Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
Department of Biostatistics, University of Virginia, Charlottesville, VA.
J Vasc Surg. 2023 May;77(5):1424-1433.e1. doi: 10.1016/j.jvs.2023.01.015. Epub 2023 Jan 18.
Optimal temporal surgical management of significant carotid stenosis and coronary artery disease remains unknown. Carotid endarterectomy (CEA) and coronary artery bypass (CABG) are performed concurrently (CCAB) or in a staged (CEA-CABG or CABG-CEA) approach. Using the Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network-Medicare-linked dataset, this study compared operative and long-term outcomes after CCAB and staged approaches.
The Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network dataset was used to identify CEAs from 2011 to 2018 with combined CABG or CABG within 45 days preceding or after 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 within 30 days from the last procedure as well as in the long term. Univariate analysis and risk-adjusted analysis using inverse propensity weighting were performed. Kaplan-Meier curves of stroke, MI, and death were created and compared.
There were 1058 patients included: 643 CCAB and 415 staged (309 CEA-CABG and 106 CABG-CEA). Compared with staged patients, those undergoing CCAB had a higher preoperative rate of congestive heart failure (24.8% vs 18.4%; P = .01) and decreased renal function (14.9% vs 8.5%; P < .01), as well as fewer prior neurological events (23.5% vs 31.4%; P < .01). Patients undergoing CCAB had similar weighted rate of 30-day stroke (4.6% vs 4.1%; P = .72), death (7.0% vs 5.0%; P = .32), and composite outcomes (stroke and death, 9.8% vs 8.5%; P = .56; stroke, death, and MI, 14.7% vs 17.4%; P = .31), but a lower weighted rate of MI (5.5% vs 11.5%; P < .01) vs the staged cohort. Long-term adjusted risks of stroke (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.54-1.36; P = .51) and mortality (HR, 1.02; 95% CI, 0.76-1.36; P=.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 = .02).
In patients undergoing CCAB or staged open revascularization for carotid stenosis and coronary artery disease, the staged approach had an increased risk of postoperative cardiac event, but the short- and long-term rates of stroke and mortality seem to be comparable. Adverse cardiovascular event risk is high between operations when staged and should be a consideration when selecting an approach. Although factors leading to staged sequencing performance need further clarity, CCAB seems to be safe and should be considered an equally reasonable option.
颈动脉狭窄和冠状动脉疾病的最佳手术治疗时间仍不明确。颈动脉内膜切除术（CEA）和冠状动脉旁路移植术（CABG）可同时进行（CCAB）或分期进行（CEA-CABG 或 CABG-CEA）。本研究利用血管质量倡议-血管植入物监测和干预结果协调注册网络-医疗保险链接数据集，比较了 CCAB 和分期方法的手术和长期结果。
血管质量倡议-血管植入物监测和干预结果协调注册网络数据集用于确定 2011 年至 2018 年期间接受 CEA 并在 CEA 前或后 45 天内联合进行 CABG 或 CABG 的患者。患者根据同期或分期方法进行分层。主要结局为中风、心肌梗死（MI）、全因死亡率、中风和死亡复合（SD）以及最后一次手术 30 天内和长期的所有复合结局。进行了单变量分析和使用逆概率加权的风险调整分析。绘制了中风、MI 和死亡的 Kaplan-Meier 曲线并进行了比较。
共纳入 1058 例患者：643 例 CCAB 和 415 例分期（309 例 CEA-CABG 和 106 例 CABG-CEA）。与分期患者相比，同期手术患者术前充血性心力衰竭发生率（24.8% vs 18.4%；P =.01）和肾功能下降发生率（14.9% vs 8.5%；P <.01）更高，且既往神经系统事件发生率较低（23.5% vs 31.4%；P <.01）。同期手术患者的 30 天内中风（4.6% vs 4.1%；P =.72）、死亡（7.0% vs 5.0%；P =.32）和复合结局（中风和死亡，9.8% vs 8.5%；P =.56；中风、死亡和 MI，14.7% vs 17.4%；P =.31）的加权发生率相似，但 MI 发生率较低（5.5% vs 11.5%；P <.01）。与分期组相比，两组之间的中风（风险比[HR]，0.85；95%置信区间[CI]，0.54-1.36；P =.51）和死亡率（HR，1.02；95%CI，0.76-1.36；P =.91）的长期调整风险相似，但分期患者的 MI 长期风险更高（HR，1.49；95%CI，1.07-2.08；P =.02）。
在接受 CCAB 或分期开放血运重建治疗颈动脉狭窄和冠状动脉疾病的患者中，分期方法术后心脏事件风险增加，但短期和长期的中风和死亡率似乎相当。分期时手术之间的心血管不良事件风险较高，在选择治疗方法时应予以考虑。尽管导致分期排序表现的因素需要进一步明确，但 CCAB 似乎是安全的，应被视为同样合理的选择。
