CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 3, May/June 2014
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highlighted the critical role of examination of the carotid artery
stenosis pre-operatively.
There are also several studies showing a neurological accident
rate of 7.4–20.3% with a mortality rate of 6.9–13.8% in
patients with concomitant carotid artery disease undergoing
CABG alone.
5,22,23
In addition, as higher morbidity rates (7–8%),
which were strongly associated with peri-operative MI were
reported in patients requiring CABG with isolated CEA
procedure,
22
simultaneous CEA and CABG is currently usually
recommended.
24,25
Furthermore, there is controversy on the optimal treatment for
patients with concomitant carotid and coronary artery disease.
Surgeons should consider a number of clinical parameters when
selecting the simultaneous or staged approach. To illustrate,
postoperative MI was reported to be 7% in symptomatic patients
and 1% in asymptomatic patients with coronary artery disease
who underwent CEA followed by CABG.
19,26
The incidence of peri-operative stroke, on the other hand, is
markedly increased in patients with
≥
80% carotid artery stenosis,
suggesting a staged approach, including CABG followed by
CEA.
27
However, the incidence of cardiovascular accidents is
mainly associated with embolism rather than low cardiac-output
thrombosis rate in patients undergoing elective CABG surgery.
28
Simultaneous intervention was first described in a single-
anesthesia period.
29
Trachiotis
et al
.
30
and Akins
et al
.
18
reported
that the simultaneous approach was highly effective in reducing
neurological and myocardial complications. Additionally, Takach
et al
.
31
indicated that simultaneous intervention was as safe as the
staged approach in high-risk patients, which was consistent with
our study findings.
In another single-centre study, the simultaneous approach
to CEA and CABG was reported to be associated with
equivalent mortality and stroke profiles, as well as lower overall
complication rates and hospital charges.
20
There are several
studies reporting a shorter length of hospital stay,
26,32
lower
costs
26,33
and acceptable early mortality and morbidity rates.
34-36
Similarly, we found the mortality and major stroke rates to be
0.9 and 2%, respectively.
Nevertheless, despite an increased number of studies showing
themerits of the simultaneous approach, national and international
guidelines have provided no consensus yet due to the lack of
prospective, randomised clinical trials. However, simultaneous
CEA and CABG in asymptomatic patients with bilateral severe
disease in particular, has been widely recommended.
13
Moreover, carotid artery stenting (CAS), which is less
invasive, with a lower rate of myocardial events, has been popular
in recent years. However, deliberate action should be taken until
its long-term results are documented, as there is currently limited
evidence supporting the use of CAS.
10
Conclusion
Our clinical experience indicated that simultaneous CEA and
CABG can be performed safely. Furthermore, it increases patient
comfort, since anaesthesia is given once, and two operations
are carried out at a single session. Therefore, we recommend
the simultaneous approach for patients with coronary and
carotid artery disease. However, further large-scale, multi-
centred, randomised clinical studies are required to draw final
conclusions.
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