Treatment of concomitant carotid and coronary artery disease. Decision-making regarding surgical options.

Myocardial infarction is the most common cause of early and late mortality after carotid endarterectomy (CEA). Stroke after coronary artery bypass grafting (CABG) is a devastating and dreaded complication. Up to 28% of patients presenting for CEA have severe, reconstructible coronary artery disease, and up to 22% of patients presenting for CABG have severe carotid artery disease. The treatment for these patients is controversial, and surgical decision-making is difficult. The 3 options for treatment include the staged approach (CEA followed by CABG), the reversed staged approach (CABG followed by CEA), and the combined approach (CEA and CABG during the same anesthetic). The result of each of these approaches varies widely, and primarily depends on patient selection. The combined approach is well accepted in those patients with severe, symptomatic disease in both the carotid and coronary artery territories. These patients are at significant risk for both stroke and myocardial infarction (MI), and the combined approach minimizes these risks. In those patients with asymptomatic or stable disease in one of the vascular territories, the choice of a staged or combined procedure is more controversial and the outcome data is less authoritative. No data confirms the superiority of one approach. Until a multi-institutional, randomized trial can provide further objective data, management of these patients should be guided by the relative severity of their carotid and coronary artery disease and the surgeon's own results in the treatment of these patient populations.