Contemporary Management of Patients with Concomitant Coronary and Carotid Artery Disease

Synchronous carotid endarterectomy and coronary artery bypass graft: Four case reports

BACKGROUND

One of the major perioperative complications for coronary artery bypass graft (CABG) is stroke. The risk of perioperative stroke after CABG is approximately 2%. Carotid stenosis (CS) is considered an independent predictor of perioperative stroke risk in CABG patients. The optimal management of such patients has been a source of controversy. One of the possible surgical options is synchronous carotid endarterectomy (CEA) and CABG. Here, we have presented 4 cases of successful synchronous CEA and CABG.

CASE SUMMARY

Our center's experience with 4 cases of significant carotid artery stenosis, which were successfully managed with combined CEA and CABG, are detailed. The first case was a female who presented for CABG after a ST-elevation myocardial infarction. She had right internal carotid artery (ICA) occlusion and 90% left ICA stenosis. The second case was a male who was electively admitted for CABG. It was discovered that he had left ICA occlusion and 90% right ICA stenosis. The third case was a male with a history of stroke, two months prior to admission. He presented with non-ST-elevation myocardial infarction. Preoperatively, it was discovered that he had > 90% right ICA stenosis. The final case was a male who was electively admitted for CABG. It was discovered that he had bilateral > 90% ICA stenosis. We have also reviewed the current evidence and guidelines for managing CS in patients undergoing CABG.

CONCLUSION

Our case series demonstrated that synchronous CEA and CABG was safe. A multicenter study with additional patients is needed. It is necessary for clinicians to screen for CS in high-risk patients with features.

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.

Synchronous Carotid Endarterectomy and Anaortic Off-Pump Coronary Artery Bypass Surgery

BACKGROUND

There is ongoing debate regarding the optimal strategy and timing for the surgical management of patients with severe concomitant carotid and coronary artery disease. Anaortic off-pump coronary artery bypass (anOPCAB), which avoids aortic manipulation and cardiopulmonary bypass, has been shown to reduce the risk of perioperative stroke. We present the outcomes of a series of synchronous carotid endarterectomy (CEA) and anOPCAB.

METHODS

A retrospective review was performed. The primary endpoint was stroke at 30 days post-operation. Secondary endpoints included transient ischaemic attack, myocardial infarction and mortality 30 days post-operation.

RESULTS

From 2009 to 2016, 1,041 patients underwent anOPCAB with a 30-day stroke rate of 0.4%. The majority of patients had preoperative carotid-subclavian duplex ultrasound screening and 39 were identified with significant concomitant carotid disease who underwent synchronous CEA-anOPCAB. The mean age was 71±7.5 years. Nine patients (23.1%) had previous neurological events. Thirty (30) patients (76.9%) underwent an urgent operation. For CEA, a conventional longitudinal carotid endarterectomy with patch angioplasty was performed in all patients. For anOPCAB, total arterial revascularisation rate was performed in 84.6% and the mean number of distal anastomoses was 2.9±0.7. In the 30-day postoperative period, there was one stroke (2.63%), two deaths (5.26%), two transient ischemic attacks (TIAs) (5.26%) and no myocardial infarction. Two patients experienced acute kidney injury (5.26%), one of which required haemodialysis (2.63%). Mean length of stay was 11.37±7.9 days.

CONCLUSION

Synchronous CEA and anOPCAB is a safe and effective option for patients' severe concomitant disease. Preoperative carotid-subclavian ultrasound screening allows identification of these patients.

Midterm outcomes of simultaneous carotid revascularization combined with coronary artery bypass grafting

BACKGROUND

Simultaneous carotid endarterectomy (CEA) combined with coronary artery bypass grafting (CABG) has been widely used in patients with coronary heart disease complicated with severe carotid stenosis to reduce the risk of stroke and death. Carotid artery stenting (CAS) has been proven to be an alternative to CEA in recent years. We investigated the early and mid-term outcomes of simultaneous CEA or CAS combined with CABG in these patients.

