Abstract 1938: The Risk of Carotid Endarterectomy Preceding Coronary Artery Bypass Grafting in Patients with Concomitant Significant Coronary Artery Disease and Critical Carotid Stenosis
Background: AHA guidelines regard carotid endarterectomy (CEA) as an intermediate risk procedure (reported cardiac risk 5%). The risk of CEA, in patients with known coronary artery disease (CAD) severe enough to warrant coronary artery bypass grafting (CABG), is not well defined. Also, there is no consensus on whether CEA or CABG should be performed first in these patients. Often, in this situation, CEA is performed before CABG in the absence of any definite evidence.
Objective: To determine the risk of CEA before CABG in a high risk subset and compare it with a low risk subset.
Methods: We identified 2129 consecutive patients who had CEA in our institution from 1/1/1998 to 8/31/2006. Patients were divided into high risk (Group 1) with CAD requiring CABG, found to have critical carotid stenosis on pre-CABG evaluation and patients with CAD requiring CABG found on pre-CEA evaluation and low risk (Group 2) based on clinical evaluation or noninvasive testing or PCI performed before CEA. ICD-9 codes were used to identify patients in both groups who had in-hospital complications. The records of patients (cardiac catheterization, echocardiogram, H&P, consultations, operative reports and discharge summaries) with complications were extensively reviewed for events following CEA (before CABG in Group 1).
Results: Total patients 2129, male 56.4%, 92% Caucasian, mean age 72 years. Odds ratios adjusted for gender, race and age.
Conclusion: Patients with critical CAD requiring CABG had a significantly higher risk of mortality, nonfatal acute coronary syndrome (ACS) and nonfatal cerebrovascular accident/transient ischemic attack (CVA/TIA) when CEA was performed before CABG as compared to a relatively low risk group as defined above. This data needs to be taken into consideration in the care of these patients. Randomized trials are necessary to determine the best approach in the management of concomitant critical coronary and carotid disease in the high risk patient as we defined.