RS09 - Finding the Optimal Timing for Staged Carotid Endarterectomy - Coronary Artery Bypass Grafting

Objectives: Coronary artery bypass grafting (CABG) in patients with concomitant carotid artery disease presents a complex clinical challenge, requiring careful consideration of the timing of carotid endarterectomy (CEA). While Society for Vascular Surgery (SVS) guidelines provide recommendations for carotid revascularization in patients requiring CABG, clear guidance regarding the optimal interval between staged CEA and CABG remains limited.

Methods: We identified all patients who underwent Carotid Endarterectomy (ICD-9-CM: 381.2x; ICD-10-CM: 03C(H/J/K/L)0x) and subsequently Coronary Artery Bypass Grafting (ICD-9-CM: 361.xx; ICD-10-CM: 021(0/1/2/3)0x) within the same hospitalization in the NIS between 2000-2021. Patients were excluded if their indications for CEA was stroke or TIA or for CABG was myocardial infarction. Patients were stratified by interval between CEA and CABG: Hyperacute (CABG postoperative day [POD] 1), Acute (POD 2–3), Subacute (POD 4–7), and Delayed (POD >7). Major adverse cardiovascular events (MACE) were defined as postoperative stroke after CABG, cardiac dysfunction after CEA or CABG, or in-hospital death. Cardiac dysfunction includes acute heart failure, myocardial infarction, cardiogenic shock. Due to the nature of ICD coding, there is no further granularity of cardiac outcomes. Outcomes were compared using Student’s t-test and multivariable logistic regression.

Results: 14,230 patients underwent elective CEA-CABG during their hospitalization between 2000 and 2021 in the U.S. Patients who underwent Acute CABG after CEA (POD 2-3) experienced a lower postoperative stroke (3.6%) versus Hyperacute (5.2%), Subacute (4.0%), and Delayed (5.7%), though only significant compared to Delayed CABG (p < 0.01). Similarly, patients who underwent Acute CABG experienced a lower postoperative cardiac dysfunction (12.2%) and MACE (16.0%) compared with Hyperacute (16.0%p=0.04, 19.6%p=0.04), Subacute (12.6%p=0.78, 16.4%p=0.85), and Delayed CABG (21.0%, 29.0%; both p< 0.01) (FigureI). On logistic regression, Hyperacute (OR=1.37,p=0.04) and Delayed (OR=1.92,p < 0.01) CABG had significantly higher risk of postoperative cardiac dysfunction, with Delayed CABG also exhibiting higher risk of postoperative stroke and MACE (OR=3.08,OR=2.14;both p< 0.01)(TableI).

Conclusions: In this large national analysis of elective staged CEA–CABG performed during the same hospitalization, timing between procedures was strongly associated with perioperative neurologic and cardiac outcomes. CABG performed on postoperative days 2–3 after CEA was associated with the lowest rates of postoperative stroke, cardiac dysfunction, and MACE, suggesting a short recovery interval may optimize physiologic stability while avoiding prolonged exposure to untreated coronary disease. These findings refine existing guideline recommendations by identifying a potential optimal window for staged coronary revascularization following CEA and support performing CABG within 2–7 days after carotid intervention when a staged approach is selected.