Combined Carotid and Coronary Artery Surgery: What Have We Learned after 15 Years?

Abstract

Optimal surgical strategy in patients with concomitant coronary and carotid artery disease is debatable. We have analysed 15-years of experience (January 1981-August 1996) with 195 consecutive patients in whom we have used two different surgical approaches. Group A consisted of 48 patients who underwent a single-stage surgical procedure, and group B (147 patents) underwent a two-stage procedure, either as carotid endarterectomy followed by coronary artery bypass surgery (group B₁, 97 patients), or as coronary artery bypass surgery followed by carotid endarterectomy (group B₂, 50 patients). Overall, there were 40 (20.5%) patients with left main coronary artery disease, 49 (25.1%) with poor left ventricular function, 128 (65.6%) with previous myocardial infarction, 134 (68.7%) were in New York Health Authority (NYHA) functional class III or IV, and bilateral carotid involvement was present in 57 patients (29.2%). Unstable angina was more frequent in groups A and B₂ (P < 0.0001), NYHA class III-IV was more frequent in group A (versus B₁, P = 0.001 and versus B₂, P = 0.02), low ejection fraction (EF) was more frequent in groups A and B₂ (P < 0.0001 for both), bilateral carotid stenosis in groups A and B₁ (P = 0.02 and P = 0.0001, respectively) and ulcerated plaque in group B₁ (versus A, P = 0.0001). These differences dictated the surgical strategy, which resulted in different protocols for clinical and operative management.

Results:

Early mortality for the entire group was 4.6% (9/195–6.2% in group A, 6.2% in group B₁ and 0% in group B₂, respectively P > 0.05). Serious morbidity occurred in 7.3% of patients (14/195–8.3% in group A. 7.2% in group B₁ and 6% in group B, respectively P > 0.05). Univariate analysis revealed only bilateral carotid stenosis as a predictor of outcome (P = 0.04). Follow-up was completed for 156 patients (80.0%) and averaged 84.1 ± 13.3 months (range 1–180 months). Kaplan–Meier survival estimate for the entire group was 81% and event-free survival was 76% at 5 years. Actuarial and event-free survivals were similar for all groups. Early and late outcome in these patients were influenced more by their preoperative clinical status than by the surgical strategy itself. It is therefore concluded that surgical approach should be individualized for the majority of patients.