CABG in Patients with Carotid Disease: What Is the Best Operative Strategy?

Summary and Comment |
October 10, 2017

CABG in Patients with Carotid Disease: What Is the Best Operative Strategy?

  1. Joel M. Gore, MD

Despite this study's limitations, its findings suggest that performing carotid endarterectomy simultaneously with coronary artery bypass grafting provides no advantage over CABG alone.

  1. Joel M. Gore, MD

The optimal operative strategy for patients in need of coronary artery bypass grafting (CABG) who have concomitant severe carotid artery disease is unknown. Investigators conducted a randomized trial in Germany and the Czech Republic comparing outcomes with simultaneous CABG and carotid endarterectomy (CEA) to those with CABG alone.

Significant carotid artery stenosis was defined as ≥80%. The trial, which had an initial planned size of 1160, was terminated early because of insufficient recruitment. The final enrollment, occurring between 2010 and 2014, was 129 patients.

In the intent-to-treat analysis, the primary composite endpoint of any stroke or death from any cause within 30 days postsurgery occurred in 18.5% of the simultaneous-surgery group and 9.7% of the CABG-alone group. The absolute risk reduction with CABG alone was 8.8%, which was statistically nonsignificant. In the per-protocol analysis, primary composite-endpoint events at 30 days occurred in 19.6% of the simultaneous-surgery group (11/56 patients) and 11.3% of the CABG-alone group (6/53). No significant differences were seen on any secondary endpoint at 30 days and 1 year. More than 90% of patients were on antithrombotic treatment, predominantly aspirin, after 1 year.

Comment

This is the first randomized, controlled multicenter trial comparing a strategy of simultaneous CEA and CABG versus CABG alone for patients with significant coronary and carotid disease. Unfortunately, the researchers could not recruit enough patients to determine clinical significance. Nevertheless, there appears to be no benefit of CEA in patients in need of CABG, given the elevated rate of events in these CEA patients.

Editor Disclosures at Time of Publication

  • Disclosures for Joel M. Gore, MD at time of publication Grant / Research support NIH–National Heart, Lung, and Blood Institute

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