The role of combined carotid endarterectomy and coronary artery bypass grafting in the era of carotid stenting in view of long-term results.

OBJECTIVES

The management of concomitant coronary and carotid artery disease is still in evolution. The surgical options are staged approach--carotid endarterectomy (CEA), followed by coronary artery bypass grafting (CABG) or a reversed-staged approach, or combined approach--CEA and CABG under the same anaesthesia. In view of the percutaneous carotid artery stenting option, we have reviewed our short- and long-term experience with combined CEA and CABG to define the role of this procedure.

METHODS

From January 1992 to December 2006, we operated on 80 patients performing combined carotid endarterctomy and myocardial revascularization. Short- and long-term results were reviewed.

RESULTS

Operative mortality was 3.7%. Perioperative cerebrovascular accident (CVA) occurred in 2 patients (2.5%). Perioperative myocardial infarction (MI) occurred in 3 patients (3.7%). Combined complications of death + MI + CVA = 10%. During the mean follow-up of 10 ± 3.2 years (1-14 years), 6 patients (7.6%) had neurological events. Freedom from neurological events for 10 years was 92 ± 4%. Nearly 17 (21.5%) had cardiac events. The 5-year and 10-year survival rates were 74 ± 5 and 62 ± 6%, respectively.

CONCLUSIONS

Although the short-term results of the non-surgical carotid therapeutic alternative is similar to our surgical results, there are limitations to carotid artery stenting: the need for aggressive antiplatelets therapy, and the haemodynamic changes during the procedure that may be unacceptable for patients with unstable coronary artery disease. Therefore, there is still a role for concomitant surgical CEA and CABG to the results of which the other options should be compared.