Trends and outcomes of concurrent carotid revascularization and coronary bypass

Abstract

Background: The management of concurrent carotid and coronary artery disease is controversial. Although single-center observational studies have revealed acceptable outcomes of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG), community-based outcomes have been substantially inferior. Recently, carotid artery stenting (CAS) has been introduced for the management of high-risk patients with carotid stenosis, including those with severe coronary artery disease. This study was undertaken to evaluate the nationwide trends and outcomes of CAS before CABG vs combined CEA and CABG and to assess the risk for adverse events.

Methods: The Nationwide Inpatient Sample (NIS) was used to identify patients discharged after concurrent carotid and coronary revascularization procedures. All patients that underwent CAS before CABG and combined CEA-CABG during the years 2000 to 2004 were included. The type of revascularization and major adverse events (ie, in-hospital stroke and death rates) were determined by cross-tabulating discharge diagnostic and procedural codes. Risk stratification was performed using the Charlson Comorbidity Index. Weighted exact Cochrane-Armitage trend test and multivariate logistic regression were used to assess the association between types of revascularization, comorbidities, complications, and risk-adjusted mortality.

Results: During the 5-year period, 27,084 concurrent carotid revascularizations and CABG were done. Of these, 96.7% underwent CEA-CABG, whereas only 3.3% (887 patients) had CAS-CABG. From 2000 to 2004, the proportion of patients undergoing CAS-CABG vs CEA-CABG did not significantly changed (P = .27). Patients undergoing CAS-CABG had fewer major adverse events than those undergoing CEA-CABG. CAS-CABG patients had a lower incidence of postoperative stroke (2.4% vs 3.9%), and combined stroke and death (6.9% v. 8.6%) than the combined CEA-CABG group (P < .001), although in-hospital death rates were similar (5.2% vs 5.4%). After risk-stratification, CEA-CABG patients had a 62% increased risk of postoperative stroke compared with patients undergoing CAS before CABG (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.1-2.5; P = .02). However, no differences in the risk of combined stroke and death were observed (OR, 1.26; 95% CI, 0.9-1.6; P = NS).

Conclusion: Although CAS may currently be performed for high-risk patients, it is still infrequently used in patients who require concurrent carotid and coronary interventions. In the United States, patients who undergo CAS-CABG have significantly decreased in-hospital stroke rates compared with patients undergoing CEA-CABG but similar in-hospital mortality. CAS may provide a safer carotid revascularization option for patients who require CABG.