European Heart Journal Advance Access originally published online on March 14, 2006
European Heart Journal 2006 27(10):1258-1259; doi:10.1093/eurheartj/ehi839
Concurrent coronary and carotid artery surgery: an open debate
Department of Cardiovascular Surgery
Centro Cardiologico Monzino
University of Milan
Via Parea 4
20138 Milan
Italy
Tel: +39 02 58002563
Fax: +39 02 58011194
E-mail address: fabarili{at}libero.it
Department of Cardiovascular Surgery
Centro Cardiologico Monzino
University of Milan
Via Parea 4
20138 Milan
Italy
Department of Cardiothoracic Surgery
Columbia University College of Physicians and Surgeons
New York, NY
USA
Department of Cardiovascular Surgery
Centro Cardiologico Monzino
University of Milan
Via Parea 4
20138 Milan
Italy
Department of Cardiovascular Surgery
Centro Cardiologico Monzino
University of Milan
Via Parea 4
20138 Milan
Italy
We read with great interest the article by Kolh et al.1 dealing with the question about concurrent coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) surgery. Nevertheless, their report raises some concerns.
The article analysed factors influencing peri-operative outcomes, and ascending aortic calcification was found to be an independent predictor of both stroke and death. These data are considered a common finding in patients who underwent heart surgery.2 However, in patients with concomitant severe carotid and coronary disease, the predictive role of aortic disease on stroke and death could be significantly overestimated. Carotid disease alone is a risk factor for stroke in patients who undergo surgical revascularization and stroke represents a known complication of CEA. In a recent large study, the adjusted stroke rate was 2.67-fold greater in the combined CEA–CABG group compared with CABG alone.3 By its nature, this study did not evaluate the impact of CEA on stroke incidence and the confounding effect of carotid disease on mortality and morbidity does not emerge. Hence the predictive effect of aortic disease could be significantly altered. Further studies on patients with and without concomitant CEA are needed to unmask the effect of carotid disease on stroke and to evaluate the real predictive role of aortic disease.
In addition, the multivariate model cannot predict precisely the odds ratio for variables associated with operative mortality and morbidity, as confidence intervals are large, although P-values are significant.
Some data about cardiopulmonary bypass and surgical techniques are lacking. We think that it could be important to explain where the arterial cannulation was made in patients with ascending aorta disease, as the number of no-touch aorta technique and off-pump surgery was lower than expected. Moreover, no explanation was given about surgical approach to 17 patients with aortic dilatation, as it seems that dilated ascending aorta was not substituted.
This study confirms that concurrent CEA and CABG can be performed with acceptable mortality and morbidity, but it represents only one of the surgical option.4 We agree with the authors who consider treatment of symptomatic territory first reserving the combined simultaneous treatment for patients symptomatic in both territories.5
References
- Kolh PH, Comte L, Tchana-Sato V, Honore C, Kerzmann A, Mauer M, Limet R. Concurrent coronary and carotid artery surgery: factors influencing perioperative outcome and long-term results. Eur Heart J 2006; 27: 49–56.
[Abstract/Free Full Text] - Kapetanakis EI, Stamou SC, Dullum MK, Hill PC, Haile E, Boyce SW, Bafi AS, Petro KR, Corso PJ. The impact of aortic manipulation on neurologic outcomes after coronary artery bypass surgery: a risk-adjusted study. Ann Thorac Surg 2004; 78: 1564–1571.
[Abstract/Free Full Text] - Hill MD, Shrive FM, Kennedy J, Feasby TE, Ghali WA. Simultaneous carotid endarterectomy and coronary artery bypass surgery in Canada. Neurology 2005; 64: 1435–1437.
[Abstract/Free Full Text] - Antunes PE, Anacleto G, de Oliveira JM, Eugenio L, Antunes MJ. Staged carotid and coronary surgery for concomitant carotid and coronary artery disease. Eur J Cardiothorac Surg 2002; 21: 181–186.
[Abstract/Free Full Text] - Huh J, Wall MJ, Soltero ER. Treatment of combined coronary and carotid artery disease. Curr Opin Cardiol 2003; 18: 447–453.[CrossRef][Medline]
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