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Hansen J, Cotter E. "Combined Coronary and Carotid Disease: What to Operate on First? Or Both at the Same Time?". J Cardiothorac Vasc Anesth 2024; 38:1425-1427. [PMID: 38641467 DOI: 10.1053/j.jvca.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/21/2024]
Affiliation(s)
- Jennette Hansen
- Department of Anesthesiology, University of Kansas Medical Center, 3901 Rainbow Blvd MS 1034, Kansas City, KS 66160
| | - Elizabeth Cotter
- Department of Anesthesiology, University of Kansas Medical Center, 3901 Rainbow Blvd MS 1034, Kansas City, KS 66160.
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Golukhova E, Sigaev I, Keren M, Slivneva I, Berdibekov B, Sheikina N, Kozlova O, Arakelyan V, Volkovskaya I, Zavalikhina T, Avakova S. Early and Long-Term Results of Simultaneous and Staged Revascularization of Coronary and Carotid Arteries. PATHOPHYSIOLOGY 2024; 31:210-224. [PMID: 38651405 PMCID: PMC11036243 DOI: 10.3390/pathophysiology31020017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/15/2024] [Accepted: 04/11/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Carotid artery disease is prevalent among patients with coronary heart disease. The concomitant severe lesions in the carotid and coronary arteries may necessitate either simultaneous or staged revascularization involving coronary bypass and carotid endarterectomy. However, there is presently a lack of consensus on the optimal choice of surgical treatment tactics for patients with significant stenoses in both carotid and coronary arteries. The aim of the current study was to compare the 30-day and long-term outcomes of coronary and carotid artery revascularization surgery based on the simultaneous or staged surgical tactics. MATERIAL AND METHODS This single-center retrospective study involved 192 patients with concurrent coronary artery disease and carotid artery stenosis ≥ 70%, of whom 106 patients underwent simultaneous intervention (CABG + CEA) and 86 patients underwent staged CABG/CEA. The mean time between stages ranged from 1 to 4 months (mean 1.88 ± 0.9 months). The endpoints included death from any cause, non-fatal stroke, non-fatal myocardial infarction (MI), and major adverse cardiovascular events (MACEs) (death + non-fatal MI + non-fatal stroke) within 30 days after the last intervention and in the long-term follow-up period (median follow-up-6 years). RESULTS The 30-day all-cause mortality, incidence of postoperative non-fatal MI, non-fatal stroke, and MACEs did not exhibit differences between the groups after single-stage and staged interventions. However, the overall risk of postoperative complications (adjusted for the risk of any complication per patient) (OR 2.214, 95% CI 1.048-4.674, p = 0.035), as well as the duration of ventilatory support (p = 0.004), was elevated in the group after simultaneous interventions compared with the staged intervention group. This difference did not result in an increased incidence of death and MACEs in the group after simultaneous interventions. In the long-term follow-up period, there were no significant differences observed when comparing simultaneous or staged surgical tactics in terms of overall survival (54.9% and 62.6% in Groups 1 and 2, respectively, P log-rank = 0.068), non-fatal stroke-free survival (45.6% and 33.6% in Groups 1 and 2, respectively, P log-rank = 0.364), non-fatal MI-survival (57.6% and 73.5% in Groups 1 and 2, respectively, P log-rank = 0.169), and MACE-free survival (7.1% and 30.2% in Groups 1 and 2, respectively, P log-rank = 0.060). The risk factors associated with an unfavorable outcome included age, smoking, BMI, LV EF, and atherosclerosis of the lower extremity arteries. CONCLUSIONS This study revealed no significant difference in the impact of simultaneous CABG + CEA or staged CABG/CEA on the incidence of death, stroke, MI, and MACEs over a 30-day and long-term follow-up period. Although the immediate results indicated an increased risk of a complicated course (attributable to overall complications) and more prolonged ventilation after simultaneous CABG + CEA compared with staged CABG/CEA, this did not lead to an increase in fatal complications. Therefore, the implementation of either tactic is considered eligible and appropriate following a thorough operative risk assessment.
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Affiliation(s)
| | | | - Milena Keren
- A.N. Bakulev National Medical Scientific Center for Cardiovascular Surgery, 121552 Moscow, Russia; (E.G.); (I.S.); (B.B.); (N.S.); (O.K.); (V.A.); (I.V.); (T.Z.); (S.A.)
| | - Inessa Slivneva
- A.N. Bakulev National Medical Scientific Center for Cardiovascular Surgery, 121552 Moscow, Russia; (E.G.); (I.S.); (B.B.); (N.S.); (O.K.); (V.A.); (I.V.); (T.Z.); (S.A.)
