A personal experience with coronary artery bypass grafting, carotid patching, and other factors influencing the outcome of carotid endarterectomy

Objective: This study was conducted to investigate the influence of coronary artery bypass grafting (CABG), carotid patching, and other factors on the outcome of all carotid endarterectomies (CEAs) performed by a single surgeon at a tertiary referral center. Methods: The series includes 2262 CEAs (335 bilateral) in 1521 men and 741 women (33%) with median ages of 66 and 68 years, respectively. Surgical indications were asymptomatic stenosis for 1503 procedures (66%), retinal ischemia or cerebral transient ischemic attacks each for 271 (12%), and prior stroke for 217 (9.6%). CEA was done as an isolated operation in 1959 patients and was performed in conjunction with simultaneous CABG in 303 (13%). Primary arteriotomy closure was used for 783 CEAs (35%), vein patching for 1232 (54%), and synthetic patching for 247 (11%). Outcome event rates were assessed by logistic regression analysis, proportional hazards models, and Kaplan-Meier estimations. Results: Postoperative mortality (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.7 to 7.5; P =.001), stroke (OR, 3.2; 95% CI, 1.6 to 6.4; P =.001), and combined stroke and mortality rates (OR, 3.4; 95% CI, 2.0 to 5.8; P <.001) were significantly higher for simultaneous CEA/CABG than for isolated CEA. Ipsilateral postoperative stroke rates were similar (2.6% vs 1.7%, P =.41) in both settings. Vein patching had a lower risk for ipsilateral stroke (OF, 0.42; 95% CI, 0.21 to 0.86; P =.015) than primary closure, but was not significantly different from synthetic patching (P = .10). The documented incidence of postoperative carotid thrombosis was 1.5% with primary closure, 0.6% with vein patching, and 2.0% with synthetic patching (P =.088). Overall Kaplan-Meier survival was 92% at 1 year, 71% at 5 years, 41% at 10 years, and 20% at 15 years, but long-term mortality rates were higher after simultaneous CEA/CA-BG (hazard ratio, 1.3; 95% CI, 1.1 to 1.5; P =.002) than after CEA alone. Late strokes or retinal infarctions have been reported after 97 (5.0%) of the 1923 operations for which follow-up was available, 51 (2.3%) of which were ipsilateral to CEA. The incidence of >= 60% recurrent stenosis was independently influenced by carotid patching (OR, 0.61; 95% CI, 0.40 to 0.92; P =.019) but not by the choice of patch material (P = .11). Conclusions: These results substantiate the common observation that patients who require simultaneous CEA/CABG have a higher risk for adverse outcomes than patients who undergo isolated CEA. Carotid patching provided significant benefit with respect to the risks for ipsilateral postoperative stroke and >= 60% recurrent stenosis.