Long-term results of carotid stenting and risk factors in patients with severe carotid artery stenosis undergoing subsequent cardiac surgery

Eptifibatide bridging therapy for staged carotid artery stenting and cardiac surgery: Safety and feasibility

BACKGROUND

Prophylactic carotid artery stenting (CAS) is an effective strategy to reduce perioperative stroke in patients with severe carotid stenosis who require cardiothoracic surgery (CTS). Staging both procedures (CAS-CTS) during a single hospitalization presents conflicting demands for antiplatelet therapy and the optimal pharmacologic strategy between procedures is not established. The purpose of this study is to present our initial experience with a "bridging" protocol for staged CAS-CTS.

METHODS

A retrospective review of staged CAS-CTS procedures at a single referral center was performed. All patients had multivessel coronary and/or valvular disease and severe carotid stenosis (>70%). Patients not previously on aspirin were also started on aspirin prior to surgery, followed by eptifibatide during CAS (intraprocedural bolus followed by post-procedural infusion which was continued until the morning of surgery). Pre- and perioperative (30 days) neurologic morbidity and mortality was the primary endpoint.

RESULTS

11 CAS procedures were performed in 10 patients using the protocol. The median duration of eptifibatide bridge therapy was 36 h (range 24-288 h). There was one minor bleeding complication (1/11, 9.1%) and no major bleeding complications during the bridging and post-operative period. There was one post-operative, non-neurologic death and zero perioperative ischemic strokes.

CONCLUSIONS

For patients undergoing staged CAS-CTS, Eptifibatide bridging therapy is a viable temporary antiplatelet strategy with a favorable safety profile. This strategy enables a flexible range of time-intervals between procedures.

Same-Day Carotid Artery Stenting and Coronary Artery Bypass Surgery

BACKGROUND

The optimal treatment strategy for patients with severe carotid artery disease undergoing coronary artery bypass grafting is still problematic. The important question is whether it is necessary to treat significant carotid disease in patients who have undergone coronary artery bypass grafting. This study analyzed short- and midterm results after same-day carotid artery stenting and coronary artery bypass grafting.

METHODS

From 2013 to 2020, a total of 69 patients were enrolled in the study. Same-day carotid artery stenting and coronary artery bypass grafting were performed in all patients. The study's primary end points were the evaluation rate of stroke, myocardial infarction, and death within short- and midterm periods after the procedures.

RESULTS

The 30-day mortality was 0%. The occurrences of perioperative adverse events, namely stroke, myocardial infarction, and transient ischemic attack, were 1 (1.4%), 1 (1.4%), and 4 (5.8%), respectively. Mean (IQR) follow-up time was 28 (IQR, 17-43) months. Six (8.8%) patients died during this period. Fatal stroke was registered in 2 cases, and 1 patient experienced a disabling stroke with a fatal outcome. The other 3 patients died because of chronic renal disease, a traffic accident, and for an unknown reason, respectively. Midterm survival in the group was 91.2%.

CONCLUSION

The study showed that same-day carotid artery stenting and coronary artery bypass grafting for concomitant carotid and coronary disease treatment could be a promising and feasible therapeutic strategy.

Long-term results after simultaneous carotid and coronary revascularisation

BACKGROUND

The revascularisation strategy for concomitant carotid and coronary disease is unknown. Simultaneous or stage coronary artery stenting and carotid endarterectomy are the most common revascularisation approach in the CABG population. This study aimed to evaluate long-term results after simultaneous carotid artery stenting or carotid endarterectomy in patients who underwent coronary artery bypass surgery.

METHODS

This is a prospective cohort non-randomised single-institution study. During the period from 2012 to 2015, sixty consecutive patients (65.9 ± 7.41 mean) underwent simultaneous carotid artery stenting and coronary artery bypass surgery (n = 30) or simultaneous carotid endarterectomy and coronary artery bypass surgery (n = 30). The primary endpoints were short- and long-term rates of adverse events (transient ischemic attack, stroke, myocardial infarction, and death). The mean follow-up was 62.05 ± 11.12 months.

RESULTS

In-hospital mortality was insignificantly higher in the carotid endarterectomy, and coronary artery bypass surgery group (6.6% vs. 0%), the rate of stroke and myocardial infarction was similar (13.3% and 0% in the carotid endarterectomy and coronary artery bypass surgery group vs. 6.6% and 3.3% in the carotid artery stenting and coronary artery bypass surgery group, respectively). The intensive care unit readmission was significantly higher in the surgical revascularisation approach; it was an independent predictor of hospital mortality. The overall mortality during the follow-up period was 14.28% in both groups. Freedom of the composite adverse outcomes (stroke, myocardial infarction, and death) was 78.55%.

CONCLUSION

Comparing two revascularisation strategies is not straightforward due to different anatomical indications for carotid artery stenting and endarterectomy. We consider that each technique has an essential role in carotid revascularisation. Good selection of patients, according to indications, contributes to satisfactory short- and long-term results.

