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A Propensity Score Matched Analysis of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) vs. Coronary Artery Bypass Graft (CABG) vs. Combined CEA-CABG in the ACS-NSQIP
Li Wang, BS, Thomas Curran, MD, John C. McCallum, MD, Dominique Buck, MD, Jeremy Darling, BA, Mark Wyers, MD, Raul J. Guzman, MD, Allen Hamdan, MD, Elliot Chaikof, MD, PhD, Marc L. Schermerhorn, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.

OBJECTIVES:
Carotid endarterectomy (CEA) and coronary artery bypass graft (CABG) may be combined to treat concomitant coronary artery and carotid artery atherosclerotic disease. Previous reports on combined CEA/CABG have shown wide variation in adverse event rates for asymptomatic patients and have often been limited by small sample size and/or lack of granularity. We aim to compare stroke and death after CEA/CABG with CEA or CABG alone in asymptomatic patients using the ACS-NSQIP.
METHODS:
All patients undergoing CEA, CABG or CEA/CABG from 2005 to 2011 in the NSQIP database were identified. NSQIP documented neurologic symptoms lack laterality and temporal detail for assignment of positive current neurologic symptoms while asymptomatic patients are captured with excellent accuracy. Accordingly only asymptomatic patients were analyzed. Propensity score matched groups of asymptomatic patients were based on age, sex and ASA class 4. Chi-square, ANOVA and multivariable logistic regression were used to compare stroke, death and combined stroke/death across procedures.
RESULTS:
We identified 47,667 patients; 42,474 CEA (89%), 5,018 CABG (11%), 175 CEA/CABG (&lt1%). Forty percent of all patients had a history of neurologic symptoms and were omitted from consideration; 43% CEA, 12% CABG, 28% CEA-CABG. Unmatched rates of stroke/death in asymptomatic patients were: 1.4% (CEA), 3.3% (CABG) and 6.7% (CEA/CABG). Propensity score matching identified 1,332 asymptomatic patients; 606 CEA, 607 CABG, 119 CEA/CABG. Stroke, death and stroke/death rates are compared across procedures in the Table. Independent risk factors for stroke/death among matched asymptomatic patients were: recent myocardial infarction OR: 4.0 (95% CI: 2.0-8.0), COPD OR: 4.7 (95% CI: 2.4-9.2) and age &gt 70 years OR: 2.7 (95% CI: 1.4-5.2); CEA/CABG, as compared to CABG alone, did not have increased risk of stroke/death (OR: .6, 95%CI: .2-1.4). No significant difference was seen between the stroke/death rate of CEA/CABG (6.7%) as compared to the aggregate of CEA and CABG alone (2.1% + 4.2%).
CONCLUSIONS:
In asymptomatic patients CEA/CABG does not confer increased risk for stroke/death as compared to the combined risk of CEA and CABG alone. CEA/CABG should be considered a safe approach in asymptomatic patients requiring both CEA and CABG.
Propensity Score Matched Group Outcome Comparison
CEA
(N=606)
CABG
(N=607)
CEA-CABG
(N=119)
p value
(CABG vs. CEA/CABG)
Death (%)1.22.33.4.516
Stroke (%)1.22.03.4.314
Stroke/Death (%)2.14.16.7.227


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