Timing and Outcomes of Precoronary Artery Bypass Grafting Carotid Endarterectomy

The Society for Vascular Surgery Clinical Practice Guidelines suggests the timing of carotid endarterectomy (CEA) in patients with symptomatic or bilateral severe asymptomatic carotid stenosis needing coronary artery bypass grafting (CABG) be performed either with preoperative CEA or concomitantly with CABG. The optimal timing of CEA in patients with high grade unilateral stenosis, however, has been controversial due to equivocal and/or scarce data. This study examines our experience with pre-CABG CEA and timing in this patient population. This is a single-center retrospective review of all patients who underwent CEA before or during CABG between January 2010 and January 2021. All patients receiving CEA were anesthetized by a dedicated cardiac anesthesiologist. Patients were compared based on timing of CEA in relation to CABG: concomitant (CABG day 0 from CEA) and nonconcomitant (CABG day 1-30 after CEA). The nonconcomitant cohort was substratified into hyperacute (CABG within 48 hours), acute (CABG within 2 weeks), and subacute (CABG within 30 days). Demographics and status of carotid disease were collated. Primary outcomes included stroke, defined as new neurologic deficit, myocardial infarction (MI), 30-day readmission, and 30-day mortality. A total of 39 patients were identified in the study population. Of these, 9 (23%) patients underwent CEA and CABG concomitantly, with 30 receiving nonconcomitant CEA (hyperacute [9, 23%]; acute [16, 41%]; subacute [5, 13%]). Baseline demographics and comorbidities were similar between groups. The degree of internal carotid artery stenosis, presence of high-grade contralateral stenosis, and symptomatic carotid presentation did not impact perioperative outcomes. One stroke occurred after a concomitant CEA/CABG that was a bi-hemispheric event believed to be due to cannulating a highly diseased ascending aorta. One patient in the concomitant cohort developed postoperative MI, cardiogenic shock, and subsequent death (Table I). There was no observed stroke, MI, or death in the nonconcomitant cohort. Thirty-day readmission and mortality were similar between all groups (Tables I and II). However, when comparing aggregate stoke/MI (Table I), a statistically significant difference was observed in favor of the nonconcomitant cohort (P = .007). Careful consideration is needed when determining appropriate timing for coronary revascularization in patients with carotid disease. These data suggest that nonconcomitant, preoperative CEA can be performed safely by a dedicated cardiac anesthesiologist before CABG. Concomitant CEA/CABG, as reflected in these data, carries an added procedural risk of stroke and a potentially poor cardiac outcome. Further study is warranted to elucidate the role of timing in perioperative outcomes for patients requiring CEA and CABG.Table IPerioperative outcomes for patients undergoing coronary artery bypass grafting (CABG) within 30 days of carotid endarterectomy (CEA)Concomitant CABG (n = 9)Nonconcomitant CABG (n = 30)P valuePostoperative events (MI, NS), No. (%)2 (22.2)0 (0).007a30-day readmission, No. (%)1 (11.1)3 (10).9330-day mortality, No. (%)1 (11.1)0 (0).07MI, Myocardial infarction; NS, neurologic symptoms. Open table in a new tab Table IIPerioperative outcomes for patients undergoing coronary artery bypass grafting (CABG) within 30 days of carotid endarterectomy (CEA), with the nonconcomitant CEA/CABG cohort substratified by timingConcomitant CABG (n = 9)Hyperacute CABG (n = 9)Acute CABG (n = 16)Subacute CABG (n = 5)P valuePostoperative events (MI, NS), No. (%)2 (11.1)0 (0)0 (0)0 (0).3530-day readmission, No. (%)1 (11.1)0 (0)1 (6.3)2 (40).1130-day mortality, No. (%)1 (11.1)0 (0)0 (0)0 (0).35MI, Myocardial infarction; NS, neurologic symptoms. Open table in a new tab