1618 ADULT CARDIAC
NABAGIEZ ET AL TWENTY-FOUR HOUR STAGED CEA/OFF-PUMP CABG
We thank Georganne Santello and Doreen Battista in Health Information Management for their assistance in retrieving the charts and managing the records in spite of Hurricane Sandy. In addition, we thank the volunteers who assisted with data collection (Christopher Aseervatham, Edward Daniele, and Natasha Povar). Special thanks to Dr Cara Chasin for assisting with the development of the data registry.
References 1. Steinvil A, Sadeh B, Arbel Y, et al. Prevalence and predictors of concomitant carotid and coronary artery atherosclerotic disease. J Am Coll Cardiol 2011;57:779–83. 2. Tanimoto S, Ikari Y, Tanabe K, et al. Prevalence of carotid artery stenosis in patients with coronary artery disease in Japanese population. Stroke 2005;36:2094–8. 3. Venkatachalam S, Gray BH, Mukherjee D, Shishehbor MH. Contemporary management of concomitant carotid and coronary artery disease. Heart 2011;97:175–80. 4. Kougias P, Kappa JR, Sewell DH, et al. Simultaneous carotid endarterectomy and coronary artery bypass grafting: results in specific patient groups. Ann Vasc Surg 2007;21:408–14. 5. Antunes PE, Anacleto G, de Oliveira JM, Eug enio L, Antunes MJ. Staged carotid and coronary surgery for concomitant carotid and coronary artery disease. Eur J Cardiothorac Surg 2002;21:181–6. 6. Borger MA, Fremes SE, Weisel RD, et al. Coronary bypass and carotid endarterectomy: does a combined approach increase risk? A metaanalysis. Ann Thorac Surg 1999;68:14–20. 7. Moore WS, Barnett HJ, Beebe HG, et al. Guidelines for carotid endarterectomy. A multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association. Circulation 1995;91:566–79. 8. Prasad SM, Li S, Rankin JS, et al. Current outcomes of simultaneous carotid endarterectomy and coronary artery bypass graft surgery in North America. World J Surg 2010;34: 2292–8. 9. Illuminati G, Ricco JB, Cali o F, et al. Short-term results of a randomized trial examining timing of carotid endarterectomy in patients with severe asymptomatic unilateral carotid stenosis undergoing coronary artery bypass grafting. J Vasc Surg 2011;54:993–9. 10. Birchley D, Villaquiran J, Akowuah E, Lewis T, Ashley S. Staged carotid endarterectomy under local anaesthetic in patients requiring cardiac surgery. Ann R Coll Surg Engl 2010;92:373–8. 11. Tarhan S, Moffitt EA, Taylor WF, Giuliani ER. Myocardial infarction after general anesthesia. JAMA 1972;220:1451–4. 12. Iyem H, Buket S. Early results of combined and staged coronary bypass and carotid endarterectomy in advanced age patients in single centre. Open Cardiovasc Med J 2009;3:8–14. 13. Van der Heyden J, Suttorp MJ, Bal ET, et al. Staged carotid angioplasty and stenting followed by cardiac surgery in patients with severe asymptomatic carotid artery stenosis: early and long-term results. Circulation 2007;116:2036–42. 14. Naylor AR, Mehta Z, Rothwell PM. A systematic review and meta-analysis of 30-day outcomes following staged carotid artery stenting and coronary bypass. Eur J Vasc Endovasc Surg 2009;37:379–87.
