Multistate population-based outcomes of combined carotid endarterectomy and coronary artery bypass☆☆☆★★★♢♢♢
Presented at the Fiftieth Annual Meeting of the American Association for Vascular Surgery, Boston, Mass, Jun 9-12, 2002.
Received 18 June 2002; accepted 26 August 2002.
Abstract
Objectives: The management of combined carotid and coronary disease is controversial, and the outcomes of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) have not been determined on a community-wide basis. This study was undertaken to evaluate the community-wide outcomes of combined CEA and CABG and to evaluate the risk for adverse events. Methods: A complete medical record review of 10,561 CEA procedures randomly selected from Medicare patients undergoing CEA in 10 states was performed. In this sample, 226 procedures were performed in combination with CABG in the same operative event. Results: Recent ipsilateral stroke or transient ischemic attack was the indication for the CEA in only 12% of patients undergoing CEA/CABG, and 56% were asymptomatic with respect to the carotid lesion. The combined stroke and death rate was 17.7% (25 nonfatal strokes, two fatal strokes, and 13 nonstroke deaths). Eighty percent of the nonfatal strokes were disabling. Proximal aortic arch atherosclerosis and symptomatic carotid stenosis were associated with stroke (P < .05). Female gender, emergent operation, redo CABG, blood pressure on pump, total pump time, presence of left main disease, and number of diseased coronaries were associated with mortality (P < .05). The strokes appeared to be associated with the operative event, but diagnosis was delayed and postevent carotid patency was not documented. Most strokes were not limited to the hemisphere ipsilateral to the CEA. Conclusion: The community-wide outcomes of combined CEA/CABG in the Medicare population are inferior to those reported in many single-institution reviews. Diagnosis of postoperative stroke is often delayed, and most strokes are not limited to the hemisphere ipsilateral to the CEA operative site. (J Vasc Surg 2003;37:32-9.)
aUniversity of Chicago Robert Wood Johnson Clinical Scholars Progam Iowa City, Iowa
bDivision of Vascular Surgery, University of Iowa Iowa City, Iowa
cIowa Foundation for Medical Care. Iowa City, Iowa
☆ Supported by the Iowa Foundation for Medical Care and the Robert Wood Johnson Clinical Scholars Program.
☆☆ Analyses on which this publication is based were performed under Contract Number 500-99-IA03, entitled “Utilization and Quality Control Peer Review Organization for the State of Iowa,” sponsored by the Centers for Medicare and Medicaid Services, Department of Health and Human Services. Content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organization imply endorsement by the US Government.
★ The author assumes full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Centers for Medicare and Medicaid Services, which has encouraged identification of quality improvement projects derived from analysis of patterns of care and therefore required no special funding on the part of this contractor. Ideas and contributions to the author concerning experience in engaging with issues presented are welcomed.
ABSTRACT