Operative- and Long-Term Outcomes of Combined and Staged Carotid Endarterectomy and Coronary Bypass.
Academic Article
Overview
abstract
OBJECTIVE: Optimal temporal surgical management of significant carotid stenosis (CS) and coronary artery disease (CAD) remains unknown. Carotid endarterectomy (CEA) and coronary bypass (CABG) are performed concurrently (CCAB) or in staged (CEA-CABG or CABG-CEA) approach. Using the Vascular Quality Initiative (VQI)-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network (VISION)-Medicare linked dataset, this study compared operative and long-term outcomes following CCAB and staged approaches. METHODS: The VQI-VISION dataset was used to identify CEAs from 2011-2018 with combined CABG or CABG within 45 days preceding or following CEA. Patients were stratified based on concurrent or staged approach. Primary outcomes were stroke, myocardial infarction (MI), all-cause mortality, stroke and death as composite (SD) and all as composite (SMD) within 30-days from the last procedure as well as long-term. Univariate analysis and risk-adjusted analysis using inverse propensity weighting (IPW) were performed. Kaplan-Meier curves of stroke, MI, and death were created and compared. RESULTS: There were 1,058 patients included: 643 CCAB and 415 staged (309 CEA-CABG and 106 CABG-CEA). Compared to staged patients, those undergoing CCAB had higher preoperative rate of congestive heart failure (24.8% vs 18.4%, p=0.01) and decreased renal function (14.9% vs 8.5%, p<0.01) as well as fewer prior neurological events (23.5% vs 31.4%, p<0.01). Patients undergoing CCAB had similar weighted rate of 30-day stroke (4.6% vs 4.1%, p=0.72), death (7.0% vs 5.0%, p=0.32), and composite outcomes (SD: 9.8% vs 8.5%, p=0.56; SDM: 14.7% vs 17.4%, p=0.31) but a lower weighted rate of MI (5.5% vs 11.5%, p<0.01) versus the staged cohort. Long-term adjusted risks of stroke (HR, 0.85; 95% CI, 0.54 - 1.36; p=0.51) and mortality (HR, 1.02; 95% CI, 0.76 - 1.36; p=0.91) were similar between groups, but higher risk of MI long-term was seen in those staged (HR, 1.49; 95% CI, 1.07 - 2.08; p=0.02). CONCLUSIONS: In patients undergoing CCAB or staged open revascularization for CS and CAD, the staged approach had increased risk of postoperative cardiac event, but short- and long-term rates of stroke and mortality appear comparable. Adverse cardiovascular event risk is high between operations when staged and should be a consideration when selecting approach. Although factors leading to staged sequencing performance need further clarity, CCAB appears safe and should be considered an equally reasonable option.