Ann Thorac Surg 2014;98:1613–9
15. Santos A, Washington C, Rahbar R, Benckart D, Muluk S. Results of staged carotid endarterectomy and coronary artery bypass graft in patients with severe carotid and coronary disease. Ann Vasc Surg 2012;26:102–6. 16. Shishehbor MH, Venkatachalam S, Sun Z, et al. A direct comparison of early and late outcomes with three approaches to carotid revascularization and open heart surgery. J Am Coll Cardiol 2013;62:1948–56. 17. Sharma V, Deo SV, Park SJ, Joyce LD. Meta-analysis of staged versus combined carotid endarterectomy and coronary artery bypass grafting. Ann Thorac Surg 2014;97:102–9. 18. Grant EG, Benson CB, Moneta GL, et al. Carotid artery stenosis: gray-scale and Doppler US diagnosis–Society of Radiologists in Ultrasound Consensus Conference. Radiology 2003;229:340–6. 19. 2007 The Society of Thoracic Surgeons’ STS Adult Cardiac Data Specifications. Available at http://www.sts.org/stsnational-database/database-managers/adult-cardiac-surgerydatabase/data-collection. Accessed May 7, 2014. 20. Gansera B, Schmidtler F, Weingartner J, et al. Simultaneous carotid endarterectomy and cardiac surgery: early results of 386 patients. Thorac Cardiovasc Surg 2012;60:508–16. 21. Brott TG, Hobson RW 2nd, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010;1(363):11–23. 22. Darling RC III, Dylewski M, Chang BB, et al. Combined carotid endarterectomy and coronary bypass grafting does not increase the risk of perioperative stroke. Cardiovasc Surg 1998;6:448–52. 23. Kovacevic P, Redzek A, Kovacevic-Ivanovic S, Velicki L, Ivanovic V, Kieffer E. Coronary and carotid artery occlusive disease: single center experience. Eur Rev Med Pharmacol Sci 2012;16:483–90. 24. Gopaldas RR, Chu D, Dao TK, et al. Staged versus synchronous carotid endarterectomy and coronary artery bypass grafting: analysis of 10-year nationwide outcomes. Ann Thorac Surg 2011;91:1323–9. 25. Roffi M, Ribichini F, Castriota F, Cremonesi A. Management of combined severe carotid and coronary artery disease. Curr Cardiol Rep 2012;14:125–34. 26. Fareed KR, Rothwell PM, Mehta Z, Naylor AR. Synchronous carotid endarterectomy and off-pump coronary bypass: an updated, systematic review of early outcomes. Eur J Vasc Endovasc Surg 2009;37:375–8. 27. Boules TN, Proctor MC, Aref A, Upchurch GR Jr, Stanley JC, Henke PK. Carotid endarterectomy remains the standard of care, even in high risk surgical patients. Ann Surg 2005;241: 356–63. 28. Roach GW, Kanchuger M, Mangano CM, et al. Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med 1996;335:1857–63. 29. Stamou SC, Hill PC, Dangas G, et al. Stroke after coronary artery bypass: incidence, predictors and clinical outcome. Stroke 2001;32:1508–13. 30. Chiti E, Troisi N, Marek J, et al. Combined carotid and cardiac surgery: improving the results. Ann Vasc Surg 2010;24: 794–800. 31. Djaiani GN. Aortic arch atheroma: stroke reduction in cardiac surgical patients. Sem Cardiothoracic Vasc Anesth 2006;10:143–57.
INVITED COMMENTARY Stroke is the most feared complication of cardiac surgery for many patients and a leading cause of postoperative mortality. Predictors of stroke risk have been identified. Although the pathogenesis is multifactorial, postoperative Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
stroke is often attributed to embolic sources from carotid stenosis, atherosclerosis of the ascending aorta, and atrial fibrillation. Concomitant carotid stenosis and coronary artery disease may be found in many patients with 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.07.003
common risk factors. Isolated or staged treatment of either disorder places the patient at an increased risk of a complication from the other condition, whereas combined repair has a higher reported complication rate. Thus, the strategy for surgical repair remains controversial. In the present report, Nabagiez and coauthors [1] have described their approach to combined carotid and coronary disease using carotid endarterectomy (CEA) followed within 24 hours with off-pump coronary bypass (CABG). The author’s hypothesis is that staging within 24 hours after CEA reduces the risk of myocardial infarction (MI) and stroke. In their study, 89% of patients met the study’s goal of CABG within 24 hours. Surgical outcomes were commendable, with a post-CEA complication rate of 1% stroke and 1% MI and a CABG outcome with no stroke or MI and 1% mortality. The length of stay (7.5 days) was not prolonged. Although the authors deemed 89% of patients had an urgent status for CABG, only 68% had symptomatic coronary disease with 47% class 3 or 4 angina, and only 6% had symptomatic carotid disease. The authors stated that patients with unstable coronary disease underwent urgent CABG without carotid assessment and were thus excluded from the study. One patient in the study experienced a subendocardial MI after CEA, and 3 patients with neurologic abnormalities had CABG delayed. This strategy may expose higher-risk patients to additional risk of MI from delayed CABG.
