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