Synchronous carotid stenting and cardiac surgery: An initial single-center experience

Systematic review and meta-analysis of the treatment strategies for coronary artery bypass graft patients with concomitant carotid artery atherosclerotic disease

OBJECTIVE

Stroke is one of the devastating complications after coronary artery bypass graft (CABG). Underlying carotid artery atherosclerotic disease is reported to be an independent risk factor. The optimal treatment strategy for these patients remains under debate.

METHODS

We aimed to perform a network meta-analysis to evaluate the safety and efficacy of additional carotid interventions for patients with concomitant carotid artery atherosclerotic disease who require CABG by comparing perioperative adverse event rates. All articles through February 2022 were searched using MEDLINE and EMBASE to identify studies that investigated outcomes of CABG only as well as additional staged vs combined carotid interventions by both carotid endarterectomy (CEA) and carotid artery stenting (CAS).

RESULTS

Two randomized controlled trials and 23 observational studies were included, yielding a total of 32,473 patients who underwent combined CEA and CABG (n = 20,204), CEA and staged CABG (n = 6882), CABG and staged CEA (n = 340), CAS and CABG regardless of timing and sequences (n = 1224), and CABG only (n = 3823). No strategy showed a significant advantage over CABG only in all perioperative outcomes. CEA and staged CABG was associated with the lowest perioperative stroke/transient ischemic attack (TIA) rate, significantly lower compared with CAS and CABG (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.36-0.76) as well as CABG and staged CEA (OR, 0.41; 95% CI, 0.23-0.74), but was also associated with the highest perioperative mortality (OR, 2.50; 95% CI, 1.67-3.85, vs CAS and CABG) and myocardial infarction rate (OR, 3.70 [95% CI, 1.16-12.5] and OR, 2.50 [95% CI, 1.35-4.55] vs CAS and CABG, vs combined CEA and CABG, respectively).

CONCLUSIONS

CEA and staged CABG are associated with low perioperative stroke/transient ischemic attack rates with a tradeoff of higher mortality and myocardial infarction rate. No strategy showed a significant advantage over the CABG-only strategy in all perioperative outcomes, outlining the importance of a tailored approach and determining proper indications for carotid intervention in these patients.

Contemporary Management of Patients with Concomitant Coronary and Carotid Artery Disease

The ideal management of concomitant carotid and coronary artery occlusive disease remains elusive. Although researchers have advocated the potential benefits of varying treatment strategies based on either concomitant or staged surgical treatment, there is no consensus in treatment guidelines among national or international clinical societies. Clinical studies show that coronary artery bypass grafting (CABG) with either staged or synchronous carotid endarterectomy (CEA) is associated with a high procedural stroke or death rate. Recent clinical studies have found carotid artery stenting (CAS) prior to CABG can lead to superior treatment outcomes in asymptomatic patients who are deemed high risk of CEA. With emerging data suggesting favorable outcome of CAS compared to CEA in patients with critical coronary artery disease, physicians must consider these diverging therapeutic options when treating patients with concurrent carotid and coronary disease. This review examines the available clinical data on therapeutic strategies in patients with concomitant carotid and coronary artery disease. A treatment paradigm for considering CAS or CEA as well as CABG and percutaneous coronary intervention is discussed.

Early results after synchronous carotid stent placement and coronary artery bypass graft in patients with asymptomatic carotid stenosis

BACKGROUND

The optimal management of patients with combined carotid and coronary artery disease requiring cardiac surgery is still unknown. Staged carotid endarterectomy and carotid artery stenting (CAS), each followed by coronary artery bypass graft (CABG), are options frequently employed. However, for patients with severe carotid artery disease in urgent need of open cardiac revascularization, staged operations may not be the most appropriate alternative. The aim of this study was to describe our experience using a synchronous CAS-CABG method with minimal interprocedural time. We used this synchronous combination of procedures in patients with combined carotid and coronary artery disease admitted for urgent CABG.

METHODS

Patients with concomitant severe carotid and coronary artery disease scheduled for synchronous CAS and urgent CABG between December 2006 and January 2010 were included in the study. All procedures were performed at a single center: the Cardiovascular Foundation of Colombia, in Floridablanca, Santander, Colombia. The study cohort was characterized according to demographic and clinical characteristics, which included degree of carotid stenosis, presence/absence of preoperative neurological symptoms, and cardiac operative risk profile. All patients underwent CAS under embolic protection devices and then CABG within the next 2 hours. Patients received aspirin pre- and postprocedure but were started on clopidogrel only after CABG. The primary end point of the study was the composite incidence rate of myocardial infarction, stroke, and death 30 days after CAS-CABG.

RESULTS

Fifteen patients with concomitant severe carotid and coronary artery disease underwent synchronous CAS-CABG. Most patients (60%) were men, and mean (± standard deviation) age was 65.2 (± 8.4) years. Most patients (93%) were neurologically asymptomatic. The median (interquartile range) ejection fraction and logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) for the cohort were 55% (36%-62%) and 9.7% (4.6%-14.8%), respectively. There were no deaths, major strokes, minor strokes, or myocardial infarctions during the procedure or within 30 days of CAS-CABG. One patient experienced neurological symptoms likely as a result of transient ischemic attack ipsilateral to the CAS procedure. None of the patients required cardiac or carotid reinterventions, and there were no cases of postoperative bleeding requiring reoperation.

CONCLUSIONS

Synchronous CAS-CABG, when CABG is performed within the 2 hours of the CAS procedure, may be a viable alternative to the more generally accepted staged combination, particularly among patients for whom CABG cannot be postponed. We hope that this strategy will be further evaluated in larger prospective studies and adequately powered randomized clinical trials.