NABAGIEZ ET AL TWENTY-FOUR HOUR STAGED CEA/OFF-PUMP CABG
1619
Most would agree with the authors’ comment that “unstable or severely symptomatic coronary disease should not be considered for a staged strategy and are better served by CABG alone or combined with CEA” and agree that “the symptomatic lesion takes precedence in determining the sequence of procedure when staged.” The excellent outcomes reported herein may be more a reflection of procedural advantages of off-pump CABG and avoidance of aortic atheroma than the timing of the staged procedures. Cardiac surgeons should make stroke prevention a priority by using carotid and aortic screening and modifying surgical strategies in high-risk patients. James J. Livesay, MD Texas Heart Institute 1101 Bates Ave, Ste #P514 Houston, TX 77030 e-mail: [email protected]
Reference 1. Nabagiez JP, Bowman K, Shariff MA, et al. Twenty-four hour staged carotid endarterectomy followed by off-pump coronary bypass grafting for patients with concomitant carotid and coronary disease. Ann Thorac Surg 2014;98:1613–9.
ADULT CARDIAC
Ann Thorac Surg 2014;98:1613–9
NABAGIEZ ET AL TWENTY-FOUR HOUR STAGED CEA/OFF-PUMP CABG
We thank Georganne Santello and Doreen Battista in Health Information Management for their assistance in retrieving the charts and managing the records in spite of Hurricane Sandy. In addition, we thank the volunteers who assisted with data collection (Christopher Aseervatham, Edward Daniele, and Natasha Povar). Special thanks to Dr Cara Chasin for assisting with the development of the data registry.
References 1. Steinvil A, Sadeh B, Arbel Y, et al. Prevalence and predictors of concomitant carotid and coronary artery atherosclerotic disease. J Am Coll Cardiol 2011;57:779–83. 2. Tanimoto S, Ikari Y, Tanabe K, et al. Prevalence of carotid artery stenosis in patients with coronary artery disease in Japanese population. Stroke 2005;36:2094–8. 3. Venkatachalam S, Gray BH, Mukherjee D, Shishehbor MH. Contemporary management of concomitant carotid and coronary artery disease. Heart 2011;97:175–80. 4. Kougias P, Kappa JR, Sewell DH, et al. Simultaneous carotid endarterectomy and coronary artery bypass grafting: results in specific patient groups. Ann Vasc Surg 2007;21:408–14. 5. Antunes PE, Anacleto G, de Oliveira JM, Eug enio L, Antunes MJ. Staged carotid and coronary surgery for concomitant carotid and coronary artery disease. Eur J Cardiothorac Surg 2002;21:181–6. 6. Borger MA, Fremes SE, Weisel RD, et al. Coronary bypass and carotid endarterectomy: does a combined approach increase risk? A metaanalysis. Ann Thorac Surg 1999;68:14–20. 7. Moore WS, Barnett HJ, Beebe HG, et al. Guidelines for carotid endarterectomy. A multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association. Circulation 1995;91:566–79. 8. Prasad SM, Li S, Rankin JS, et al. Current outcomes of simultaneous carotid endarterectomy and coronary artery bypass graft surgery in North America. World J Surg 2010;34: 2292–8. 9. Illuminati G, Ricco JB, Cali o F, et al. Short-term results of a randomized trial examining timing of carotid endarterectomy in patients with severe asymptomatic unilateral carotid stenosis undergoing coronary artery bypass grafting. J Vasc Surg 2011;54:993–9. 10. Birchley D, Villaquiran J, Akowuah E, Lewis T, Ashley S. Staged carotid endarterectomy under local anaesthetic in patients requiring cardiac surgery. Ann R Coll Surg Engl 2010;92:373–8. 11. Tarhan S, Moffitt EA, Taylor WF, Giuliani ER. Myocardial infarction after general anesthesia. JAMA 1972;220:1451–4. 