METHODS

From January 2011 to January 2021, 88 patients who underwent simultaneous carotid revascularization combined with CABG under the same anesthesia in Beijing Anzhen Hospital were retrospectively analyzed, and this study included 25 patients who underwent CAS-CABG and 63 patients who underwent CEA-CABG. The main outcomes included all-cause death, stroke, myocardial infarction and combined adverse events. The main outcomes of the two groups were compared at 30 days after the operation and the mid-term follow-up. Univariate and multivariate Cox proportional hazards regression analyses were performed to determine the independent risk factors affecting mid-term mortality.

RESULTS

Within 30 days after the operation, there was no significant difference in combined adverse events between the two groups (P = 0.88). During the median follow-up period of 6.69 years (IQR, 5.82-7.57 years), 9 patients (14.30%) in the combined CEA-CABG group died, while 1 patient (4.00%) in the combined CAS-CABG group died. There were no significant differences in mid-term death (P = 0.20), stroke (P = 0.78), myocardial infarction (P = 0.88), or combined adverse events (P = 0.62) between the two groups. Univariate and multivariate Cox proportional hazards regression showed that NYHA grade IV (HR 5.01, 95% CI 1.16-21.64, P = 0.03) and previous myocardial infarction (HR 5.43, 95% CI 1.01-29.29, p = 0.04) were independent risk factors for mid-term mortality. We also found that combined CEA-CABG surgery may be associated with a higher risk of death (HR, 13.15; 95% CI 1.10-157.69, p = 0.04).

CONCLUSIONS

Combined CAS-CABG is a safe and effective treatment for patients with coronary heart disease complicated with severe carotid stenosis. NYHA grade IV and previous MI were independent risk factors for mid-term mortality.

Predicting early mortality following single-stage coronary artery or valve surgery and carotid endarterectomy

BACKGROUND

Surgical management of coexisting cardiac disease and extra-cranial carotid artery disease is a controversial area of debate. Thus, in this challenging scenario, risk stratification may play a key role in surgical decision making.

AIM

To report the results of single-stage coronary/valve surgery (CVS) and carotid endarterectomy (CEA), and to identify predictive factors associated with 30-day mortality.

METHODS

This was a multicenter, retrospective study of prospectively maintained data from three academic tertiary referral hospitals. For this study, only patients treated with single-stage CVS, meaning coronary artery bypass surgery or valve surgery, and CEA between March 1, 2000 and March 30, 2020, were included. Primary outcome measure of interest was 30-day mortality. Secondary outcomes were neurologic events rate, and a composite endpoint of postoperative stroke/death rate.

RESULTS

During the study period, there were 386 patients who underwent the following procedures: CEA with isolated coronary artery bypass graft in 243 (63%) cases, with isolated valve surgery in 40 (10.4%), and combination of coronary artery bypass grafting and valve surgery in 103 (26.7%). Postoperative neurologic event rate was 2.6% (n = 10) which includes 5 (1.3%) transient ischemic attacks and 5 (1.3%) strokes (major n = 3, minor n = 2). The 30-day mortality rate was 3.9% (n = 15). Predictors of 30-day mortality included preoperative left heart insufficiency (odds ratio [OR]: 5.44, 95% confidence interval [CI]: 1.63-18.17, p = .006), and postoperative stroke (OR: 197.11, 95% CI: 18.28-2124.93, p < .001). No predictor for postoperative stroke and for composite endpoint was identified.

CONCLUSIONS

Considering that postoperative stroke rate and mortality was acceptably low, single-stage approach is an effective option in such selected high-risk patients.

Staged Versus Synchronous Carotid Endarterectomy and Coronary Artery Bypass Grafting: A Meta-Analysis and Systematic Review

BACKGROUND

There are several treatment options for patients with concomitant carotid and coronary artery disease, and it is difficult to identify an optimal treatment strategy that has consensus. Here, we performed a meta-analysis to compare the early and long-term outcomes of staged and synchronous carotid endarterectomy and coronary artery bypass grafting approaches.

METHODS

We performed a meta-analysis that compared staged and synchronous carotid endarterectomy and coronary artery bypass grafting approaches between July 1976 and September 2021. PubMed, EMBASE, and the Cochrane Library were systematically searched for related articles.