Management of carotid disease in patients undergoing coronary artery bypass surgery: is it time to change our approach?

PURPOSE OF REVIEW

The management of concurrent severe carotid and coronary disease is a subject of ongoing debate in the absence of randomized clinical trials. Amidst the growing controversy, the clinician has to carefully tailor the best strategy for a given patient based on neurologic and cardiac symptoms. This review aims to compile current evidence in this area to help plan strategies for the optimal management of coexisting severe carotid and coronary disease.

RECENT FINDINGS

Carotid revascularization with carotid endarterectomy (CEA) or stenting (CAS) is frequently performed in conjunction with coronary artery bypass surgery (CABG) in the United States for asymptomatic carotid disease. The risk of perioperative stroke with unilateral asymptomatic 70-99% carotid stenosis is likely small based on several observational data. Moreover, the risk associated with both staged and combined CEA-CABG procedures in the asymptomatic population may outweigh any benefit. Carotid artery stenting is an alternative option in patients with severe coronary disease who are considered 'high risk' for CEA. Neurologically symptomatic patients require carotid revascularization prior to or in conjunction with CABG surgery. Ultimately, the choice of carotid revascularization or conservative management will depend on clinical characteristics, anatomy, and local expertise.

SUMMARY

Severe carotid disease in the CABG population is often unilateral and asymptomatic. Based on the available data, conservative carotid therapy in the low-risk asymptomatic individuals is likely the best treatment option. Carotid revascularization may be justified in symptomatic or high-risk patients such as those with contralateral carotid occlusion or bilateral severe stenosis.

Treatment strategies in severe symptomatic carotid and coronary artery disease

Coexistent carotid artery stenosis (CS) and multivessel coronary artery disease (CAD) is not infrequent. One in 5 patients with multivessel CAD has a severe CS, and CAD incidence reaches 80% in those referred for carotid revascularization. We reviewed treatment strategies for concomitant severe CS and CAD.

We performed a literature search (MEDLINE) with terms including carotid artery stenting (CAS), coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), stroke, and myocardial infarction (MI).

The main therapeutic option for CS-CAD has been (simultaneous or staged) CEA-CABG. This, however, is associated with a high risk of MI (in those with CEA prior to CABG) or stroke (CABG prior to CEA), and the cumulative major adverse event rate (MAE – death, stroke or MI) reaches 10–12%. With increasing adoption of CAS, a sequential strategy of CAS followed by CABG has emerged. Registries (usually single-centre) indicate an MAE rate of ≈7% for CAS followed by CABG (frequently after >30 days, due to double antiplatelet therapy). Recently, 1-stage CAS-CABG has been introduced. This involves different antiplatelet regimens and, in some centers, preferred off-pump CABG, with a cumulative MAE of 1.4–4.5%.

No randomized trial comparing different treatment strategies in CS-CAD has been conducted, and thus far reported series are prone to selection/reporting bias. In addition to the established surgical treatment (CEA-CABG, sequential/simultaneous), hybrid revascularization (CAS-CABG) is emerging as a viable therapeutic option. Larger, preferably multi-centre, studies are required before this can become widely applied.

Current outcomes of simultaneous carotid endarterectomy and coronary artery bypass graft surgery in North America

OBJECTIVE

Management of patients with concomitant carotid and coronary artery disease has been controversial. Divergent strategies have been employed, including simultaneous carotid endarterectomy and coronary bypass (SCC) versus various staged procedures. Although no strict comparison group is available, this study defines current outcomes of SCC, compared qualitatively to two reference categories.

METHODS

Utilizing the STS database from 2003 to 2007, patients who had SCC were compared with patients with cerebrovascular disease who had coronary bypass (CABG) with prior carotid endarterectomy (CEA), and those with carotid Doppler stenosis >75% and no carotid intervention. Logistic regression analysis adjusted for differences in baseline characteristics and operative mortality (OM), and a composite of neurological complications (NC) was assessed.

RESULTS

Of 745,769 patients who underwent isolated CABG with/without CEA, 108,212 (14%) had cerebrovascular disease. Of this group, 5,732 (5%) underwent SCC. The SCC group had more males and lower preoperative risk factors. After statistical adjustment for all baseline differences, SCC had clinically and statistically higher OM and NC compared with any of the reference groups, with 20-40% higher event risk.

CONCLUSIONS

Although no quantitative control group exists for comparison, SCC as recently performed in North America has a high risk compared with any of the reference groups. Suboptimal results associated with the SCC strategy suggest a need for quality improvement and research on the optimal management of patients with simultaneous carotid and coronary disease.

A critical look at "high-risk" in choosing the proper intervention for patients with carotid bifurcation disease

Refinements in the technique of carotid endarterectomy have been accompanied by a growing literature calling into question the notion that a broad class of patients is at high-risk for surgery due to clinical comorbidities. Moreover, progress in the percutaneous revascularization of carotid bifurcation disease has highlighted the need for direct comparisons between endarterectomy and stenting across the entire spectrum of perioperative risk. The improved safety of carotid stenting, to some extent due to the advent of cerebral protection devices, has further altered the risk-to-benefit analysis. Lastly, dramatic improvements in medical therapy for the systemic manifestations of atherosclerosis have prompted a reevaluation of carotid revascularization as the standard of care for patients with severe carotid bifurcation stenosis. Endarterectomy and stenting each have unique procedure-specific factors that determine whether a patient is at increased risk for perioperative complications. Determining which patients are at high-risk for these modalities will impact the individualized treatment algorithm. This article examines the anatomical and physiologic conditions that can affect the anticipated outcome of each treatment modality. Ultimately, a tailored approach to each patient's clinical situation is likely to result in the best outcome following treatment.