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Coronary Artery Bypass Graft After Carotid Endarterectomy Minimizes Risk of Myocardial Infarction & Stroke

By Bridgett Novak

NEW YORK (Reuters Health) – A new study presented February 20 at the annual meeting of the American College of Preventive Medicine in New Orleans shows that performing a coronary artery bypass graft (CABG) within 24 hours of a carotid endartectomy (CEA) reduces the risk of myocardial infarction and stroke.

Ninety patients with severe coronary artery disease and carotid stenosis were treated with this dual approach. Their mean age was 69; 68% were male. The average duration between CEA and CABG was 1.8 days, with 89% taking place within 24 hours.

Post-CEA surgical outcomes (up to 30 days post-CABG ) included myocardial infarction (1%) and acute embolic cerebrovascular accident (1%); some instances of atrial fibrillation (34%), anemia (12%), pneumonia (7%), and bleeding (4%) followed the CABG, but no CVAs. Patients were discharged, on average, 7-1/2 days after surgery.

“According to current literature, MI rates following CEA range from 1.5% to 7.3%, depending on whether it is combined with CABG or staged. So our 1% rate is encouraging,” noted Dr. John P. Nabagiez, lead researcher and Director of Research for the Division of Cardiothoracic Surgery at the Heart Institute at Staten Island University Hospital. “The reported risk of post-CABG CVA is 2% to 11%. I was pleasantly surprised to find a post-CABG CVA rate of zero.”

“One caveat is that all of our CABG procedures were performed ‘off pump’ (without the use of cardiopulmonary bypass) and that may have played a role in our observed freedom from postoperative CVA,” Nabagiez added.

“The question of performing CABG on patients with significant cerebrovascular disease is an old one, and there isn’t a consensus in the medical community regarding exactly how to best treat these patients. Our preference is to perform concomitant CEA/CABG for patients with unilateral severe carotid stenosis whether it is symptomatic or asymptomatic. This is also true and probably more important in patients who have severe stenosis on one side and a complete occlusion on the other side,” observed Dr. Sam Baradarian, cardiothoracic surgeon at Scripps Memorial Hospital in La Jolla, California.

Defining the patient population for whom staging will be most effective is very important, agreed Nabagiez. “This approach might not be applicable to all patients who are actively symptomatic from both regions (carotids and coronaries), for example, in the case of unstable angina. For some patients, due to symptoms and disease progression, there is not a single correct method. If one lesion is relatively more symptomatic one may choose to stage that procedure first; if they are both equally symptomatic one may elect for a simultaneous procedure. Our study does not invalidate the simultaneous CEA-CABG method, we simply prefer the staged approach and are encouraged by these findings.”

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