Outcome after combined carotid endarterectomy and coronary artery bypass is related to patient selection

Objective: The optimal management of patients with significant coronary and carotid artery disease remains controversial. Since reporting on a series of 100 patients undergoing combined carotid endarterectomy and coronary art ery bypass (CEA/CAB) 4 years ago, we have liberalized our selection criteri a for combined operation. We sought to compare outcomes of the recent cohor t of 74 patients and the previous group. Methods AU patients who underwent CEA/CAB since 1984 have been tracked in a database containing identifying information, demographic factors, anatomic information, details of surgery, and short- and long-term follow-up data. We compared the 74 patients (Group 2) undergoing CEA/CAB since 1994 with th e previously reported group of 100 patients (Group 1) who underwent CEA/CAB between 1984 and 1994. We examined demographic and comorbidity factors, pr esence of cerebrovascular symptoms, degree of contralateral carotid stenosi s, and perioperative stroke and death. Statistical comparisons were made wi th the chi (2) test. Results: The groups had similar age and sex distributions and similar incid ences of hypertension, diabetes, congestive heart failure, prior myocardial infarction, and hypercholesterolemia. More patients in Group 1 had preoper ative transient cerebral ischemia or monocular blindness (55% vs 31%, P < . 002) and preoperative stroke (18% vs 7%, P < .03). More patients in Group 2 had unilateral asymptomatic carotid artery stenosis (55% vs 18%, P < .001) . The incidence of all perioperative strokes was higher in Group 1 (9% vs 1 .4%, P < .035). There were fewer deaths (3% vs 8%) and ipsi lateral strokes (0 vs 4%) in Group 2, though these were not statistically significant. Conclusion: We have liberalized our criteria for performing combined CEA/CA B, such that more than 50% of our recent patients have asymptomatic unilate ral carotid stenosis. This practice is associated with a lower incidence of all perioperative strokes and a trend toward lower ipsilateral stroke and death. These observations suggest that perioperative stroke after CEA/CAB i s related to patient selection and that low-risk patients can undergo CEA/C AB with the benefits of low morbidity, patient convenience, and cost saving s from avoiding a second hospitalization and operation.