Multistate population-based outcomes of combined carotid endarterectomy and coronary artery bypass

Objectives. The management of combined carotid and coronary disease is controversial, and the outcomes of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CA-BG) have not been determined on a community-wide basis. This study was undertaken to evaluate the community-wide outcomes of combined CEA and CABG and to evaluate the risk for adverse events. Methods. A complete medical record review of 10,561 CEA procedures randomly selected from Medicare patients undergoing CEA in 10 states was performed. In this sample, 226 procedures were performed in combination with CABG in the same operative event. Results. Recent ipsilateral stroke or transient ischemic attack was the indication for the CEA in only 12% of patients undergoing CEA/CABG, and 56% were asymptomatic with respect to the carotid lesion. The combined stroke and death rate was 17.7% (25 nonfatal strokes, two fatal strokes, and 13 nonstroke deaths). Eighty percent of the nonfatal strokes were disabling. Proximal aortic arch atherosclerosis and symptomatic carotid stenosis were associated with stroke (P < .05). Female gender, emergent operation, redo CABG, blood pressure on pump, total pump time, presence of left main disease, and number of diseased coronaries were associated with mortality (P < .05). The strokes appeared to be associated with the operative event, but diagnosis was delayed and postevent carotid patency was not documented. Most strokes were not limited to the hemisphere ipsilateral to the CEA. Conclusion: The community-wide outcomes of combined CEA/CABG in the Medicare population are inferior to. those reported in many single-institution reviews. Diagnosis of postoperative stroke is often delayed, and most strokes are not limited to the hemisphere ipsilateral to the CEA operative site.