Surgical strategy in patients with combined symptomatic carotid and coronary artery lesions

• Vachev A.N.
• Tereshina O.V.
• Dmitriev O.V.
• Belkin Yu.S.
• Lebedev P.A.

Abstract

Background. Currently, the approach to the management of symptomatic concomitant lesions of the carotid and coronary arteries remains controversial. No randomized trials on this issue have been conducted.

Objective. The purpose of this study was to validate the choice of surgical strategy in patients with significant symptomatic carotid and coronary artery lesions.

Patients and methods. Our single-center cohort prospective study included a total of 117 consecutively operated patients presenting with significant concomitant carotid and coronary artery disease. All patients underwent surgery at the Clinic of Faculty Surgery of the Samara State Medical University, being symptomatic in both carotid and coronary circulations. They were subdivided into two groups depending on the staging of surgical treatment: 42 patients were subjected to one-stage surgical intervention [carotid endarterectomy (CEA) + coronary artery bypass grafting (CABG) during single anesthesia] and the remaining 75 patients underwent two-stage surgery (CEA at the first stage, followed by CABG performed within not more than a 3-month period). The groups were comparable by most parameters. The primary endpoints were stroke and myocardial infarction, as well as mortality from stroke and mortality from myocardial infarction in the perioperative period.

Results. There were no significant statistical differences in the incidence of myocardial infarction, stroke, and perioperative mortality between the two groups (p>0.05). A risk factor significantly associated with perioperative stroke appeared to be the presence of transitory ischemic attacks (TIAs) during 6 months before surgery (OR 18.400; 95% CI, p=0.002). Risk factors for perioperative myocardial infarction were the occurrence of postoperative bleeding and resternotomy (OR 12,333; 95% CI, p=0.021). A risk factor for patient death was the presence of TIAs within 6 months before surgery (OR 7.360; 95% CI, p=0.019).

Conclusions. Two-stage or one-stage surgical tactics in symptomatic patients with significant ICA and coronary artery disease had similar rates of perioperative myocardial infarctions, cerebrovascular events, and mortality. The main risk factors for the development of adverse outcomes in these patients were the presence of TIA during 6 months before surgery, as well as postoperative bleeding combined with resternotomy.

Keywords: carotid endarterectomy; coronary artery bypass grafting; simultaneous carotid endarterectomy and coronary artery bypass grafting; myocardial infarction; stroke; combined surgery; symptomatic carotid stenosis; two-stage treatment; one-stage treatment

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