Combined Carotid Endarterectomy and Coronary
Artery Bypass Grafting vs. Sequential Procedures:
A Retrospective Review of Outcomes at Our Institution

Background: It remains controversial whether patients with both carotid and coronary disease should undergo operative repair separately or in combination. The purpose of the current study is to compare the outcomes after carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) alone and in combination at our institution.
Methods: A retrospective case-matched control study of the prospectively collected vascular and cardiothoracic surgery registries from January 1995 to December 2006 was performed. Analysis of all patients undergoing CEA or CABG was performed using univariate and multivariate analysis to determine risk factors for the primary outcome (stroke) and secondary outcomes (myocardial infarction (MI) and 30 day mortality). Risk-factor matched case controls were randomly selected in a 3:1 ratio from patients undergoing either CEA or CABG, alone. These control patients were then compared with all patients undergoing combined CEA/CABG with regard to the primary and secondary outcomes of interest.
Results: 1543 patients who underwent CEA only were identified from the CEA registry. Among CEA patients, there were no predictors for perioperative stroke, while diabetes was an independent predictor for perioperative MI (P<0.05) or death (P<0.05) and renal failure (P<0.05) was an independent predictor for death. Over this same time period a total of 114 patients were identified who underwent combined CEA/CABG. Using risk factors of advanced age, female gender, and presence of symptoms of transient cerebral ischemia or stroke, 342 control patients undergoing CEA only were stratified and matched. Combined CEA/CABG patients had a higher 30 day perioperative stroke rate (4% vs. 0.6%, P=0.012) and combined cardiovascular morbidity (4% vs. 0.6%, P=0.012) than matched CEA only patients, but no differences in MI or death rates.
Similarly, 4812 patients who underwent CABG only were identified from the CABG registry. Among CABG patients, risk factors identified for perioperative stroke included advanced age, female gender, hypertension, renal failure, and the presence of carotid disease. Using these risk factors from among a subset of isolated CABG patients with carotid disease, a total of 342 further control patients were further identified. There were no statistically significant differences between CEA/CABG and matched CABG only patients in the perioperative risk of stroke (4% vs. 3%, P=0.56), death (0.9% vs. 5%, P=0.08), MI (0% vs. 0%) and combined cardiovascular morbidity (4% vs. 6%, P=0.64).
Conclusion: In this retrospective risk-matched case-control study, the risk of stroke with combined CEA/CABG was greater than that of CEA alone. Addition of CEA to CABG did not increase the risk of perioperative stroke among our patients, but neither did it decrease the risk. In the absence of prospective trials showing long term benefit from carotid endarterectomy at the time of coronary artery bypass surgery, the decision to proceed with combined operation must be made on a case-by-case basis.