Meta-analysis of staged versus combined carotid endarterectomy and coronary artery bypass grafting

Background The multiple options in the management of patients with concomitant carotid and coronary artery disease (CAD) make it difficult to find a clear consensus regarding the ideal surgical strategy. We performed a meta-analysis of studies comparing early outcomes of synchronous and staged approach of carotid endarterectomy and coronary artery bypass grafting. Methods All English language publications were searched using the terms "carotid artery disease," "coronary artery disease," "carotid endarterectomy," and "coronary artery bypass grafting" alone or in combination. The endpoints studied were early mortality, major stroke, and major postoperative morbidity; myocardial infarction (MI) and stroke, and combined early mortality or stroke. Early events were compared using pooled estimates of risk ratios (RR) (random effects model) utilizing the inverse-variance method. Results Twelve studies were identified with a total of 17,469 and 7,552 patients in the combined and staged group, respectively. The pooled analysis revealed no difference in the early mortality (RR 1.36 [0.78, 2.36]; p = 0.27), post operative stroke (RR 1.14 [0.99, 1.31], p = 0.07), combined early mortality or stroke (RR 1.08 [0.98, 1.20], p = 0.11) and combined endpoint of MI or stroke (RR 0.75 [0.48, 1.17; I² = 11%], p = 0.2) between the 2 surgical approaches. Conclusions Our meta-analysis of observational studies suggests comparable outcomes in combined and staged approach for synchronous carotid and coronary artery disease. Hence, the 2 strategies can be used interchangeable in the clinical practice, with each having specific applications linked to specific clinical conditions. A randomized trial is warranted to answer this question definitively.