PERIOPERATIVE MORBIDITY AND MORTALITY IN COMBINED VS. STAGED APPROACHES TO CAROTID AND CORONARY REVASCULARIZATION

Between 1986 and 1994 we identified 57 patients who underwent carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) during the same hospitalization. Simultaneous CABG and CEA was performed in 28 patients (mean age 70.5 years, 58% male). Indications for CABG in t hese patients were myocardial infarction in two, crescendo angina in 1 9, congestive heart failure in two and left main or triple-vessel coro nary artery disease noted during carotid preoperative evaluation in fi ve, Indications for CEA were transient ischemic attack (TIA) in 12, cr escendo TIA in six, cerebrovascular accident (CVA) in five, and asympt omatic stenosis in five. There were no postoperative myocardial infarc tions or perioperative deaths. Two patients developed atrial fibrillat ion, and four patients had CVAs (two were ipsilateral to the side of C EA). Twenty-nine patients underwent staged procedures (i.e., not perfo rmed concomitantly but during the same hospitalization), Indications f or CABG and CEA were comparable to those in the group undergoing simul taneous procedures. In 17 patients CEA was performed before CABG. Ther e was a single CVA, the result of an intracerebral hemorrhage. Five of the 17 patients had a myocardial infarction and two died; one patient had first-degree heart block requiring a pacemaker. Four additional p atients developed atrial fibrillation, one of whom required cardiovers ion. The remaining 12 patients had CABG followed by CEA. There were no CVAs, myocardial infarctions, arrhythmias, or deaths in this subgroup . These data demonstrate that the performance of simultaneous CABG and CEA procedures is associated with increased neurologic morbidity (14. 3%), both ipsilateral and contralateral to the side of carotid surgery in contrast to staged CABG and CEA (3.4%), In addition, when staged c arotid surgery preceded coronary revascularization in those with sever e coronary artery disease, the combined cardiac complication and morta lity rate was significantly higher than when coronary revascularizatio n preceded CEA. This evidence suggests that when CABG and CEA must be performed during the same hospitalization, the procedures should be st aged with CABG preceding CEA.