The case for concomitant carotid and coronary artery surgery.

Editorial The case for concomitant carotid and coronary artery surgery There is continuing controversy about the best management for patients with severe coronary artery disease who also have important carotid disease. Approaches vary from totally ignoring carotid stenoses at the time of myocardial revascularisation, to performing staged operations, or combining the two operations during one anaesthesia. Numerous studies have been published which when considered together establish a strong case for concomi-tant carotid endarterectomy and coronary bypass grafting being the safest and most long lasting approach in patients with coexistent severe carotid and coronary disease. To arrive at this conclusion, one must answer the questions facing any new technique, namely, "Does it work?" and "Is it necessary?" Therefore, one must establish that each surgical procedure is the appropriate treatment for patients with carotid or coronary disease, that each disease poses a risk during operations that address only one of the lesions, and that the combined operation yields the best results. Carotid endarterectomy for patients with symptomatic carotid stenoses In 1986 Hertzer and coworkers reported significant freedom from neurological events in symptomatic patients who had carotid endarterectomy rather than medical treatment.' The North American Symptomatic Carotid Endarterectomy Trial confirmed significant freedom from any stroke, any ipsilateral stroke, and any stroke or death in patients who had endarterectomy rather than medical treatment.2 Similar results were reported from the European Carotid Surgery Trial.' Carotid endarterectomy for patients with asymptomatic carotid lesions Also in 1986 Hertzer and associates reported significant freedom from late neurological events in surgically treated patients when they were compared with medically treated patients with asymptomatic stenoses.4 In 1993 the Veterans Affairs Cooperative Study Group reported a significant reduction in the overall incidence of ipsilateral neurological events after carotid endarterectomy in patients with asymptomatic lesions.5 Lately, the National Institutes of Health abruptly ended a randomised trial of carotid endarterectomy versus medical treatment for asymptomatic carotid lesions because of the overwhelming advantages of surgery.6 Coronary bypass grafting in patients with coronary artery disease Coronary bypass grafting has long-term advantages in terms of survival and symptom relief over medical treatment for most cohorts of patients with coronary artery disease.7 Additionally in all major studies comparing bypass grafting and percutaneous angioplasty, patients treated surgically had a significant advantage in terms of event-free survival.8-'0 The risks Does the presence of significant disease in one arterial system pose an important threat to patients with combined diseases if …