IS AN INTEGRATED APPROACH WARRANTED FOR CONCOMITANT CAROTID AND CORONARY-ARTERY DISEASE

Background. The management of patients with severe, concomitant corona ry and carotid artery occlusive disease is controversial. Methods. Bet ween 1975 and 1996, 512 patients (mean age, 64.9 years; 70% male) were admitted for coronary revascularizatian; 316 (61.7%) had asymptomatic , severe carotid disease (stenosis >70%) and 196 (38.3%) had symptomat ic carotid disease (159 [31.1%] with transient ischemia and 37 [7.2%] with completed stroke). In group 1, coronary revascularization and car otid endarterectomy were simultaneously performed in 255 patients (49. 8%) with unstable angina. In group 2 (staged approach), carotid endart erectomy was performed before coronary revascularization in 257 patien ts (50.2%) without unstable angina. Results. Before 1986, the incidenc e oi: stroke and death was greater in group 1 (n = 149) than in group 2 (n = 156) (14 [9.4%] versus 4 [2.6%]; p < 0.01). Since 1986, outcome s in group 1 (n = 106) and group 2 (n = 101) have been similar for str oke (2 [1.9%] versus 2 [2.0%]), death (4 [3.8%] versus 3 [3.0%]), and myocardial infarction (4 [3.8%] versus 5 [5.0%]). Significant univaria te and multivariate predictors of adverse outcome were primarily heart -related (reoperation, intraaortic balloon use, ejection fraction <0.5 0, and angina grade 4 for death; age >70 years and congestive heart fa ilure Fnr sh stroke). Conclusions. Despite highly selected populations , contemporary surgical results do not indicate that staged treatment of severe, concomitant coronary and carotid artery occlusive disease h as an advantage over simultaneous treatment. Advances in myocardial pr otection and perioperative hemodynamic management may account for the low incidences of stroke and death in these operations. (C) 1997 by Th e Society of Thoracic Surgeons.