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Eur J Cardiothorac Surg 2002;22:329-330
© 2002 Elsevier Science NL
Letter to the Editor |
Hospital da Universidade Coimbra, Cirurgia Cardiotoracica, 3000 Coimbra, Portugal
Received 3 April 2002; accepted 12 April 2002.
* Corresponding author. Tel.: +351-239-400418; fax: +351-239-829674
e-mail: antunes.cct.huc{at}mail.telepac.pt
We appreciate the interest showed by Dr Minami and co-workers in our paper [1] and would like to point out the following issues in response to their comments. The choice of treatment for patients who present with concomitant carotid and coronary artery stenosis is still a matter of debate. The options vary from a simultaneous (same anaesthetic) to a staged procedure and, to date, no well-designed prospective randomized trial has clarified this problem. Each of these methods has its advantages and disadvantages, which can be measured, essentially, by the global mortality and the incidence of myocardial infarction (MI) and of stroke, or by the combination of these factors.
We have opted for the staged procedure essentially because in our country the two procedures are performed by different specialities, as also happens in other countries, which makes the procedure more cumbersome.
We agree that this group of patients are at higher risk of perioperative coronary ischaemic events, but our results including the staging interval, with no mortality and an incidence of MI of 3.6%, appear to demonstrate the relative safety of this approach. In contrast to the opinion expressed by Minami and co-workers in their letter, we do not consider these results a reason to abandon the method.
The study published by Minami et al. [2] on 340 patients consecutively operated using cardiopulmonary bypass for both procedures done simultaneously constitutes, obviously, a reference work. It was not included in our list in Table 5 because it only contemplated series without concomitant operations. In their study, Minami et al. reported rates of MI, neurologic complications (both reversible and permanent stroke) and death of 0.6, 4.7 and 2.6%, respectively. Although their incidence of MI was very low, perhaps difficult to reproduce (to our knowledge, an incidence of 0.6% had never been reported in a large series of patients), the composite death and stroke (6.3%) was similar to that obtained in our study.
In many circumstances, as in the treatment of combined carotid and coronary disease, there is no ideal solution and a best possible one has to be found. The optimal strategy for management of these cases remains undefined and each centre must select its own treatment policy, also depending on the specific logistics, and compare the results with those described by others. In this context, and comparing our results with those reported using the combined approach, we found an increased, yet acceptable and largely unconsequential, risk for the myocardium.
We emphasize that we had no fatal MI, while Minami et al. reported two. Although this is not statistically significant, it does not warrant their saying that the simultaneous procedure affords better protection of the myocardium. Most importantly, in our view, favourable results concerning the composite rate of death and stroke, the two more dreadful complications, favour our preferred approach.
Finally, more recently, our approach has been refined by performing percutaneous dilatation and/or stenting of carotid lesions in cases with favourable anatomy, virtually without morbidity. We consider this a most important advance.
In conclusion, there is more than one way to skin a cat. Whether carotid endarterectomy is done prior to or during CABG, significant lesions, symptomatic or assymptomatic, cannot be ignored. Each surgical team must select the method which in their own experience gives better results. Clearly, in our case, the sequential procedure proved to be the best.
References
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