[Simultaneous and staged surgical treatment of carotid artery stenosis in patients with coronary artery disease: remote results].

Abstract

Background: The systemic nature of vascular lesions in atherosclerosis leads in 2.4-14% of patients to hemodynamically significant combined lesions of the coronary and carotid basins. For these patients, recommendations on surgical treatment remain uncertain, with the discussions concerning advantages of various surgical techniques still going on.

Objective: This study was aimed at assessing the results of simultaneous and staged treatment of patients with combined lesions of brachiocephalic arteries and coronary artery disease.

Patients and methods: Patients were recruited into the study retrospectively according to the 'continuous observation'. Between September 2012 and March 2022, we performed surgical treatment of a total of 5,340 patients with coronary artery disease. Significant concomitant lesions of coronary arteries and brachiocephalic arteries were diagnosed in 852 (16%) patients. The mean age of patients amounted to 65.9±14.2 years (form 38 to 84 years). Staged surgical treatment (with the first stage consisting in carotid endarterectomy and the second stage being coronary artery bypass grafting) was performed in 693 (81.3%) patients and simultaneous treatment in 159 (18.7%) patients. Risk stratification according to the EuroSCORE II scale amounted to 2.2±1.2%.

Results: In-hospital mortality in the groups of staged and simultaneous treatment amounted to 1 (0.1%) and 2 (1.3%), respectively. Patients of both groups underwent predominantly eversion carotid endarterectomy (97.8%). The frequency of complications such as postoperative bleeding, postoperative wound infection, stroke and acute myocardial infarction did not differ between groups and amounted to: 14 (2%) and 4 (2.5%) (p=0.410); 5 (0.7%) and 2 (1.2%) (p=0.41); 1 (0.1%) and 1 (0.6%) (р=0.339); 1 (0.1%) and 1 (0.6%) (p=0.339), respectively. In the remote follow-up period (65.1 months) after simultaneous (carotid endarterectomy + coronary artery bypass grafting) and staged (carotid endarterectomy followed by CABG) operations, there were no significant differences in long-term survival - 92.7% vs 89.2% (p=0.437), recurrent myocardial infarction - 8.7% vs 7.7% (p=0.51), and acute ischemic stroke - 5.5% vs 8.2% (p=0.959), respectively.

Conclusion: Simultaneous interventions are indicated for patients presenting with coronary artery disease and significant stenosis of brachiocephalic arteries in unstable angina pectoris, as well as in lesion of the left coronary artery trunk. Staged surgical treatment (first carotid endarterectomy then CABG) is indicated for stable patients with coronary artery disease. Such differentiated approach makes it possible to perform oeprations for these patients relatively safely and with good efficacy in both the immediate and remote postoperative periods.