Short- and Long-Term Outcomes Following Concurrent Carotid Endarterectomy and Open Heart Surgery
Linda J. Wang, MD, MBA, Emel A. Ergul, MS, Christopher A. Latz, MD, Adam Tanious, MD, MMSc, W. Darrin Clouse, MD, Mark F. Conrad, MD, MMSc.
Massachusetts General Hospital, Boston, MA, USA.
OBJECTIVES: Controversy remains over the safety of concurrent carotid endarterectomy (CEA) and open heart surgery (OHS). Most of the literature focuses on combined CEA and coronary artery bypass grafting (CABG) without consideration of the additional risk associated with valve procedures. This study sought to assess the outcomes of concurrent CEA and OHS with an emphasis on the difference between CABG and valve procedures. METHODS: Using a prospective single-institution database, all patients who underwent concurrent CEA and OHS from January 2010 to January 2017 were included. Patients were stratified into CEA-CABG and CEA-valve (with or without CABG) cohorts. Demographics were assessed using hospital records. Outcomes included 30-day post-operative stroke, 5-year mortality and stroke, and rates of carotid artery restenosis (≥50%). All strokes, regardless of laterality, were included. Univariate analysis was performed and Cox proportional hazards models were created to assess risk factors for survival.
RESULTS: 108 patients were identified during the study period (67(62%) CEA-CABG, 41(38%) CEA-valve). In this population, 72% were male, 94% had hypertension, 35% had diabetes mellitus, and 93% had coronary artery disease. Overall 30-day stroke rate was 4.6% (3.0% CEA-CABG, 7.3% CEA-valve, p=0.37). Of the five 30-day strokes, 2(40%) were ipsilateral to the CEA. There was no difference in 5-year survival (p=0.11). At 5-year follow-up, the stroke rates were 4.5% and 14.6% in the CEA-CABG and CEA-valve groups, respectively (p<0.05); 66% of the strokes in the CEA-valve were ipsilateral to the CEA. There was a statistically significant increased risk of combined stroke and death at 5 years in the CEA-valve group (p=0.03). Rates of carotid artery restenosis were similar between the two cohorts (p=0.88). A Cox proportional hazards model adjusting for comorbidities showed that the most important risk factors for survival were female gender (hazard ratio (HR) 3.87, p <0.01), urgency of operation (HR 3.63, p <0.01), and need to return to the operating room (HR 6.14, <0.01). CONCLUSIONS: Concurrent CEA and OHS can be performed safely with low 30-day post-operative stroke rates and excellent long-term survival. While the 5-year risk of stroke in patients undergoing CEA-valve is higher when compared to CEA-CABG, there is no increased risk when compared to patients undergoing valve replacement alone.
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