Combined Carotid Endarterectomy and Coronary Artery Bypass Graft Surgery Provides Durable Long-term Cerebral Ischemia and Mortality Prevention in the Vascular Quality Initiative

The purpose of this study was to investigate long-term outcomes simultaneous carotid endarterectomy (CEA) and coronary artery bypass (CABG) using the Vascular Quality Initiative. All CEAs in Initiative between January 2003 May 2022 were queried. We extracted two cohorts from these CEAs. first group underwent CEA CABG (N = 3137). second or percutaneous angioplasty/stent within 5 years 27,387). investigated following a multivariable fashion: follow-up mortality, neurological ischemic event, perioperative event. Differences baseline characteristics as well. On analysis, patients undergoing combined had equivalent survival who revascularization ultimately CEA. Five-year is noted be 84.5% vs 86% with Cox regression nonsignificant P value .203 (Table I, Fig 1). Significant risks 2) for reduced (P < .03 all) included advancing age (hazard ratio [HR]: 2.48/y), smoking history (HR: 1.26), diabetes 1.33), congestive heart failure 1.66), chronic obstructive pulmonary disease 1.54), renal insufficiency at time surgery 1.30), anemia 1.64), lack preoperative aspirin 1.12), statin 1.32), patch placement site 1.16), myocardial infarction 2.04), dysrhythmia 1.36), cerebral reperfusion injury 2.23), event 2.48), discharge 2.04). Patients over 99% freedom an ipsilateral after II). Comparison secondary outcome risk evaluations are listed Tables III-VII). Combined provides excellent ischemia mortality prevention coexisting severe atherosclerosis. Simultaneous provide stroke both cohort isolated literature. most impactful modifiable factors toward CEA-CABG adherence medication therapy.Fig 2A, 10 Year Survival In Respect Patch Placement Endarterectomy Site. B, year With Without Statin Time Discharge.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Table IRisks follow-up—Cox analysis significant univariable all patientsVariableLong-term % (n/N)Univariable valueHazard (95% CI)Multivariable valueMean (SD), Yes LTFU71.73 (8.95)<.0012.48 (2.08-2.95)/y<.001 No LTFU69.50 (9.09)Sex Male10.2 (2114/20,823) Female11.2 (1095/9743).0041.06 (0.99-1.14).120Hx Never8.5 (640/7535) Yes11.2 (2569/23,031)<.0011.26 (1.15-1.37)<.001Hypertension No9.5 (172/1803) Yes10.6 (3037/28,763).171Diabetes mellitus No9.2 (1542/16,700) Yes12.0 (1667/13,866)<.0011.33 (1.24-1.43)<.001Hx CHF No9.0 (2152/23,876) Yes15.8 (1057/6690)<.0011.66 (1.54-1.79)<.001Hx COPD No9.1 (2062/22,612) Yes14.4 (1147/7954)<.0011.54 (1.43-1.66)<.001Baseline (2147/23,525) Yes15.1 (1062/7041)<.0011.30 (1.21-1.41)<.001Anemia No8.9 (2443/27,354) Yes23.8 (766/3212)<.0011.64 (1.49-1.79)<.001Preoperative No11.8 (458/3890).0051.12 (1.01-1.24).029 Yes10.3 (2751/26,676)Preoperative No13.3 (510/3842)<.0011.32 (1.17-1.49)<.001 Yes10.1 (2699/26,724)Symptomatic No10.5 (2448/23,307).962 