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Sung LC, Chang CC, Yeh CC, Cherng YG, Chen TL, Liao CC. How Long After Coronary Artery Bypass Surgery Can Patients Have Elective Safer Non-Cardiac Surgery? J Multidiscip Healthc 2024; 17:743-752. [PMID: 38404717 PMCID: PMC10887866 DOI: 10.2147/jmdh.s449614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/07/2024] [Indexed: 02/27/2024] Open
Abstract
Objective To evaluate the complications and mortality after noncardiac surgeries in patients who underwent previous coronary artery bypass grafting (CABG). Methods We used insurance data and identified patients aged ≥20 years undergoing noncardiac surgeries between 2010 and 2017 in Taiwan. Based on propensity-score matching, we selected an adequate number of patients with a previous history of CABG (within preoperative 24 months) and those who did not have a CABG history, and both groups had balanced baseline characteristics. The association of CABG with the risk of postoperative complications and mortality was estimated (odds ratio [OR] and 95% confidence interval [CI]) using multiple logistic regression analysis. Results The matching procedure generated 2327 matched pairs for analyses. CABG significantly increased the risks of 30-day in-hospital mortality (OR 2.28, 95% CI 1.36-3.84), postoperative pneumonia (OR 1.49, 95% CI 1.12-1.98), sepsis (OR 1.49, 95% CI 1.17-1.89), stroke (OR 1.53, 95% CI 1.17-1.99) and admission to the intensive care unit (OR, 1.75, 95% CI 1.50-2.05). The findings were generally consistent across most of the evaluated subgroups. A noncardiac surgery performed within 1 month after CABG was associated with the highest risk for adverse events, which declined over time. Conclusion Prior history of CABG was associated with postoperative pneumonia, sepsis, stroke, and mortality in patients undergoing noncardiac surgeries. Although we raised the possibility regarding deferral of non-critical elective noncardiac surgeries among patients had recent CABG when considering the risks, critical or emergency surgeries were not in the consideration of delay surgery, especially cancer surgery.
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Affiliation(s)
- Li-Chin Sung
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
- Department of General Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chuen-Chau Chang
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-Chieh Yeh
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
- Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Yih-Giun Cherng
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ta-Liang Chen
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Anesthesiology, Wang Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chien-Chang Liao
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Research Center of Big Data and Meta‑Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
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Gerfer S, Ivanov B, Krasivskyi I, Djordjevic I, Gaisendrees C, Avgeridou S, Kuhn-Régnier F, Mader N, Rahmanian P, Kröner A, Kuhn E, Wahlers T. Heart surgery and simultaneous carotid endarterectomy - 10-years single-center experience. Perfusion 2023; 38:1617-1622. [PMID: 35841145 DOI: 10.1177/02676591221114953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patients with coronary artery heart disease frequently suffer concomitant carotid vascular disease and are at high perioperative risk for neurological adverse events. Several concepts regarding the timing and modality of carotid revascularization are controversially discussed in patients with heart disease. Current guidelines recommendations on myocardial revascularization recommend a concomitant carotid endarterectomy (CEA) in patients with a history of stroke/transient ischemic attack (TIA) or 50-99% grade of the carotid stenosis. Our study aimed to analyze early outcome parameters of patients undergoing coronary artery bypass grafting (CABG), but also including concomitant heart valve surgery and simultaneous CEA. METHODS This study retrospectively analyzed a cohort of 111 patients from our institutional database undergoing heart surgery with CABG or heart-valve surgery between 2010 and 2020 with concomitant carotid surgery due to significant carotid stenosis. RESULTS Patients undergoing heart and simultaneous carotid surgery were 77 ± 8.0 years of age with a body mass index of 28 ± 1.7 kg/m2 and a mean EuroSCORE II of 6.5 ± 2.3. Most patients (61%) had a smoking history and arterial hypertension (97%). The preoperative mean grade of internal carotid stenosis was 87 ± 4.2%, 13% of patients suffered from internal carotid artery stenosis on both sites. In total, 4.5% of patients had previously undergone internal carotid artery intervention before and 6.3% had a history of stroke with a persistent neurologic disorder in 1.8%, 8.9% of cases had prior TIA. Thirty-day all-cause mortality was 6.3% and postoperative neurologic events occurred with 7.2% TIA and 4.5% of disabling stroke. CONCLUSION Within the reported patient population of coronary artery heart disease and significant internal carotid stenosis, a one-time approach with CABG or heart-valve surgery and CEA is safe and feasible as justified by clinical and neurological postoperative outcomes.