12. Iyem H, Buket S. Early results of combined and staged coronary bypass and carotid endarterectomy in advanced age patients in single centre. Open Cardiovasc Med J 2009;3:8–14. 13. Van der Heyden J, Suttorp MJ, Bal ET, et al. Staged carotid angioplasty and stenting followed by cardiac surgery in patients with severe asymptomatic carotid artery stenosis: early and long-term results. Circulation 2007;116:2036–42. 14. Naylor AR, Mehta Z, Rothwell PM. A systematic review and meta-analysis of 30-day outcomes following staged carotid artery stenting and coronary bypass. Eur J Vasc Endovasc Surg 2009;37:379–87.
Ann Thorac Surg 2014;98:1613–9
15. Santos A, Washington C, Rahbar R, Benckart D, Muluk S. Results of staged carotid endarterectomy and coronary artery bypass graft in patients with severe carotid and coronary disease. Ann Vasc Surg 2012;26:102–6. 16. Shishehbor MH, Venkatachalam S, Sun Z, et al. A direct comparison of early and late outcomes with three approaches to carotid revascularization and open heart surgery. J Am Coll Cardiol 2013;62:1948–56. 17. Sharma V, Deo SV, Park SJ, Joyce LD. Meta-analysis of staged versus combined carotid endarterectomy and coronary artery bypass grafting. Ann Thorac Surg 2014;97:102–9. 18. Grant EG, Benson CB, Moneta GL, et al. Carotid artery stenosis: gray-scale and Doppler US diagnosis–Society of Radiologists in Ultrasound Consensus Conference. Radiology 2003;229:340–6. 19. 2007 The Society of Thoracic Surgeons’ STS Adult Cardiac Data Specifications. Available at http://www.sts.org/stsnational-database/database-managers/adult-cardiac-surgerydatabase/data-collection. Accessed May 7, 2014. 20. Gansera B, Schmidtler F, Weingartner J, et al. Simultaneous carotid endarterectomy and cardiac surgery: early results of 386 patients. Thorac Cardiovasc Surg 2012;60:508–16. 21. Brott TG, Hobson RW 2nd, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010;1(363):11–23. 22. Darling RC III, Dylewski M, Chang BB, et al. Combined carotid endarterectomy and coronary bypass grafting does not increase the risk of perioperative stroke. Cardiovasc Surg 1998;6:448–52. 23. Kovacevic P, Redzek A, Kovacevic-Ivanovic S, Velicki L, Ivanovic V, Kieffer E. Coronary and carotid artery occlusive disease: single center experience. Eur Rev Med Pharmacol Sci 2012;16:483–90. 24. Gopaldas RR, Chu D, Dao TK, et al. Staged versus synchronous carotid endarterectomy and coronary artery bypass grafting: analysis of 10-year nationwide outcomes. Ann Thorac Surg 2011;91:1323–9. 25. Roffi M, Ribichini F, Castriota F, Cremonesi A. Management of combined severe carotid and coronary artery disease. Curr Cardiol Rep 2012;14:125–34. 26. Fareed KR, Rothwell PM, Mehta Z, Naylor AR. Synchronous carotid endarterectomy and off-pump coronary bypass: an updated, systematic review of early outcomes. Eur J Vasc Endovasc Surg 2009;37:375–8. 27. Boules TN, Proctor MC, Aref A, Upchurch GR Jr, Stanley JC, Henke PK. Carotid endarterectomy remains the standard of care, even in high risk surgical patients. Ann Surg 2005;241: 356–63. 28. Roach GW, Kanchuger M, Mangano CM, et al. Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med 1996;335:1857–63. 29. Stamou SC, Hill PC, Dangas G, et al. Stroke after coronary artery bypass: incidence, predictors and clinical outcome. Stroke 2001;32:1508–13. 30. Chiti E, Troisi N, Marek J, et al. Combined carotid and cardiac surgery: improving the results. Ann Vasc Surg 2010;24: 794–800. 31. Djaiani GN. Aortic arch atheroma: stroke reduction in cardiac surgical patients. Sem Cardiothoracic Vasc Anesth 2006;10:143–57.