Yes10.5 (761/7259)Anesthesia Local/regional11.9 (257/2155).0251.06 (0.93-1.21).388 General10.4 (2952/28,411)Contralateral stenosis >70% No10.9 (2659/24,376)<.0011.04 (0.94-1.14).441 Yes8.9 (550/6190)Patch use No27.9 (682/2444)<.0011.16 (1.05-1.28).004 Yes9.0 (2527/28,122)Shunt No10.7 (1612/15,070).265 (1597/15,496)Protamine No11.7 (984/8376)<.0011.02 (0.94-1.10).693 Yes10 (2218/22,121)Return OR rexploration10.4 (3134/30,048) rexploration14.2 (67/471).0081.01 (0.79-1.29).962EEG No10.0 (2179/21,798) Yes11.7 (1020/8708)<.0011.1 (1.02-1.19).019Stump pressure No10.8 (2913/26,967)<.0011.07 (0.95-1.21).279 Yes8.1 (286/3535)Postoperative MI No10.4 (3133/30,252) Yes24.2 (76/314)<.0012.04 (1.61-2.58)<.001Dysrhythmia No10.2 (3034/29,604) Yes18.1 (169/933)<.0011.36 (1.15-1.61)<.001Postoperative No10.3 (3132/30,295) Yes28.8 (70/243)<.0011.49 (1.17-1.91).001Cerebral (3179/30,472) Yes35.5 (22/62)<.0012.23 (1.45-3.44)<.001Combined (2792/27,387) Yes13.1 (410/3137)<.0011.08 (0.96-1.21).203Perioperative neuro (3064/29,979) Yes24.7 (145/587)<.0012.48 (2.08-2.95)<.001Antiplatelet D/C (176/1488)<.0011.07 (0.997-1.16).059 Yes10.4 (3033/29,018)Statin No21.5 (672/3124)<.0012.04 (1.82-2.29)<.001 Yes9.2 (2537/27,442)Smoking LTFU (2700/25,845) Yes10.8 (509/4721).49LTFU anticoagulation (2943/28,033).996 (266/2533)LTFU antiplatelet (1424/13,478).73 (1785/17,088)LTFU (1039/9921).919 (2170/20,645)Recurrent (3124/29,816) Yes11.3 (85/750).45Ipsilateral (3111/30,272) Yes33.3 (98/294)<.0011.06 (0.85-1.31).608CABG, Coronary graft; CAD, disease; CEA, endarterectomy; CHF, failure; CI, confidence interval; COPD, D/C, discharge; EEG, electroencephalogram; Hx, of; LTFU, follow-up; MI, infarction; OR, operating room; SD, standard deviation. Open table new tab Table IIRisks Age LTFU69.05 (8.92).192 without LTFU69.74 (9.10)Sex Male1.0 (198/20,823) Female1.0 (96/9743).774Hx No1.0 (72/7535) Yes1.0 (222/23,031).948Hx HTN No1.6 (29/1803) Yes0.9 (265/28,763).0041.37 (0.93-2.01).111Hx DM (172/16,700) (122/13,866).181Hx (246/23,876).0211.20 (0.88-1.64).247 Yes0.7 (48/6690)Hx (224/22,612).385 (70/7954)Baseline No0.9 (219/23,525) Yes1.1 (75/7041).311Anemia No0.5 (126/27,354) Yes5.2 (168/3212)<.0014.28 (3.28-5.59)<.001Preoperative No0.8 (33/3890) (261/26,676).437Preoperative No1.2 (47/3842).076 (247/26,724)Symptomatic (283/23,307)<.0012.75 (1.47-5.16).002 Yes0.2 (11/7259)Anesthesia groups Local/regional1.1 (23/2155).603 General1.0 (271/28,411)Contralateral No1.1 (274/24,376)<.0011.04 (0.64-1.70).876 Yes0.3 (20/6190)Patch No8.2 (201/2444)<.000110.62 (7.84-14.38)<.001 (93/28,122)Shunt (154/15,070) (140/15,496).289Combined (271/27,387) (23/3137).164Return re-exploration0.9 (285/30,048) re-exploration1.9 (9/471).0341.19 (0.81-2.32).615EEG No0.7 (161/21,798) Yes1.5 (133/8708)<.0011.25 (0.98-1.58).069Stump (283/26,967)<.0011.69 (0.92-3.12).094 (11/3535)Postoperative (291/30,252) (3/314).991Perioperative (293/29,979).0475.83 (0.82-41.62).079 No0.2 (1/587)Dysrhythmia (287/29,604).5 Yes0.8 (7/933)Postoperative (291/30,295) Yes1.2 (3/243).663Cerebral (294/30,472) Yes0 (0/62).437Antiplatelet on DC (10/1488).24 (284/29,079)Statin No3.2 (99/3124)<.0011.42 (1.09-1.86).01 (195/27,442)Statin (73/9921) (221/20,645).0051.66 (1.25-2.20)<.001Smoking (231/25,845) Yes1.3 (63/4721).0041.44 (1.08-1.91).012Anticoagulation (248/28,033) Yes1.8 (46/2533)<.0011.75 (1.27-2.41)<.001Antiplatelet (138/13,478).3241.26 (0.99-1.60).063 (156/17,088)CABG, DM, mellitus; HTN, hypertension; IIIComparison treatment variables graft cohortVariableCoronary before 27,387)Combined 3137)P years69.85 (9.19)68.79 (8.81).033Male67.772<.001Hx smoking75.576.601Hypertension94.491<.001Diabetes mellitus45.544.268Symptomatic carotid24.914<.001Hx CHF21.823.153Hx COPD26.225.055Hx insufficiency23.122.248No ASA12.317<.001No statin11.918<.001Contralateral >70%19.626<.001Yes used92.191.01Shunt used50.950.227Protamine used72.573.657Yes EEG used28.231<.001Stump used12.08<.001No D/C10.55<.001No D/C10.111.034No LTFU44.937<.001No LTFU32.532.892ASA, Aspirin; deviation.Data presented unless otherwise specified. IVRisks 90 days operation—binary logistic studyVariablePerioperative valueAdjusted odds those days72.61 (9.37)<.0011.03 (1.02-1.05)/y<.001 days69.69 (9.08)History Never1.5 (112/7535).229 Active former1.7 (389/23,031)Sex Male1.5 (313/20,823) Female1.9 (188/9743).0061.21 (.99-1.48).063Diabetes No1.4 (227/16,700) Yes2.0 (274/13,866)<.0011.32 (1.09-1.60).005Hypertension (29/1803).916 Yes1.6 (472/28,763)Hx (284/23,876) Yes3.2 (217/6690)<.0012.17 (1.78-2.65)<.001Hx (324/22,612) Yes2.2 (177/7954)<.0011.46 (1.19-1.78)<.001Baseline No1.3 (317/23,525) Yes2.6 (184/7041)<.0011.46 (1.19-1.80)<.001Anemia (382/27,354) Yes3.7 (119/3212)<.0011.45 (1.15-1.84).002Preoperative No1.9 (74/3890).166 (427/26,676)Preoperative No2.1 (81/3842).0143.35 (2.47-4.56)<.001 (420/26,724)Symptomatic No1.5 (338/23,307) (163/7259)<.0011.76 (1.43-2.17)<.001Anesthesia Local1.8 (38/2155).637 General1.6 (463/28,411)Contralateral (398/24,376) Yes1.7 (103/6190).863Patch No2.0 (50/2444).099 (451/28,122)Shunt (245/15,070).856 (256/15,496)Protamine (138/8376).923 (361/22,121)Return room (486/30,048) (15/471).0081.4 (0.80-2.50).234EEG No1.7 (361/21,798).71 (139/8708)Stump (458/26,967).0251.20 (0.86-1.66).295 (42/3535)Combined (CEA only, prior CAD Tx)1.3 (364/27,387) (combined surgery)4.4 (137/3137)<.0012.48 (1.93-3.18)<.001Perioperative (424/29,979) (77/587)<.0015.45 (3.98-7.47)<.001Postoperative (461/30,252) Yes12.7 (40/314)<.0014.51 (2.93-6.94)<.001Postoperative (417/29,604) Yes8.6 (80/933)<.0012.22 (1.61-3.10)<.001Postoperative (463/30,295) Yes13.6 (33/243)<.0012.15 (1.34-3.42).001Cerebral (479/30,472) Yes25.8 (16/62)<.0014.15 (2.02-8.52)<.001Antiplatelet (486/29,078).06 (15/1488)Statin No6.3 (197/3124)<.0018.91 (6.93-11.46)<.001 (304/27,442)CABG, deviation; Tx, treatment. VRisks neurologic during