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Affiliation(s)
- Stephen Gerfer
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Ihor Krasivskyi
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Christopher Gaisendrees
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Soi Avgeridou
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Ferdinand Kuhn-Régnier
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Parwis Rahmanian
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Axel Kröner
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
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Gerfer S, Bennour W, Chigri A, Elderia A, Krasivskyi I, Großmann C, Gaisendrees C, Ivanov B, Avgeridou S, Eghbalzadeh K, Rahmanian P, Kuhn-Régnier F, Mader N, Djordjevic I, Sabashnikov A, Wahlers T. Major Adverse Cardiac and Cerebrovascular Events in Patients Undergoing Simultaneous Heart Surgery and Carotid Endarterectomy. J Cardiovasc Dev Dis 2023; 10:330. [PMID: 37623343 PMCID: PMC10455249 DOI: 10.3390/jcdd10080330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/13/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Patients with simultaneous relevant internal carotid artery stenosis and coronary artery heart or valve disease represent a high-risk collective with respect to cerebral or cardiovascular severe events when undergoing surgery. There exist several concepts regarding the timing and modality of carotid revascularization, which are controversially discussed in patients with heart disease. More data regarding outcome predictors and measures are needed to gain a better understanding of the best treatment option of the discussed patient collective. METHODS This single-center study retrospectively analyzed n = 111 patients undergoing heart surgery with coronary artery bypass grafting or heart-valve surgery and concomitant carotid surgery due to significant internal carotid artery stenosis. In order to do so, patients were divided into two groups with respect to postoperative major adverse cardiac and cerebrovascular events (MACCE) with thirty-day all-cause mortality, valve related mortality, myocardial infarction, stroke and transitory ischemic attack. RESULTS Preoperative patient's characteristic in the no-MACCE and MACCE group were mainly balanced, other than higher rates of chronic obstructive pulmonary disease, chronic kidney disease, instable angina pectoris and prior transitory ischemic attack in the MACCE cohort. The analysis of intraoperative characteristics revealed a higher number of intra-aortic balloon pump implantation, which is in line for a higher number of postoperative supports. Besides MACCE, patients suffered significantly more often from postoperative bleeding events and re-thoracotomy, cardiopulmonary reanimation, new onset postoperative dialysis and prolonged intensive care unit stay related complications. CONCLUSIONS Within the reported patient population suffering from MACCE after a simultaneous carotid endarterectomy and heart surgery, a preoperative history of transitory ischemic attack and kidney disease might account for worse outcomes, as severe events were not only neurologically driven but also associated with postoperative cardiovascular complications following heart surgical procedures.
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Affiliation(s)
- Stephen Gerfer
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, 50937 Cologne, Germany (A.E.); (S.A.)
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Haywood NS, Ratcliffe SJ, Zheng X, Mao J, Farivar BS, Tracci MC, Malas MB, Goodney PP, Clouse WD. Operative and long-term outcomes of combined and staged carotid endarterectomy and coronary bypass. J Vasc Surg 2023; 77:1424-1433.e1. [PMID: 36681256 PMCID: PMC10353412 DOI: 10.1016/j.jvs.2023.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/31/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Optimal temporal surgical management of significant carotid stenosis and coronary artery disease remains unknown. Carotid endarterectomy (CEA) and coronary artery bypass (CABG) are performed concurrently (CCAB) or in a staged (CEA-CABG or CABG-CEA) approach. Using the Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network-Medicare-linked dataset, this study compared operative and long-term outcomes after CCAB and staged approaches. METHODS The Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network dataset was used to identify CEAs from 2011 to 2018 with combined CABG or CABG within 45 days preceding or after CEA. Patients were stratified based on concurrent or staged