RS32 - Operative- and Long-Term Outcomes of Combined and Staged Carotid Endarterectomy and Coronary Bypass: A Medicare-linked VQI/VISION Analysis

Objectives: Optimal temporal surgical management of significant carotid stenosis (CS) and coronary artery disease (CAD) remains unknown. Carotid endarterectomy (CEA) and coronary bypass (CABG) are performed concurrently (CCAB) or in staged (CEA-CABG or CABG-CEA) approach. Using the Vascular Quality Initiative (VQI)-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network (VISION)-Medicare linked dataset, this study compared operative and long-term outcomes following CCAB and staged approaches.

Methods: The VQI-VISION dataset was used to identify CEAs from 2011–2018 with combined CABG or CABG within 45 days preceding or following CEA. Patients were stratified based on concurrent or staged approach. Primary outcomes were stroke, myocardial infarction (MI), all-cause mortality, and these as composite (SMD) within 30-days from the last procedure as well as long-term. Univariate analysis and risk-adjusted analysis using inverse propensity weighting (IPW) were performed. Kaplan-Meier freedom from stroke-, MI-, and death- curves were created and compared.

Results: There were 1,058 patients included: 643 CCAB and 415 staged (309 CEA-CABG and 106 CABG-CEA). Compared to staged, patients undergoing CCAB had higher preoperative rate of congestive heart failure (24.8% vs 18.4%, p< 0.01) and decreased renal function (15.3% vs 8.7%, p< 0.01) as well as fewer prior neurological events (23.5% vs 31.4%, p< 0.01). While there was no difference in unadjusted rate of postoperative stroke (5.3% vs 3.8%, p=0.26), mortality (4.6% vs 3.6%, p=0.46), or SMD (14.1% vs 15.4%, p=0.56) following CCAB compared to staged, there was a lower rate of MI following CCAB (5.4% vs 9.3%, p=0.02). This remained true following IPW (Table I). Within the staged group, 22 (5.3%) patients experienced stroke and 79 (19%) had MI between procedures. Stroke was more common between CABG-CEA (p <.001) and MI between CEA-CABG (p <.01) sequencing, respectively. Of the 79 with MI between procedures, 12 (15.2%) experienced additional MI following the second procedure. Compared to CCAB, patients undergoing staged approach had similar long-term adjusted risks of stroke (HR, 0.82; 95% CI, 0.50–1.33; p=0.41) and mortality (HR, 1.03; 95% CI, 0.76–1.39; p=0.86) but higher risk of MI (HR, 1.44; 95% CI, 1.02–2.02; p=0.04).

Conclusions: In patients undergoing CCAB or staged procedures for CS and CAD, the staged approach had increased risk of postoperative cardiac event, but short- and long-term rates of stroke and mortality appear comparable. Cardiovascular event risk is high between operations when staged. Although factors leading to staged sequencing performance need further clarity, CCAB appears safe and should be considered an equally reasonable option.