Coronary bypass and carotid endarterectomy: Does a combined approach increase risk? A metaanalysis

Background. Patients with concomitant carotid and coronary artery disease p resent a surgical dilemma. We compared the stroke and mortality rates for c ombined coronary artery bypass grafting and carotid endarterectomy in which both procedures were performed under a single anesthetic, versus a staged approach, in which coronary artery bypass grafting and carotid endarterecto my were performed separately. Methods. A computerized MEDLINE search supplemented with a manual bibliogra phic review was performed for all peer-reviewed English language publicatio ns that contained both combined and staged coronary artery bypass grafting/ carotid endarterectomy patient cohorts. Outcomes of interest were stroke, d eath, and stroke or death; aggregation of outcome rates was performed with the Mantel-Haenszel method. Results. Sixteen studies were identified with a total of 844 combined patie nts and 920 staged patients. None of the studies was completely randomized. The combined surgical group had a higher prevalence of unstable angina; th e two groups had a similar prevalence of symptomatic carotid disease and se vere carotid stenosis. Meta-analysis revealed a significantly increased ris k of the composite end point, stroke or death, for patients undergoing comb ined procedures (relative risk 1.49; 95% confidence interval 1.03-2.15; p = 0.034). There was also a trend toward increased risk during combined proce dures for the end points of stroke (relative risk 1.50; 95% confidence inte rval 0.97-2.32; p = 0.068) and death (relative risk 1.55; 95% confidence in terval 0.94-2.53; p = 0.084) considered separately. The crude event rates f or stroke were 6.0% versus 3.2% for combined versus staged procedure, 4.7% versus 2.9% for death, and 9.5% versus 5.7% for stroke or death. Two of the 16 individual studies showed a statistically significant increase in the r isk of stroke or death for combined procedure (p < 0.05). Conclusions. Combined coronary artery bypass grafting and carotid endartere ctomy may be associated with a higher risk of stroke or death than staged p rocedures. A randomized trial needs to be performed to determine the optima l management of patients with concomitant carotid and coronary artery disea se. (C) 1999 by The Society of Thoracic Surgeons.