Cerebrovascular Events in Patients Undergoing Simultaneous Heart Surgery and Carotid Endarterectomy

Gerfer,

Bennour,

Chigri

et al. 2023

JCDD

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Background. Patients with simultaneous relevant internal carotid artery stenosis and coronary artery heart or valve disease represent a high-risk collective with respect to cerebral or cardiovascular severe events when undergoing surgery. There exist several concepts regarding the timing and modality of carotid revascularization, which are controversially discussed in patients with heart disease. More data regarding outcome predictors and measures are needed to gain a better understanding of the best treatment option of the discussed patient collective. Methods. This single-center study retrospectively analyzed n = 111 patients undergoing heart surgery with coronary artery bypass grafting or heart-valve surgery and concomitant carotid surgery due to significant internal carotid artery stenosis. In order to do so, patients were divided into two groups with respect to postoperative major adverse cardiac and cerebrovascular events (MACCE) with thirty-day all-cause mortality, valve related mortality, myocardial infarction, stroke and transitory ischemic attack. Results. Preoperative patient’s characteristic in the no-MACCE and MACCE group were mainly balanced, other than higher rates of chronic obstructive pulmonary disease, chronic kidney disease, instable angina pectoris and prior transitory ischemic attack in the MACCE cohort. The analysis of intraoperative characteristics revealed a higher number of intra-aortic balloon pump implantation, which is in line for a higher number of postoperative supports. Besides MACCE, patients suffered significantly more often from postoperative bleeding events and re-thoracotomy, cardiopulmonary reanimation, new onset postoperative dialysis and prolonged intensive care unit stay related complications. Conclusions. Within the reported patient population suffering from MACCE after a simultaneous carotid endarterectomy and heart surgery, a preoperative history of transitory ischemic attack and kidney disease might account for worse outcomes, as severe events were not only neurologically driven but also associated with postoperative cardiovascular complications following heart surgical procedures.

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Section: Discussionmentioning

confidence: 99%

Major Adverse Cardiac and Cerebrovascular Events in Patients Undergoing Simultaneous Heart Surgery and Carotid Endarterectomy

Gerfer,

Bennour,

Chigri

et al. 2023

JCDD

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“…This is of little surprise as the adoption of statin use has improved medical outcomes in patients with high-grade asymptomatic carotid artery stenosis and in patients undergoing CABG. 18,19 It is also interesting to note that in Minisandram et al 19 's retrospective study reviewing the 30-year experience with combined CABG/CEA, they found perioperative stroke decreased in later years of CABG/CEA, at a time when statin use was also increasing. Therefore we recommend all patients without contraindications should be discharged with statin to reduce perioperative and long term adverse events.…”

Section: Impact Of Perioperative Variables and Demographics On Outcomesmentioning

confidence: 99%

Investigation of Combined Carotid Endarterectomy and Coronary Artery Bypass Graft Surgery Outcomes and Adverse Event Risk Factors in the Vascular Quality Initiative

Penton

Lin

Kolde

et al. 2023

Vasc Endovascular Surg

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Objective The purpose of this study was to investigate outcomes of simultaneous CEA and CABG utilizing the Vascular Quality Initiative (VQI). Additionally, we seek to investigate risks for both perioperative and long-term mortality and adverse neurological outcomes. Methods All carotid endarterectomies in the VQI between January 2003 and May 2022 were queried. We identified 171,816 CEA in the database. We extracted 2 cohorts from these CEA. The first group was patients who underwent simultaneous carotid endarterectomy (CEA) and coronary artery bypass (CABG) (N = 3137). The second group encompassed patients who underwent CABG or percutaneous coronary artery angioplasty/stent within 5 years of ultimately undergoing CEA (N = 27,387). We investigated the following outcomes in a multivariable fashion: 1. Risks for mortality in long term follow-up for both cohorts combined; 2. Risks for ischemic event in the cerebral hemisphere ipsilateral to the CEA site after index hospital admission in follow up for both cohorts combined. Tertiary outcomes are also investigated in the manuscript. Results On multivariable analysis, patients undergoing simultaneous combined CEA and CABG had equivalent long-term survival to patients who underwent coronary revascularization within 5 years of ultimately undergoing CEA. Five-year survival is noted to be 84.5% vs 86% with a Cox regression non-significant P-value (.203). Significant multivariable risks for reduced long term survival (P < .03 for all) included: advancing age (HR 2.48/year); smoking history (HR 1.26); Diabetes (HR 1.33); history of CHF (HR 1.66); history of COPD (HR 1.54); baseline renal insufficiency at the time of surgery (HR 1.30); anemia (HR1.64); lack of preoperative aspirin (HR 1.12); and lack of preoperative statin (HR 1.32); lack of patch placement at CEA site (HR 1.16); perioperative MI (HR 2.04); perioperative CHF (1.66); perioperative dysrhythmia (HR 1.36); cerebral reperfusion injury (HR 2.23); perioperative ischemic neurological event (HR 2.48); and lack of statin at discharge (HR 2.04). Amongst patients with documented neurological status in follow up, combined CEA and CABG had over 99% freedom from ischemic cerebral event ipsilateral to the CEA site after discharge. Conclusions Combined CEA and CABG provides excellent long-term mortality prevention in patients with co-existing severe coronary and carotid atherosclerosis. Simultaneous CEA and CABG provides equivalent stroke prevention and long-term survival to both a cohort of patients undergoing coronary revascularization within 5 years of CEA and patients undergoing isolated CEA or CABG in the literature. The two most impactful modifiable risk factors towards long-term stroke and mortality prevention for patients undergoing simultaneous CEA-CABG are patch placement at CEA site and adherence to statin medication therapy.