RESULTS

Nineteen studies were identified with a total of 39,269 and 30,066 patients in the synchronous and staged groups, respectively. Early mortality was lower in the staged group than in the synchronous group (odds ratio OR 1.256, 95% confidence interval CI 1.006-1.569, P= P < 0.05, I² = 54.5%), and stroke rates were significantly higher in the synchronous group (OR 1.356, 95% CI 1.232-1.493, P < 0.05, I² = 33.3%). The rate of myocardial ischemia was significantly higher in the staged group than in the synchronous group (OR 0.757, 95% CI 0.635-0.903, P < 0.05, I² = 51.5%), and this meta-analysis also showed a significantly higher risk of transient ischemic attacks (TIAs) in the synchronous group (OR 1.335, 95% CI 1.055-1.688, P < 0.05, I² = 0.00%). The secondary outcomes, including the rate of reoperation, were significantly lower for the staged procedure than for the synchronous procedure (OR 1.177, 95% CI 1.052-1.318, P < 0.05, I² = 4.2%), and the rate of wound infection was significantly higher in the synchronous group than in the staged group (OR 0.457, 95% CI 0.403-0.519, P < 0.05, I² = 0.0%). There was no significant difference in the rate of cardiac arrhythmia between the two groups (OR 0.544, 95% CI 0.265-1.117, P > 0.05, I² = 12.7%). There was also no statistical significance in the long-term results regarding the incidence of stroke, myocardial ischemia, and mortality between the synchronous and staged groups (P > 0.05).

CONCLUSIONS

Patients treated with the synchronous approach had a significantly higher risk of early mortality, stroke, TIA, wound infection, and reoperation and a lower risk of myocardial ischemia than those treated with the staged approach. There was no significant difference in the long-term results between the 2 groups.

[Perioperative strokes in cardiac surgery]

The frequency of perioperative stroke in cardiosurgical practice may reach up to 10%. The risk of stroke is especially high after coronary artery bypass surgery and valve replacement. Perioperative stroke is related to embolism with the fragments of atherosclerotic plaque, arterial hypotension, cardiac arrhythmias, hypercoagulation, etc. The likelihood of stroke can be reduced by preoperative assessment of the patient. It is important to control blood pressure and saturation during the surgery. The manipulation on aorta should be minimized in order to reduce the risk of perioperative stroke. Important role belongs to timely identification of those who developed stroke after surgery. The only possible method of reperfusion therapy in perioperative stroke is mechanical thrombectomy.

Relationship between the non-HDLc-to-HDLc ratio and carotid plaques in a high stroke risk population: a cross-sectional study in China

BACKGROUND

Evidence on the association between the non-high-density lipoprotein cholesterol (non-HDLc)-to-high-density lipoprotein cholesterol (HDLc) ratio (non-HDLc/HDLc) and carotid plaques is still limited. This study aims to assess the relationship between the non-HDLc/HDLc and carotid plaques in a population with a high risk of stroke.

METHODS

A cross-sectional study based on the community was conducted in Yangzhou, China. Residents (no younger than 40 years old) underwent questionnaire interviews, physical examinations, and laboratory testing during 2013-2014. The subjects with a high risk of stroke were further selected (at least three of eight risk factors including hypertension, atrial fibrillation, type 2 diabetes mellitus, dyslipidaemia, smoking, lack of exercise, overweight, and family history of stroke) or a transient ischaemic attack (TIA) or stroke history. Carotid ultrasonography was then performed on the high stroke risk participants. Carotid plaque was defined as a focal carotid intima-media thickness (cIMT) ≥1.5 cm or a discrete structure protruding into the arterial lumen at least 50% of the surrounding cIMT. Logistic regression was employed to evaluate the relationship between the non-HDLc/HDLc and carotid plaques.

RESULTS

Overall, 839 subjects with a high risk of stroke were ultimately included in the analysis, and carotid plaques were identified in 341 (40.6%) of them. Participants in the highest non-HDLc/HDLc tertile group presented a higher proportion of carotid plaques than did those in the other two groups. After adjustment for other confounders, each unit increase in the non-HDLc/HDLc was significantly associated with carotid plaques (OR 1.55, 95%CI 1.28-1.88). In the subgroup analysis, the non-HDLc/HDLc was positively and significantly associated with the presence of carotid plaques in most subgroups. Additionally, the non-HDLc/HDLc interacted significantly with three stratification variables, including sex (OR 1.31 for males vs. OR 2.37 for females, P interaction = 0.016), exercise (OR 1.18 for subjects without lack of exercise vs. OR 1.99 for subjects with lack of exercise, P interaction = 0.004) and heart diseases (OR 1.40 for subjects without heart diseases vs. OR 3.12 for subjects with heart diseases, P interaction = 0.033).

