Utilization of coronary artery bypass grafting with combined or staged carotid revascularization in a national sample

Background

Strategies to treat co-prevalent carotid and coronary artery disease include carotid endarterectomy (CEA) or stenting (CAS) with coronary artery bypass graft (CABG). There is uncertainty with respect to treatment utilization frequency. The objective of this study is to describe trends in the volume of CABGs performed concurrently with staged or combined CEA/CAS spanning a two-decade period and identify factors associated with utilization.

Methods

A nationally representative cohort was developed using National Inpatient Sample data from 1998 to 2020, identifying patients who underwent concurrent CABG and carotid revascularization. We included patients who underwent either CABG/CEA or CABG/CAS. Sample-weighted volumes of both staged (CABG+CEA/CAS during the same admission) and combined (both procedures on the same day) strategies were used to describe trends. Poisson regression models were used to identify factors predicting increased procedure volume. Interactions between strategy and procedure year, and facility CABG volume and strategy were tested.

Results

We analyzed 12,260 patients who underwent CABG with concurrent carotid revascularization, of whom 9702 (79.1%) were staged and 2558 (20.9%) were combined. In both the staged and combined groups, a significantly greater frequency of patients underwent CEA compared with CAS (97.5% and 91.7%, respectively; P < .001). In the multivariable model and as time progressed, concurrent volume decreased by 7% per year—a decrease observed across both staged and combined operations. Concurrent procedure volume significantly increased in urban relative to rural hospitals, with urban teaching hospitals reporting higher volume (urban nonteaching hospitals [incident rate ratio = 2.06, 95% confidence interval: 1.87, 2.27]; urban teaching hospitals [incident rate ratio = 3.01, 95% confidence interval: 2.73, 3.32]). Interactions between strategy, procedure year, and facility CABG volume were not statistically significant.

Conclusions

In a recent 20-year period, utilization of concurrent CABG/CEA and CABG/CAS operations decreased significantly, independent of timing strategy (either staged or combined). Resource allocation and guideline planning should consider the relative frequency of these operations.