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“…Staged and reversed interventions are associated with increased risk of myocardial infarction (MI) and stroke, respectively, hence was not commonly used in clinical practice. 2 A simultaneous treatment strategy for coronary artery bypass grafting (CABG) and carotid artery endarterectomy (CAE) was first reported in 1972. 3 A few decades later in 2009, the SHARP study demonstrated that CABG and carotid artery stenting (CAS) can be successfully performed simultaneously.…”

Section: Introductionmentioning

confidence: 99%

“…Staged and reversed interventions are associated with increased risk of myocardial infarction (MI) and stroke, respectively, hence was not commonly used in clinical practice. 2…”

Section: Introductionmentioning

confidence: 99%

Outcomes of simultaneous carotid endarterectomy and coronary artery bypass grafting: A single centre experience

et al. 2022

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Objective Stroke following a coronary artery bypass surgery is a well-known complication often predisposed by carotid artery disease. Perioperative risk of stroke after on-pump cardiac surgery can overall affect 2% of patients. Patients with 80–99% unilateral carotid artery stenosis carry a 4% risk of stroke. Significant carotid artery stenosis is present in 3–10% of patients who are candidates for coronary artery bypass grafting (CABG). Those patients might be considered for either simultaneous or staged carotid endarterectomy and CABG to reduce the risk of stroke and death. The purpose of this study was to evaluate preoperative and intraoperative risk factors for myocardial infarction (MI), stroke and death and assess complications occurring during the early postoperative period after simultaneous CABG/CAE procedure. Methods A single centre retrospective analysis of 134 patients from 2015 to 2019 who underwent simultaneous CABG/CEA was performed. At the same period, a total of 2827 CABG were performed, of which 4.7% were simultaneous interventions. We excluded staged CEA/CABG procedures, off-pump CABG and urgent CABG patients. All patients included in the study met the criteria for elective CABG for triple-vessel or left main trunk symptomatic coronary artery disease (CAD) with asymptomatic >70% carotid stenosis or symptomatic ipsilateral >50% carotid stenosis regardless of the degree of contralateral carotid artery stenosis. Patient demographics, comorbidities and operative details were reviewed. The primary endpoint was to assess the intraoperative and 30-day risk of stroke and death after simultaneous CEA/CABG procedure. Results Simultaneous CEA/CABG is effective procedure that can be performed in high-risk symptomatic patients with acceptable results. Predictors of postoperative stroke were smoking ( P = 0.011), history of MI ( P = 0.046), history of CABG ( P = 0.013), and history of stroke/TIA ( P = 0.005). Significant risk factors for adverse major postoperative complications after simultaneous CEA/CABG procedure were cardiac arrhythmia (AF or AFL) ( P = 0.045), previous MI ( P < 0.001), and smoking ( P = 0.001). Conclusions Synchronous CEA/CABG procedure can be performed with acceptable results in patients having a high risk of stroke, septuagenarians and older.

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Lessons learned during a 30-year experience with simultaneous carotid endarterectomy and coronary artery bypass grafting

Cited by 4 publications

References 17 publications

Major Adverse Cardiac and Cerebrovascular Events in Patients Undergoing Simultaneous Heart Surgery and Carotid Endarterectomy

Major Adverse Cardiac and Cerebrovascular Events in Patients Undergoing Simultaneous Heart Surgery and Carotid Endarterectomy

Investigation of Combined Carotid Endarterectomy and Coronary Artery Bypass Graft Surgery Outcomes and Adverse Event Risk Factors in the Vascular Quality Initiative

Outcomes of simultaneous carotid endarterectomy and coronary artery bypass grafting: A single centre experience

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