operative admission—binary event69.74 (9.60).981 Male1.9 (390/20,823) Female2.0 (197/9743).376Hx No1.8 (133/7535) (454/23,031).258Hx (21/1803) (566/28,763).0161.71 (1.10-2.68).018Hx (291/16,700) Yes2.1 (296/13,866).0131.20 (1.01-1.42).035Hx (442/23,876) (145/6690).096Hx (423/22,612) (164/7954).285Hx (450/23,525) Yes1.9 (137/7041).86Hx No2.2 (71/3212) (516/27,354).206Preoperative No2.3 (88/3890).096 (499/26,676)Preoperative No2.4 (93/3842).0161.29 (1.02-1.62).031 (494/26,724)Symptomatic lesion (364/23,307) Yes3.1 (223/7259)<.0012.11 (1.77-2.51)<.001Anesthesia Local/regional1.3 (27/2155) General anesthesia2.0 (560/28,411).0191.24 (0.83-1.86).296Contralateral (471/24,376).766 (116/6190)Patch (48/2444).87 (539/28,122)Shunt (327/15,496).0141.18 (0.97-1.43).101 (260/15,070)Protamine (182/8376).0491.22 (1.02-1.47).029 (404/22,121)EEG (396/21,798) (191/8708).0311.16 (0.95-1.43).148Combined only revascularization1.7 (461/27,387) CEA/CABG4.0 (126/3137)<.0012.37 (1.89-2.97)<.001Stump (543/26,967).0021.41 (1.02-1.94).038 (44/3535)Postoperative (567/30,252) Yes6.4 (20/314)<.0012.33 (1.41-3.86).001Hx (535/29,604) Yes5.4 (50/933)<.0011.52 (1.07-2.17).019Postoperative (565/30,295) Yes8.2 (20/243)<.0012.51 (1.51-4.18)<.001Cerebral (553/30,472) Yes50 (31/62)<.00140.58 (23.80-69.22)<.001CABG, VIRisks among either 90-day (CABG)—binary regressionVariablePercentage experiencing adverse (n/N)Adjusted mortality74.32 (7.43)1.08/y (1.06-1.11)<.001 mortality68.63 (8.82)History Never smokers4.1 (28/676) history4.4 (92/2088)1.295 (0.814-2.06).275Hypertension No2.7 (7/257) Yes4.5 (113/2507)1.34 (0.603-2.97).474Diabetes No4.4 (68/1557)1.16 (0.756-1.64).583 Yes4.3 (52/1207)History No3.0 (65/2152) (55/612)2.61 (1.77-3.85)<.001Chronic No4.1 (85/2097) (35/667)1.15 (0.744-1.77).534Anemia (Hgb <10 mg/dL) No3.8 (90/2343) Yes7.7 (30/421)1.37 (0.871-2.14).175Sex Male3.8 (76/1989) Female5.7 (44/775)1.58 (1.05-2.37).028Contralateral No4.5 (91/2040)1.06 (0.680-1.64).811 Yes4.0 (29/724)Chronic No3.3 (72/2153) Yes7.9 (48/611)1.76 (1.17-2.64).006Symptomatic 6 months Asymptomatic4.1 (99/2289) Symptomatic5.6 (21/376)1.68 (1.02-2.77).042CI, Confidence Hgb, hemoglobin; VIIRisks (CABG)—Cox analysisVariablePercent follow-up, (n/N)Hazard mortality72.49 (8.07)1.05/y (1.04-1.07)<.001 mortality68.32 (8.82)Smoking smokers11.1 (75/676) history14 (292/2088)1.27 (0.98-1.66).075Hypertension No12.8 (33/257) Yes13.3 (334/2507)1.12 (0.78-1.61)Diabetes No12.3 (192/1557) Yes14.5 (175/1207)1.13 (0.92-1.40).242Congestive No11.1 (239/2152) Yes20.9 (128/612)1.61 (1.29-2.01)<.001Chronic No11.4 (239/2097) Yes19.2 (128/667)1.69 (1.35-2.12)<.001Anemia No11.2 (262/2343) Yes24.9 (105/421)1.64 (1.30-2.07)<.001Sex Male12.6 (250/1989) Female15.1 (117/775)1.14 (0.91-1.43).27Contralateral No13.6 (277/2040)1.08 (0.85-1.37).527 Yes12.4 (90/724)Chronic (234/2153) Yes21.8 (133/611)1.48 (1.19-1.86)<.001Symptomatic (317/2388) (50/376)1.44 (1.07-1.95).018CI,