Early and long-term outcomes after combined percutaneous revascularization in patients with carotid and coronary artery stenoses

Coexisting Coronary and Carotid Artery Disease - Which Technique and in Which Order? Case Report and Review of Literature

Coexisting carotid artery stenosis and coronary artery disease is common and there is currently no consensus in treatment guidelines on the timing, sequence and methods of revascularization. We report a case of a patient with symptomatic triple vessel coronary artery disease as well as asymptomatic severe right internal carotid artery stenosis. Our patient underwent myocardial revascularization first, because she presented with unstable angina and was asymptomatic neurologically. This article summarizes current literature about the approach to carotid and coronary artery revascularization and addresses the decision-making process regarding the timing and sequence of revascularization.

Long-Term Outcomes of Coronary and Carotid Artery Disease Revascularization in the FRIENDS Study

Objectives

The aim of this study is to assess long-term-outcomes of patients with concomitant CAD and COD treated with different revascularization strategies.

Background

Multisite artery disease is common and patients with combined disease have poor prognosis. The best therapeutic strategy for patients with concomitant carotid obstructive disease (COD) and coronary artery disease (CAD) remains controversial.

Methods

This observational registry enrolled, between January 2006 and December 2012, 1022 consecutive patients from high volume institutions with concomitant CAD and COD suitable for endovascular, surgical, or hybrid revascularization in both territories selected by consensus of a multidisciplinary team.

Results

The cumulative incidence of 5-year major cardiovascular events (MACCE) including cardiovascular death, myocardial infarction (MI), or stroke in the overall population was 12%. The incidence of 5-year MACCE was not statistically different in the surgical, endovascular, or hybrid patients group (10.1% vs. 13.0% vs. 13.2%, P = .257, respectively). However, the hybrid group exhibited rates of myocardial infarction, chronic kidney disease, and cumulative incidence of all clinical events higher than the surgical group. After propensity score matching, the incidence of 5-year MACCE was similar in the three groups (13.0% vs. 15.0% vs. 16.0%, p = .947, respectively).

Conclusions

An individualized revascularization approach of patients with combined CAD and COD yields very good results at long-term follow-up, despite the high risk of this multilevel population even when the baseline clinical features are equalized.

A prospective registry on carotid artery revascularisation selected by consensus of a cardiovascular team

AIMS

This prospective registry was designed to evaluate the early and long-term incidence of clinical events in patients with carotid obstructive disease (COD), after carotid artery revascularisation selected by consensus of a cardiovascular team.

METHODS AND RESULTS

403 consecutive patients with COD scheduled for carotid revascularisation were included: 130 were treated with carotid endarterectomy (CEA) and 273 with carotid artery stenting (CAS). Propensity score matching was performed to assemble a cohort of patients in whom all baseline covariates would be well balanced. The occurrence of major adverse cardiac and cerebrovascular events (MACCE), including any death, non-fatal myocardial infarction or stroke, was assessed at 30 days and at long-term follow-up. The incidence of MACCE at 30 days was 4.0% (95% confidence interval: 2.1 to 6.0), without any significant difference between the CAS and CEA groups in unmatched and matched populations. The cumulative freedom from MACCE at two-year follow-up was 80.5%±0.94%, with no statistically significant differences between the CAS and CEA groups, both in the total population and in the matched cohort.

CONCLUSIONS

In this registry of patients undergoing carotid artery revascularisation selected by consensus of a cardiovascular team, the early and long-term incidence of clinical events is up to standard.

Should patients with asymptomatic significant carotid stenosis undergo simultaneous carotid and cardiac surgery?

