Delayed carotid endarterectomy associated with higher risk of stroke in coronary artery bypass graft patients, study shows

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A new study suggests that previous or simultaneous carotid revascularisation in patients with unilateral, asymptomatic carotid stenosis may reduce the rate of death and stroke after coronary artery bypass grafting.

 

Results of the randomised, controlled trial were presented by Giulio Illuminati, University La Sapienza, Rome, Italy, at the Society for Vascular Surgery Annual Meeting (Chicago, USA).

 

The objective of the trial, he said, is to evaluate the timing of carotid endarterectomy in the prevention of stroke in patients with asymptomatic carotid stenosis >70% undergoing coronary artery bypass graft surgery.

 

From January 2004 to December 2009, 185 patients with indication to a coronary artery bypass graft and presenting with unilateral asymptomatic carotid artery stenosis greater than 70% were randomised into two groups. In group A, 94 patients received a bypass graft with either previous or simultaneous carotid endarterectomy. In group B, 91 patients underwent bypass graft surgery followed by carotid endarterectomy.

 

All the patients underwent a preoperative helical CT scan excluding significant atheroma of the thoracic aorta. Baseline characteristics of the patients, type of coronary arteries lesions, preoperative myocardial function, were similar in the two groups.

 

In group A, all patients underwent carotid endarterectomy under general anaesthesia with systematic use of a carotid shunt. In this group, 79 patients had a combined procedure, and 15 underwent endarterectomy a few days before the bypass graft surgery. In group B, all patients underwent carotid endarterectomy within three months after the coronary artery bypass graft surgery.

 

Illuminati told delegates that two patients died of cardiac failure in the postoperative period – one in each group. Operative mortality was 1% in group A, and 1.1% in group B (p=0.98). No stroke occurred in group A vs. seven ipsilateral ischaemic strokes in group B including three immediate postoperative strokes and four late strokes at 39, 50, 58 and 66 days after coronary artery bypass graft surgery. These late strokes occurred in patients for whom endarterectomy was delayed due to an incomplete sternal wound healing or for completion of a cardiac rehabilitation programme. The 90-day stroke and death rate was 1% (1/94) in group A, and 8.8% (8/91) in group B (p=0.01). Logistic regression analysis showed that only delayed endarterectomy (p=0.03) and duration of cardiopulmonary bypass (p=0.004) are associated with a higher risk of stroke and death.

 

In conclusion, Illuminati said, the study suggests that previous or simultaneous endarterectomy may reduce the rate of death and stroke after coronary artery bypass graft surgery in asymptomatic carotid stenosis patients.

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