Perioperative and Long-Term Outcomes in Patients Undergoing Synchronous Carotid Endarterectomy and Coronary Artery Bypass Grafting

Objectives: Patients requiring coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) receive staged (CABG before CEA), reversed-staged (CEA before CABG), or synchronous treatment. The most efficient operative strategy remains unknown. This single-center retrospective study evaluated the outcomes in patients undergoing planned synchronous CEA and CABG.

Methods: Between 2000 and 2020, a total of 185 patients (70.0 ± 8.3 years; 27.0% female) with symptomatic triple vessel or left main coronary artery disease associated with ≥70% asymptomatic or ≥50% symptomatic uni- or bilateral internal carotid artery (ICA) stenosis underwent synchronous CEA and CABG at our institution. CEA was performed before cardiopulmonary bypass by a vascular surgeon followed by CABG. Study endpoints were defined as mortality, stroke, and myocardial infarction at 30 days. In addition, the composite endpoint of these events was investigated.

Result: Follow-up is complete with a mean of 5.5 ± 4.0 years. Symptomatic ICA stenosis was present in 15 patients (8.1%), and contralateral ICA stenosis ≥50% in 78 patients (42.2%). Mean logarithmic EuroSCORE was 9.1 ± 7.2%. Peripheral arterial disease was observed in 40.5% of patients. In 94.6% of cases, eversion carotid endarterectomy was performed. Mean aortic cross-clamp time was 39.4 ± 14.4 minutes, and cardiopulmonary bypass time was 86.4 ± 34.1 minutes. Median stay on the intensive care unit was 2 days (IQR: 1–5). At 30 days, mortality, stroke, and myocardial infarction rates were 5.9, 8.6, and 3.8% and the composite endpoint was reached in 13.5% of patients. Contralateral or bilateral ischemic events occurred in 75% of patients with a perioperative stroke. Patients suffering from perioperative stroke had more frequently a contralateral ≥50% ICA stenosis (81.3 vs. 18.8%; p = 0.001), peripheral arterial disease (68.8 vs. 31.2%; p = 0.030), and prolonged cardiopulmonary bypass time (mean: 114.6 vs. 83.6 minutes; p = 0.036). Survival probability at 10 years was 60.2% (95% CI: 52.2–69.4), and freedom from cardiovascular reintervention at 10 years was 56.1% (95% CI: 45.3–69.4).

Conclusion: Patients with coronary and cerebrovascular occlusive disease undergoing simultaneous CEA and CABG have a high risk of perioperative and late cardiovascular events, including stroke, and a poor long-term survival.

Publication History

Article published online:
19 February 2021