TUCSON, ARIZ. — The perioperative stroke risk with combined carotid endarterectomy/coronary artery bypass graft surgery proved greater than with carotid endarterectomy alone in patients with comorbid coronary disease in a retrospective case-control study.
On the other hand, combining carotid endarterectomy (CEA) with CABG did not increase the perioperative stroke risk beyond that of CABG alone in patients with concomitant carotid and coronary disease, Dr. Amanda M. Dick reported at the annual meeting of the Southern Association for Vascular Surgery.
A prospective, randomized trial would best determine whether patients with both carotid and coronary disease would benefit from combined or separate staged repairs. Given that no such trial has been done and no level 1 evidence exists, results of this new study argue for case by case decision making, said Dr. Dick of the Medical University of South Carolina, Charleston.
She reviewed the university's vascular and cardiothoracic surgery registries for 1995-2006, identifying 114 patients who had combined CEA/CABG. She matched them to 342 CEA-only patients based on risk factors for 30-day rates of stroke, MI, and cardiovascular mortality. She also identified 342 CABG-only controls with known carotid disease matched to the combined CEA/CABG patients on the basis of risk factors for perioperative stroke and cardiovascular morbidity and mortality.
The primary study end point was the 30-day perioperative stroke rate. It was 4% in the combined CEA/CABG patients, significantly higher than the 0.6% rate in the matched CEA-only patients but similar to the 3% rate in CABG-only patients.
The 30-day cardiovascular morbidity and mortality rate in the combined surgery group was 4%, significantly higher than the 0.6% rate in CEA-only patients but similar to the 6% rate with CABG-only. No perioperative MIs occurred in the study groups.
Dr. Charles West Jr. of Louisiana State University, Shreveport, a study discussant, cautioned that a retrospective case-control study design such as this can inadvertently end up comparing groups who are dissimilar in terms of total atherosclerotic burden.
However, audience member Dr. Robert W. Feldtman congratulated Dr. Dick on what he said was “a landmark paper that people will refer to for a long time.”
Dr. Feldtman of Scott and White Memorial Hospital and Clinic, Temple, Tex., was impressed by the investigators' ability to retroactively mine large, prospectively collected databases to come up with reasonable matched comparisons. In this way they were able to address a controversy not amenable to a large, randomized prospective trial.
This study argues for case by case decision making, since there is no randomized trial and no level-1 evidence. DR. DICK