Combined Carotid Endarterectomy and CABG Is Performed Well Across U.S., but Patient Selection Often Disregards Guidelines
- Asymptomatic severe unilateral carotid stenosis was the most common carotid indication for the combined procedure (CCAB), contrary to SVS guidelines
- Perioperative outcomes of CCAB were similar by region
- Because carotid symptomatic status does affect CCAB outcomes, it should be considered during preoperative risk assessment
- The 30-day stroke rate was significantly lower in the group with asymptomatic severe unilateral stenosis than in the group with symptomatic stenosis or asymptomatic severe bilateral stenosis
- According to a review of the Vascular Quality Initiative database of the Society for Vascular Surgery (SVS), there is regional variation in the U.S. in use of combined carotid endarterectomy and coronary artery bypass grafting (CCAB)
No definitive evidence exists about the safety and efficacy of combining carotid endarterectomy (CEA) with coronary artery bypass grafting (CABG) in the same procedure. Guidelines of the Society for Vascular Surgery (SVS) treat the combined approach (CCAB) as equivalent to staged intervention (CEA first with CABG performed at a later date).
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Surgical Resident Linda J. Wang, MD, MBA, and Matthew J. Eagleton, MD, chief of the Division of Vascular and Endovascular Surgery and co-director of the Fireman Vascular Center at Massachusetts General Hospital, and colleagues have identified significant regional variation across the U.S. in the use of CCAB, but they found similar short-term outcomes as with the staged approach. Their report appears in the Journal of Vascular Surgery.
Location of Patients
Using the Vascular Quality Initiative database of the SVS, the researchers identified a cohort of 1,495 patients at 155 centers who underwent CCAB between January 2003 and December 2017. The average age was 69 years, 70% were male and 92% were white.
The researchers divided the cohort and the centers according to the four regions defined by the U.S. Census Bureau:
- Northeast: 578 patients (39%), 38 centers
- Midwest: 482 patients (32%), 42 centers
- South: 379 patients (25%), 56 centers
- West: 56 patients (4%), 19 centers
42 centers performed 10 or more CCABs and accounted for 1,183 (79%) of all patients in the study. This may reflect care consolidation: the trend for more advanced procedures to be performed exclusively at selected centers of excellence.
The primary outcomes were stroke within 30 days after surgery (3.6% of patients), death within 30 days (3.0%), myocardial infarction before hospital discharge (0.6%) and the composite of those three outcomes (6.8%). There was no significant difference among geographic regions for any of the outcomes.
When the researchers used the Bonferroni correction to adjust the P-values for the multiple comparisons, there were still no significant differences in stroke, myocardial infarction or the composite outcome across regions. Mortality rates differed across regions, but there was no correlation with absolute or proportional volume.
The researchers then divided the cohort according to the carotid indication for treatment:
- Symptomatic stenosis (defined as prior ipsilateral neurologic event): 218 patients
- Asymptomatic severe bilateral stenosis (no prior stroke or transient ischemic attack): 267 patients
- Asymptomatic severe unilateral stenosis: 555 patients
The SVS guidelines recommend considering the first two groups for CEA before or concomitantly with CABG. When the researchers analyzed those two groups in combination, there was significant regional variation in adherence to the guideline (from 27% in the Northeast to 41% in the West; P = .001).
Contrary to the guidelines, CCAB was most commonly used for patients with asymptomatic severe unilateral disease (37%).
Outcomes According to Indication
In subgroup analyses performed within each indication group, no differences in primary outcomes were noted between regions, despite the regional variance in patient selection.
The researchers then compared the perioperative outcomes of the group with unilateral disease to those of the two other groups combined:
- Stroke: 2.4% vs. 4.9% (P = .03)
- Death: 2.2% vs. 2.5% (P = NS)
- Myocardial infarction: 0.7% vs. 1.2% (P = NS)
- Composite: 4.5% vs. 7.8% (P = .04)
Implications for Practice
The authors conclude that CCAB is performed well across the U.S., but carotid symptomatic status does affect CCAB outcomes and should be considered during the preoperative risk assessment.
The large proportion of CCABs performed for asymptomatic unilateral disease suggests to the researchers a continued need for quality improvement projects, with the goal of boosting adherence to guidelines or investigating the appropriateness of current guidelines.
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