INVITED COMMENTARY Stroke is the most feared complication of cardiac surgery for many patients and a leading cause of postoperative mortality. Predictors of stroke risk have been identified. Although the pathogenesis is multifactorial, postoperative Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
stroke is often attributed to embolic sources from carotid stenosis, atherosclerosis of the ascending aorta, and atrial fibrillation. Concomitant carotid stenosis and coronary artery disease may be found in many patients with 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.07.003
common risk factors. Isolated or staged treatment of either disorder places the patient at an increased risk of a complication from the other condition, whereas combined repair has a higher reported complication rate. Thus, the strategy for surgical repair remains controversial. In the present report, Nabagiez and coauthors [1] have described their approach to combined carotid and coronary disease using carotid endarterectomy (CEA) followed within 24 hours with off-pump coronary bypass (CABG). The author’s hypothesis is that staging within 24 hours after CEA reduces the risk of myocardial infarction (MI) and stroke. In their study, 89% of patients met the study’s goal of CABG within 24 hours. Surgical outcomes were commendable, with a post-CEA complication rate of 1% stroke and 1% MI and a CABG outcome with no stroke or MI and 1% mortality. The length of stay (7.5 days) was not prolonged. Although the authors deemed 89% of patients had an urgent status for CABG, only 68% had symptomatic coronary disease with 47% class 3 or 4 angina, and only 6% had symptomatic carotid disease. The authors stated that patients with unstable coronary disease underwent urgent CABG without carotid assessment and were thus excluded from the study. One patient in the study experienced a subendocardial MI after CEA, and 3 patients with neurologic abnormalities had CABG delayed. This strategy may expose higher-risk patients to additional risk of MI from delayed CABG.
NABAGIEZ ET AL TWENTY-FOUR HOUR STAGED CEA/OFF-PUMP CABG
1619
Most would agree with the authors’ comment that “unstable or severely symptomatic coronary disease should not be considered for a staged strategy and are better served by CABG alone or combined with CEA” and agree that “the symptomatic lesion takes precedence in determining the sequence of procedure when staged.” The excellent outcomes reported herein may be more a reflection of procedural advantages of off-pump CABG and avoidance of aortic atheroma than the timing of the staged procedures. Cardiac surgeons should make stroke prevention a priority by using carotid and aortic screening and modifying surgical strategies in high-risk patients. James J. Livesay, MD Texas Heart Institute 1101 Bates Ave, Ste #P514 Houston, TX 77030 e-mail: [email protected]
Reference 1. Nabagiez JP, Bowman K, Shariff MA, et al. Twenty-four hour staged carotid endarterectomy followed by off-pump coronary bypass grafting for patients with concomitant carotid and coronary disease. Ann Thorac Surg 2014;98:1613–9.
ADULT CARDIAC
Ann Thorac Surg 2014;98:1613–9
