Trends and outcomes of concurrent carotid and coronary revascularization: Effects of carotid stenting vs endarterectomy on coronary bypass

Background: The management of concurrent carotid and coronary disease is controversial. Although single center observational studies have revealed acceptable outcomes of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG), community-based outcomes have been substantially inferior. Recently, carotid stenting (CAS) has been introduced for the management of high-risk patients with carotid stenosis, including those with severe coronary artery disease. This study was undertaken to evaluate the nationwide trends and outcomes of CAS prior to CABG vs. combined CEA and CABG and to assess the risk for adverse events.
Methods: The Nationwide Inpatient Sample (NIS) was used to identify patients discharged after concurrent carotid and coronary revascularization procedures. All patients that have undergone CAS prior to CABG and combined CEA-CABG during the years 2000-2004 were included. The type of revascularization and major adverse events (MAEs), i.e. in-hospital stroke and death rates, were determined by cross-tabulating discharge diagnostic and procedural codes. Risk stratification was performed using the Charlson Comorbidity Index. Weighted exact Cochrane-Armitage trend test and multivariate logistic regression were used to assess the association between types of revascularization, comorbidities, complications and risk-adjusted mortality.
Results: Over the 5-year period, the total number of concurrent carotid revascularizations and CABG was 27,084. The vast majority of patients underwent CEA-CABG (96.7%), whereas CAS-CABG was only performed in 887 (3.3%) patients. From 2000 to 2004, the proportion of patients undergoing CAS-CABG vs. CEA-CABG has not significantly changed (P=not significant [NS]). Patients undergoing CAS-CABG had fewer MAEs than those undergoing combined CEA-CABG, despite similar overall risk profile. CAS-CABG patients had a lower incidence of postoperative stroke (2.4% vs 3.9%), and combined stroke and death (6.9% vs 8.6%) compared with the combined CEA-CABG group (P<.001), although in-hospital death rates were similar (5.2% vs 5.4%). After risk-stratification, CEA-CABG patients had a 62% increased risk of postoperative stroke, compared to patients undergoing CAS prior to CABG (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.1-2.5; P<.001). However, no differences in the risk of combined stroke and death were observed (OR, 1.26; 95% CI, 0.9-1.6; P=NS).
Conclusions: Although CAS may currently be performed for high-risk patients, including those with severe coronary artery disease, it is still infrequently used in patients that require concurrent carotid and coronary interventions. In the United States, patients who undergo CAS-CABG have significantly decreased stroke rates than those undergoing CEA-CABG, but similar in-hospital mortality. CAS may be a safer carotid revascularization option for this challenging patient population in terms of postoperative stroke prevention, but further improvements in in-hospital mortality are necessary.