The role of combined carotid endarterectomy and coronary artery bypass grafting in the era of carotid stenting in view of long-term results

OBJECTIVES: The management of concomitant coronary and carotid artery disease is still in evolution. The surgical options are staged approach-carotid endarterectomy (CEA), followed by coronary artery bypass grafting (CABG) or a reversed-staged approach, or combined approach-CEA and CABG under the same anaesthesia. In view of the percutaneous carotid artery stenting option, we have reviewed our short- and long-term experience with combined CEA and CABG to define the role of this procedure. METHODS: From January 1992 to December 2006, we operated on 80 patients performing combined carotid endarterctomy and myocardial revascularization. Short- and long-term results were reviewed. RESULTS: Operative mortality was 3.7%. Perioperative cerebrovascular accident (CVA) occurred in 2 patients (2.5%). Perioperative myocardial infarction (MI) occurred in 3 patients (3.7%). Combined complications of death + MI + CVA = 10%. During the mean follow-up of 10 +/- 3.2 years (1-14 years), 6 patients (7.6%) had neurological events. Freedom from neurological events for 10 years was 92 +/- 4%. Nearly 17 (21.5%) had cardiac events. The 5-year and 10-year survival rates were 74 +/- 5 and 62 +/- 6%, respectively. CONCLUSIONS: Although the short-term results of the non-surgical carotid therapeutic alternative is similar to our surgical results, there are limitations to carotid artery stenting: the need for aggressive antiplatelets therapy, and the haemodynamic changes during the procedure that may be unacceptable for patients with unstable coronary artery disease. Therefore, there is still a role for concomitant surgical CEA and CABG to the results of which the other options should be compared.