Synchronous Carotid Endarterectomy and Coronary Artery Bypass Graft versus Staged Carotid Artery Stenting and Coronary Artery Bypass Graft for Patients with Concomitant Severe Coronary and Carotid Stenosis: A Systematic Review and Meta-analysis

Background: Owing to the systemic nature of atherosclerosis, medium and large arteries at different sites are commonly simultaneously affected. As a result, severe coronary artery disease (CAD) requiring coronary artery bypass graft (CABG) frequently coexists with significant carotid stenosis that warrants revascularization. The aim of this study was to compare synchronous carotid endarterectomy (CEA) and CABG vs. staged carotid artery stenting (CAS) and CABG for patients with concomitant CAD and carotid artery stenosis in terms of perioperative (30-day) outcomes. Methods: This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Eligible studies were identified through a search of PubMed, Scopus, and Cochrane until July 2018. A meta-analysis was conducted with the use of a random-effects model. The I-square statistic was used to assess heterogeneity. Results: Five studies comprising 16,712 patients were included in this meta-analysis. Perioperative stroke (odds ratio [OR]: 0.84; 95% confidence interval [CI]: 0.43-1.64; I-2 = 39.1%), transient ischemic attack (TIA; OR: 0.32; 95% CI: 0.04-2.67; I-2 = 27.6%), and myocardial infarction (MI) rates (OR: 0.56; 95% CI: 0.08-3.85; I-2 = 68.9%) were similar between the two groups. However, patients who underwent simultaneous CEA and CABG were at a statistically significant higher risk for perioperative mortality (OR: 1.80; 95% CI: 1.05-3.06; I-2 = 0.0%). Conclusions: The current meta-analysis did not detect statistically significant differences in the rates of perioperative stroke, TIA, and MI between the groups. However, patients in the simultaneous CEA and CABG group had a significantly higher risk of 30-day mortality. Future randomized trials or prospective cohorts are needed to validate our results.