Should we perform carotid endarterectomy synchronously with cardiac surgical procedures?

From Jan. 1, 1979 through July 31, 1987, 63 patients had carotid endarterectomy (CEA) concurrently with cardiac surgical procedures including coronary artery bypass grafting (CABG) in 61, CABG plus mitral value replacement in one, and aortic valve replacement in one. Among the 62 patients having CABG, unstable angina had been present in 36 (58%), left main coronary artery disease in 21 (34%), and both unstable angina and left main coronary artery disease in 13 (21%). Indications for carotid surgery included previous stroke, amaurosis fugax, or hemispheric transient ischemic attacks (TIAs) in 33 patients (52%); bilaterally significant carotid disease was noted in 48% of the patients. Major neurologic complications occurred in three patients (4.8%), including perioperative stroke in two (3.2%) (fatal in one) and a TIA in a third patient. Bilateral carotid lesions, a contralateral total carotid occlusion, previous cerebrovascular symptoms, and intraaortic balloon pump support did not increase neurologic risk. Seven patients died postoperatively (11%). The mortality rate was 2.8% in patients younger than 65 years vs 22% in patients 65 years or older, 19% in patients with left main coronary artery disease vs 7.3% in patients without, 13.3% in men vs 5.6% in women, 25% in patients with a history of congestive heart failure vs 7.8% in patients without failure, and 6.2% in patients with unilateral carotid disease, 17% in patients with bilateral carotid disease, and 23% in patients with bilateral disease including a contralateral carotid occlusion. A mortality predictive index (MPI) was developed to summarize individual risk for a fatal outcome. Survivors had a mean MPI of 1.98 vs 3.30 for those who died. The mortality rate was 2.4% in patients with an MPI of 0 to 2 vs 29% for those with an index of 3 to 5. In elderly cardiac surgical patients and those with an MPI of 3 or greater, the risks of operation may outweigh the potential benefits of synchronous CEA.