PREOPERATIVE THALLIUM SCANNING, SELECTIVE CORONARY REVASCULARIZATION,AND LONG-TERM SURVIVAL AFTER CAROTID ENDARTERECTOMY

Background and Purpose-Long-term survival in patients after carotid en darterectomy (CEA) is determined mainly by their concomitant cardiac d isease. We tested to determine whether preoperative thallium scanning (PTS) and subsequent selective coronary revascularization (CR), by eit her percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG), improve long-term survival after CEA. M ethods-Two hundred twenty-six of 255 consecutive patients (88%) underg oing CEA from 1990 to 1996 had PTS. Those with significant reversible defects on PTS were referred for coronary angiography and possible CR. Patients who had undergone PTS were divided into the following 4 grou ps: group 1, normal or mild defects on PTS; group 2, moderate-severe f ixed and/or reversible defects in patients who did not undergo CR; gro up 3, patients who had CR secondary to their PTS results; and group 4, patients who had CR in the past that was not related to the PTS. Peri operative data were prospectively recorded, and data on long-term surv ival and cardiac and neurological complications were collected. Result s-Seventy-seven patients (34%) had preoperative coronary angiography, and 42 (19%) had subsequent CR: preoperative PTCA or CABG in 24, combi ned CEA+CABG in 10,and post-CEA CABG in 8 patients. No deaths resulted from the coronary angiography, CR, or CEA. Six patients had periopera tive nonfatal myocardial infarction and 8 had stroke. During the follo w-up (40+/-23 months), 47 patients (18%) died, 31 (66%) from cardiac d isease and 4 (8.5%) from stroke. Independent predictors of long-term o verall mortality were diabetes mellitus, preoperative T-wave inversion on EGG, lower-extremity arterial disease, and history of neurological symptoms [exp(beta)=3.5, 3.4, 2.5, and 2.4; P=0.0003, 0.0004, 0.01, a nd 0.04, respectively]. In addition, preoperative moderate-severe thal lium defect without CR (group 2) independently predicted long-term car diac mortality [exp(beta)=2.8; P=0.04]. Patients with preoperative CR (group 3) had long-term survival rate similar to that of group 1 and s ignificantly better than that of group 2 (P=0.02). Conclusions-PTS pre dicts long-term survival, and selective CR based on the thallium resul ts improves the survival rate of patients undergoing CEA.