approach. Primary outcomes were stroke, myocardial infarction (MI), all-cause mortality, stroke and death as composite (SD) and all as composite within 30 days from the last procedure as well as in the long term. Univariate analysis and risk-adjusted analysis using inverse propensity weighting were performed. Kaplan-Meier curves of stroke, MI, and death were created and compared. RESULTS There were 1058 patients included: 643 CCAB and 415 staged (309 CEA-CABG and 106 CABG-CEA). Compared with staged patients, those undergoing CCAB had a higher preoperative rate of congestive heart failure (24.8% vs 18.4%; P = .01) and decreased renal function (14.9% vs 8.5%; P < .01), as well as fewer prior neurological events (23.5% vs 31.4%; P < .01). Patients undergoing CCAB had similar weighted rate of 30-day stroke (4.6% vs 4.1%; P = .72), death (7.0% vs 5.0%; P = .32), and composite outcomes (stroke and death, 9.8% vs 8.5%; P = .56; stroke, death, and MI, 14.7% vs 17.4%; P = .31), but a lower weighted rate of MI (5.5% vs 11.5%; P < .01) vs the staged cohort. Long-term adjusted risks of stroke (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.54-1.36; P = .51) and mortality (HR, 1.02; 95% CI, 0.76-1.36; P=.91) were similar between groups, but higher risk of MI long-term was seen in those staged (HR, 1.49; 95% CI, 1.07-2.08; P = .02). CONCLUSIONS In patients undergoing CCAB or staged open revascularization for carotid stenosis and coronary artery disease, the staged approach had an increased risk of postoperative cardiac event, but the short- and long-term rates of stroke and mortality seem to be comparable. Adverse cardiovascular event risk is high between operations when staged and should be a consideration when selecting an approach. Although factors leading to staged sequencing performance need further clarity, CCAB seems to be safe and should be considered an equally reasonable option.
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Affiliation(s)
- Nathan S Haywood
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Sarah J Ratcliffe
- Department of Biostatistics, University of Virginia, Charlottesville, VA
| | - Xinyan Zheng
- Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Jialin Mao
- Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Behzad S Farivar
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Margaret C Tracci
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Mahmoud B Malas
- Department of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Philip P Goodney
- Department of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - W Darrin Clouse
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
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Kandimalla J, Hussain Z, Piriyawat P, Rodriguez G, Maud A, Khatri R, Cruz-Flores S, Vellipuram AR. Stroke Rates Following Surgical Versus Percutaneous Revascularization for Ischemic Heart Disease. Curr Cardiol Rep 2021; 23:45. [PMID: 33721116 DOI: 10.1007/s11886-021-01471-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Coronary revascularization is a commonly performed major procedure in the hospitals. Stroke is one of the dreaded complications after coronary revascularization procedures. The focus of this review is to understand the stroke risk in percutaneous cutaneous intervention (PCI) and coronary artery bypass grafting (CABG) procedures. RECENT FINDINGS Available data show that PCI offers less procedural stroke risk compared to CABG although the survival benefits of CABG are better in certain scenarios. Innovative advancements in techniques, pre-procedural optimum medical therapy (OMT), intraoperative neuro-monitoring, and multidisciplinary post procedural care are the few strategies in early detection and reduce stroke risk. Despite several innovations and strategies, it is evident that there is not enough data available to make concrete conclusions related to stroke risk after coronary revascularization, which warrants further investigation.
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Affiliation(s)
- Jithendhar Kandimalla
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA
| | - Zain Hussain
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA
| | - Paisith Piriyawat
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA
| | - Gustavo Rodriguez
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA
| | - Rakesh Khatri
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA
| | - Salvador Cruz-Flores
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA
| | - Anantha R Vellipuram
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA.