A best evidence topic in cardiovascular surgery was written according to a structured protocol. The question addressed was whether patients with severe asymptomatic carotid and coronary artery diseases should undergo simultaneous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG). A total of 624 papers were found using the reported search, of which 20 represent the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study results of these papers are tabulated. Previous cohort studies showed mixed results, while advocating for the necessity of a randomized controlled trial (RCT). A recent RCT showed that patients undergoing prophylactic or simultaneous CEA + CABG had lower rates of stroke (0%) compared with delayed CEA 1-3 months after CABG (7.7%), without significant perioperative mortality difference. This study included patients with unilateral severe (>70%) asymptomatic carotid stenosis requiring CABG. An earlier partly randomized trial also showed better outcomes for patients undergoing simultaneous procedures (P = 0.045). Interestingly, systematic reviews previously failed to show compelling evidence supporting prophylactic CEA. This could be partly due to the fact that these reviews collectively analyse different cohort qualities. Neurological studies have, however, shown reduced cognitive and phonetic quality and function in patients with unilateral and bilateral asymptomatic carotid artery stenosis. Twenty-one RCTs comparing lone carotid artery stenting (CAS) and CEA informed the American Heart Association guidelines, which declared CAS comparable with CEA for symptomatic and asymptomatic carotid stenosis (CS). However, the risk of death/stroke for CAS alone is double that for CEA alone in the acute phase following onset of symptoms, while CEA alone is associated with a doubled risk of myocardial infarction. There is, however, no significant difference for combined 30-day risk of death/stroke/myocardial infarction. Outcomes of hybrid or simultaneous CAS/CABG procedures show comparable results, albeit from rather small cohorts. While current evidence leans towards simultaneous CEA/CABG, the emergence of hybrid operating theatres in various institutions may allow larger cohorts with subsequent significant data on simultaneous CAS/CABG. A randomized controlled trial comparing both approaches would be crucial in informing future updates of existing guidelines.

Silent coronary artery disease in Japanese patients undergoing carotid artery stenting

BACKGROUND

The aim of this retrospective study was to determine the prevalence of silent coronary artery disease (CAD) and the risk factors associated with concomitant CAD in Japanese patients undergoing carotid artery stenting (CAS).

METHODS

The records of 112 consecutive patients (99 men and 13 women; mean age 70 ± 8 years) who underwent elective CAS at our institution for extracranial carotid artery stenosis between January 2006 and January 2011 were reviewed retrospectively. During this period, preoperative CAD screening by coronary angiography was performed in all patients. Patients were diagnosed with CAD when ≥ 1 coronary arteries had stenosis ≥ 75% and were classified into 2 groups: (1) a group with CAD that was based on preoperative coronary angiography or a history of percutaneous coronary intervention (PCI) and/or coronary artery bypass grafting (CABG), and (2) a group without CAD that had no angiographically documented stenosis ≥ 75%.

RESULTS

Sixteen (14.3%) patients had CAD that had already been treated by PCI and/or CABG. Silent CAD was detected in 39 (34.8%) of 112 patients. Taken together, 55 (49.1%) patients had clinically significant CAD. The patients with CAD were more likely to have diabetes mellitus (DM; P = .001), dyslipidemia (P = .013), and bilateral carotid disease (P = .033). Multivariate analysis revealed that DM (odds ratio 3.07; 95% confidence interval 1.25-7.53) and bilateral carotid stenosis (odds ratio 2.72; 95% confidence interval 1.10-6.75) were independent variables associated with concomitant CAD.

CONCLUSIONS

Perioperative CAD screening revealed that silent CAD was frequently diagnosed in Japanese patients scheduled for CAS, particularly in those with DM and/or bilateral carotid stenosis.

Management of combined severe carotid and coronary artery disease

Patients with severe carotid and coronary disease-especially if they require coronary artery bypass grafting (CABG)-are at high risk of cardiac events and stroke. Carotid revascularization should be considered for patients with symptomatic carotid disease and bilateral severe asymptomatic carotid stenosis. In patients with unilateral asymptomatic carotid stenosis, decision to proceed to revascularization should be based more on a perspective of long-term stroke prevention than of perioperative stroke reduction. Compared with endarterectomy, carotid artery stenting is associated with a lower incidence of periprocedural myocardial infarction, an event linked to long-term mortality. This observation may be particularly relevant for patients with advanced coronary artery disease such as those undergoing CABG. Irrespective of the carotid revascularization strategy, a broad disease management approach based on lifestyle modification and pharmacologic cardiovascular prevention is more likely to affect both the quality and duration of life than revascularization itself.

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.