Atherosclerotic Extension of Carotid Arteries: An Insertion in Clinical Practice

INTRODUCTION

Atherosclerotic disease is a diffuse disease that is strongly associated with age, risk factors, and variable progression. The anatomical prevalence of atheromas does not always follow, a sequence by sectors, and in many cases are concomitant.

OBJECTIVES

This study is aimed at studying atherosclerosis in the arterial territories of the carotid and lower limbs, in order to correlate their extension as a form of primary prevention.

METHODS

Participating patients with the main risk factors for atherosclerotic disease were composed of two groups: one with chronic peripheral obstructive arterial disease (PAD) and another without PAD. After performing carotid ultrasound Doppler (USD) of all patients, the occasional prevalence of the disease was evaluated. We performed by statistical tests the correlation between the findings in these patients and the risk factors. Obtaining n from 226 patients, in which 116 patients are from the PAD group and 110 patients are from the group without PAD.

RESULTS

Our findings add up to 8.8% for lesions over 50% in patients with PAD, with 6.2% over 70% meeting the few published scientific findings. In this study, the correlation was evaluated between carotid stenosis and PAD, in which we observed a positive association. We observed in the studies that the prevalence of moderate and severe carotid stenosis was similar to patients with coronary artery disease (CAD). There are a number of nonclassical risk factors that we do not evaluate, but even studying the traditional ones, we find that they are less than 27% dependent.

CONCLUSION

Therefore, our study proposes an improvement in the clinical approach of patients with PAD for both the carotid and coronary territory, not using only 2 factors traditional risk factors, for the extension study and to consider the PAD that has 10% dependence alone, as effect and projection of the carotid atherosclerotic plaque.

Asymptomatic carotid intraplaque hemorrhage is associated with a high risk of cerebral infarction and death after cardiovascular surgery

BACKGROUND

There is a lack of information on the natural history of asymptomatic carotid artery stenosis (AsymCS) associated with cardiovascular diseases that require surgery. The aim of this study was to investigate risk factors for postoperative ipsilateral ischemic stroke and all-cause mortality after cardiovascular surgery in patients with AsymCS.

METHODS

Among 2158 patients who underwent cardiovascular surgery, 150 patients with AsymCS who didn't undergo carotid revascularization were included. The relationships between preoperative factors, including carotid intraplaque hemorrhage (IPH), and postoperative ipsilateral ischemic stroke and all-cause mortality were analyzed retrospectively.

RESULTS

During the median follow-up of 1087 days of 150 patients with 19 IPH, 12 (8.0%) and 21 (14.0%) encountered ipsilateral infarction and all-cause mortality, respectively. Multivariable Cox regression analyses indicated that IPH was significantly predictive of both ipsilateral infarction (hazard ratio [HR] 21.31, 95% confidence interval [CI], 4.98-91.17; P ≤.001) and all-cause mortality (HR 4.64, 95% CI, 1.61-13.34; P = .004). Another significant factor was peak systolic velocity for ipsilateral infarction with the cutoff velocity of 227 cm/s by the receiver-operating characteristic curve.

CONCLUSIONS

In this cohort of patients with AsymCS undergoing cardiovascular surgery, IPH had a close connection with a high risk of both postoperative ischemic stroke and mortality after cardiovascular surgery.

Mortality and chronic obstructive pulmonary disease in patients treated with endovascular revascularization of the infra-inguinal lower limb arteries from retrograde access

Background

In this trial, our objective was to evaluate the relationship between long-term clinical outcomes in patients with peripheral arterial disease (PAD) treated with retrograde endovascular recanalization (ER) of chronic total occlusions (CTOs) regarding the infra-inguinal lower limb arteries and chronic obstructive pulmonary disease (COPD).

Methods

A total of 834 consecutive subjects were enrolled in the study. The mean age was 67.8±10.6 years (62.6% males). COPD was diagnosed in 98 patients (11.7%). The infra-inguinal location included the deep, superficial and common femoral artery, popliteal artery or below the knee arteries. During follow-up, we evaluated major adverse cardiac and cerebrovascular events (MACCE) and major adverse limb events (MALE). MACCE was considered as death, stroke/transient ischemic attack, myocardial infarction, percutaneous coronary intervention or coronary artery bypass grafting operation, while MALE regarded amputation, target lesion re-intervention, target vessel re-intervention and surgical action.

Results

The mean follow-up was 1,144.9±664.3 days and the interquartile range was 1,110.5 (504.5–1,734.7). Data were collected between 2006 and 2016. We noticed significant differences in death rates among the COPD and non-COPD groups. The cumulative number of events (deaths) was 12.2%, 17.3%, 18.4%, 22.4%, 23.5%, 23.5% and 23.5% in the COPD group and 6.1%, 7.5%, 10.5%, 11.3%, 11.4% 11.5% and 11.5% in the non-COPD group after 1, 2, 3, 4, 5, 6 and 7 years of follow-up, and was notably greater for COPD (P=0.0007).

Conclusions

Patients with COPD and PAD treated with the ER and retrograde approach due to CTOs are related to higher mortality than non-COPD patients.