Concurrent coronary and carotid artery surgery: an open debate

We read with great interest the article by Kolh et al.1 dealing with the question about concurrent coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) surgery. Nevertheless, their report raises some concerns. The article analysed factors influencing peri-operative outcomes, and ascending aortic calcification was found to be an independent predictor of both stroke and death. These data are considered a common finding in patients who underwent heart surgery.2 However, in patients with concomitant severe carotid and coronary disease, the predictive role of aortic disease on stroke and death could be significantly overestimated. Carotid disease alone is a risk factor for stroke in patients who undergo surgical revascularization and stroke represents a known complication of CEA. In a recent large study, the adjusted stroke rate was 2.67-fold greater in the combined CEA–CABG group compared with CABG alone.3 By its nature, this study did not evaluate the impact of CEA on stroke incidence and the confounding effect of carotid disease on mortality and morbidity does not emerge. Hence the predictive effect of aortic disease could be significantly altered. Further studies on patients with and without concomitant CEA are needed to unmask the effect of carotid disease on stroke and to evaluate the real predictive role of aortic disease. In addition, the multivariate model cannot predict precisely the odds ratio for variables associated with operative mortality and morbidity, as confidence intervals are large, although P-values are significant. Some data about cardiopulmonary bypass and surgical techniques are lacking. We think that it could be important to explain where the arterial cannulation was made in patients with ascending aorta disease, as the number of no-touch aorta technique and off-pump surgery was lower than expected. Moreover, no explanation was given about surgical approach to 17 patients with aortic dilatation, as it seems that dilated ascending aorta was not substituted. This study confirms that concurrent CEA and CABG can be performed with acceptable mortality and morbidity, but it represents only one of the surgical option.4 We agree with the authors who consider treatment of symptomatic territory first reserving the combined simultaneous treatment for patients symptomatic in both territories.5