CONCLUSION

The non-HDLc/HDLc was positively associated with the presence of carotid plaques in a Chinese high stroke risk population. A prospective study or randomized clinical trial of lipid-lowering therapy in the Chinese population is needed to evaluate their causal relationship.

Synchronous CEA and CABG in asymptomatic carotid artery stenosis: A case study

In the United States, there were 213,700 coronary artery bypass grafting (CABG) surgeries and 102,700 carotid endarterectomies (CEA) in 2011. Combined CEA and CABG surgeries are lower than either CEA or CABG, with an estimated 1,370 surgeries in 2012. There is some literature which supports that the surgeries can be performed safely together (referred to as combined, synchronous, tandem, or concomitant procedures). The purpose of this article is to describe the merits and potential complications involved with undergoing synchronous carotid artery and coronary artery bypass procedures. This purpose will be addressed by examining a case study of a patient who completed a synchronous procedure and by also reviewing the literature which addresses the benefits versus the risks associated with the synchronous procedures. Some studies found an increased incidence of perioperative and postoperative risks such as stroke, myocardial infarction, and death with the combined procedures, whereas some studies found no difference in the risks when the operations were performed sequentially. Combined or synchronous coronary artery bypass and carotid artery endarterectomy may be a safe surgical option for a specific subset of patients.

Comorbidities and Health-Related Quality of Life Following Revascularization for Asymptomatic Critical Internal Carotid Artery Stenosis Treated with Carotid Endarterectomy or Angioplasty with Stenting

Background

This study aimed to evaluate the relationship between existing comorbidities and the effectiveness of revascularization of asymptomatic critical internal carotid artery (ICA) stenosis treated with carotid endarterectomy (CEA) or carotid artery stenting (CAS) and short-term and long-term outcome in terms of health-related quality of life (HRQoL).

Material/Methods

Patients with asymptomatic critical ICA stenosis (n=62) included a group treated with CEA (n=31) and a group treated with CAS (n=31). A Health Assessment Questionnaire designed for this study was used to assess ten comorbidities, and the Short Form 36 Health Survey Questionnaire (SF-36) was used to evaluate HRQoL following CEA and CAS.

Results

Three comorbidities significantly influenced the effectiveness of revascularization in all patients studied who underwent CEA and CAS, which included symptomatic atherosclerosis in other vascular areas (p=0.048), coronary artery disease (CAD) (p=0.004), and previous myocardial infarction (MI) (p=0.004). In the CEA group, CAD and previous MI were significant comorbidities (p=0.002), when compared with the CAS group (p=0.635). In the CAS group, chronic obstructive pulmonary disease (COPD) was a significant comorbidity in terms of outcome (p=0.025).

Conclusions

The comorbidities of atherosclerotic vascular disease, CAD, and previous MI had a significant influence of the effectiveness of the revascularization and postoperative HRQoL in all patients studied with asymptomatic critical ICA stenosis who were treated with CEA and CAS. When the two groups were compared, CAD and previous MI were significant comorbidities in the CEA group, and COPD was a significant comorbidity in the CAS group.

Perioperative stroke: pathophysiology and management

Although perioperative stroke is uncommon during low-risk non-vascular surgery, if it occurs, it can negatively impact recovery from the surgery and functional outcome. Based on the Society for Neuroscience in Anesthesiology and Critical Care Consensus Statement, perioperative stroke includes intraoperative stroke, as well as postoperative stroke developing within 30 days after surgery. Factors related to perioperative stroke include age, sex, a history of stroke or transient ischemic attack, cardiac surgery (aortic surgery, mitral valve surgery, or coronary artery bypass graft surgery), and neurosurgery (external carotid-internal carotid bypass surgery, carotid endarterectomy, or aneurysm clipping). Concomitant carotid and cardiac surgery may further increase the risk of perioperative stroke. Preventive strategies should be individualized based on patient factors, including cerebrovascular reserve capacity and the time interval since the previous stroke.