**5. Conclusion**

Mendiz et al reported 30 high surgical risk patients for CEA who underwent synchronous CAS then CABG and/or valve surgery. Among these patients, 1 patient had TIA and no patients suffered stroke or MI.(Mendiz, Fava et al. 2006) Versaci et al reported 101 patients who underwent CABG immediately after CAS. The 30-day composite incidence of disabling stroke, AMI or death was 4%: 2 patients had stroke after CAS. (Versaci, Reimers et al. 2009). Another series of 22 patients who underwent true hybrid procedure showed no deaths or MI and one case of contralateral stroke. There were no cases of major postoperative bleeding or stent thrombosis.(Palombo, Stella et al. 2009) Van der Heyden et al reported 356 patients with asymptomatic ECAS who underwent staged CAS - CABG with a mean interval of 22 days between the 2 procedures. The 30-day post-CABG stroke and death rate was 4.8%, MI was 2% and MI and death was 6.7%.(Van der Heyden, Suttorp et al. 2007) Naylor et al performed a meta-analysis of 11 studies involving 760 CAS plus CABG procedures.(Naylor, Mehta et al. 2009) Majority of the patients in this analysis were asymptomatic (87%) and majority had unilateral ECAS (82%). The study reported a mortality of 5.5% (95% confidence interval, CI: 3.4-7.6), ipsilateral stroke rate of 3.3% (95% CI: 1.6-5.1), all-cause stroke rate of 4.2% (95% CI: 2.4-6.1) and a MI rate of 1.8% (95% CI: 0.5-3.0) at 30-day follow-up. These results are comparable to systematic reviews of staged and concomitant carotid CEA-CABG, and suggest that staged

Decision regarding appropriate procedure and strategy for carotid revascularization in

There are no randomized clinical trials comparing CAS and CEA in this patient group. Data from the Nationwide Inpatient Sample consisting of 27,084 patients who underwent carotid stenting before CABG or combined CEA - CABG surgery during the 5 years from 2000 to 2004 reported that 96.7% underwent CEA plus CABG surgery versus 3.3% who had carotid stenting plus CABG. Fewer perioperative strokes were reported among patients undergoing staged carotid stenting - CABG than among those undergoing staged CEA - CABG stroke (2.4% versus 3.9%). In this non-randomized data, patients undergoing staged CEA - CABG surgery faced a 62% greater risk of postoperative stroke than patients undergoing staged CAS-CABG surgery (OR 1.62, 95% CI 1.1 to 2.5; p<0.02).(Timaran, Rosero et al. 2008) There was no difference in the combined risk of stroke and death between the treatment (OR 1.26, 95% CI 0.9 to 1.6; p=NS).(Timaran, Rosero et al. 2008) Another study compared hybrid CAS - CABG procedures (n=56) to concomitant CEA-CABG procedure (n=111). In this study patients undergoing CAS at baseline were more likely to have unstable/severe angina (52% vs 27%, p = 0.002), severe left ventricular dysfunction (20% vs. 9%, p = 0.05), symptomatic carotid disease (46% vs. 23%, p = 0.002), and the need for repeat open heart surgery (32% vs. 9%, p = 0.0002). Severe contralateral carotid disease was more prevalent in the concomitant CEA+CABG group (28% vs. 11%, p = 0.01). On 30-day follow-up, CAS group had a significantly lower incidence of stroke or MI (5% vs. 19%, p = 0.02). (Ziada, Yadav et al. 2005) Another study involving 659 patients in whom CEA-CABG, CAS–CABG (staged) or CAS-CABG (hybrid) was performed in 28.1%, 57.4% and 13.5% of patients respectively showed a 30-day compo‐

CAS-CABG appears to as effective as staged CEA-CABG.

patients with undergoing CABG:

396 Artery Bypass

To date, stroke remains one of the most devastating complications after open heart surgery with serious adverse economic, psychological and clinical implications on healthcare and individuals suffering from it.(Roach, Kanchuger et al. 1996; Hogue, Murphy et al. 1999) Identifying patients at risk of stroke after CABG and applying measures to reduce its occur‐ rence are extremely vital.