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Clouse WD. Reply. J Vasc Surg 2020; 72:2214-2215. [PMID: 33222826 DOI: 10.1016/j.jvs.2020.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/17/2020] [Indexed: 10/22/2022]
Affiliation(s)
- W Darrin Clouse
- Division of Vascular & Endovascular Surgery, University of Virginia Health System, Charlottesville, Va
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9
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Furlanetto ML, Chagas EFB, SLM P. Atherosclerotic Extension of Carotid Arteries: An Insertion in Clinical Practice. Int J Vasc Med 2020; 2020:3120327. [PMID: 32655952 PMCID: PMC7330634 DOI: 10.1155/2020/3120327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 04/21/2020] [Accepted: 05/08/2020] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
| | - E. F. B. Chagas
- Faculdade de Medicina de Marília, Marília, São Paulo, Brazil
| | - Payão SLM
- Faculdade de Medicina de Marília, Marília, São Paulo, Brazil
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10
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Williams Z, Olivere LA, Gilmore B, Weissler H, Cox MW, Long C, Shortell CK, Schroder J, Southerland KW. Safety and Feasibility of Simultaneous Transcarotid Revascularization With Flow Reversal and Coronary Artery Bypass Grafting for Concomitant Carotid Artery Stenosis and Coronary Artery Disease. Vasc Endovascular Surg 2020; 54:395-399. [PMID: 32319354 DOI: 10.1177/1538574420918971] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The management of patients with combined severe carotid artery and coronary artery disease (CAD) is controversial. Transcarotid stenting with flow reversal (TCAR) is a novel hybrid technique for carotid revascularization. We sought to investigate the safety and feasibility of simultaneous TCAR and coronary artery bypass grafting (CABG) for concomitant carotid and CAD. METHODS A single-institution, retrospective study of patients with critical carotid artery stenosis and symptomatic CAD who underwent simultaneous TCAR-CABG was completed. The primary outcomes were technical success, perioperative stroke, death, and hemorrhage. RESULTS Four patients underwent TCAR-CABG. All patients were male with a mean age of 64. Technical success was achieved in all cases. There were no perioperative strokes or deaths. There were no reexplorations for hemorrhage. CONCLUSIONS Transcarotid stenting with flow reversal-CABG is a technically feasible hybrid approach for simultaneous carotid and coronary revascularization. It should be part of the vascular surgeon's armamentarium for coexisting carotid and coronary disease. Further research focused on patient selection and perioperative antiplatelet management is warranted prior to the widespread adoption of this technique.
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Affiliation(s)
- Zachary Williams
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Brian Gilmore
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Hope Weissler
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mitchell W Cox
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Chandler Long
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Jacob Schroder
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Levin SR, Farber A, Goodney PP, Schermerhorn ML, Patel VI, Arinze N, Cheng TW, Jones DW, Rybin D, Siracuse JJ. Shunt intention during carotid endarterectomy in the early symptomatic period and perioperative stroke risk. J Vasc Surg 2020; 72:1385-1394.e2. [PMID: 32035768 DOI: 10.1016/j.jvs.2019.11.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/21/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Whether recent stroke mandates planned shunting during carotid endarterectomy (CEA) is controversial. Our goal was to determine associations of various shunting practices with postoperative outcomes of CEAs performed after acute stroke. METHODS The Vascular Quality Initiative database (2010-2018) was queried for CEAs performed within 14 days of an ipsilateral stroke. Surgeons who prospectively planned to shunt either shunted routinely per their usual practice or shunted selectively for preoperative indications. Surgeons who prospectively planned not to shunt either shunted selectively for intraoperative indications or did not shunt. Univariable and multivariable analyses compared shunting approaches. RESULTS There were 5683 CEAs performed after acute ipsilateral stroke. Surgeons planned to shunt in 56.1% of cases. Patients whose surgeons planned to shunt vs planned not to shunt were more likely to have severe contralateral stenosis (8.8% vs 6.9%; P = .008), to receive general anesthesia (97.5% vs 89.1%; P < .001), and to undergo conventional CEA (94% vs 81.8%; P < .001). Unadjusted outcomes were similar between the cohorts for operative duration (124.3 ± 48.1 minutes vs 123.6 ± 47 minutes; P = .572) and 30-day stroke (3.4% vs 3%; P = .457), myocardial infarction (1.1% vs 0.8%; P = .16), and mortality (1.6% vs 1.3%; P = .28). On multivariable analysis, planning to shunt vs planning not to shunt was associated with similar risk of 30-day stroke (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.82-1.67; P = .402). On subgroup analysis, in 38.4% patients, no shunt was placed, whereas the remainder received routine shunts (44.4%), preoperatively indicated shunts (11.6%), and intraoperatively indicated shunts (5.5%). Compared with no shunting, shunting by surgeons who routinely shunt was associated with a similar stroke risk (OR, 1.39; 95% CI, 0.91-2.13; P = .129), but shunting by surgeons who selectively shunt on the basis of preoperative indications (OR, 2.11; 95% CI, 1.22-3.63; P = .007) or intraoperative indications (OR, 3.34; 95% CI, 1.86-6.01; P < .001) was associated with increased stroke risk. Prior coronary revascularization independently predicted increased intraoperatively indicated shunting (OR, 1.37; 95% CI, 1.05-1.8; P = .022). CONCLUSIONS In CEAs performed after acute ipsilateral stroke, there is no difference in postoperative stroke risk when surgeons prospectively plan to shunt or not to shunt. Shunting is often not necessary; however, when shunting is performed, routine shunters achieve better outcomes.
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Affiliation(s)
- Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, New York, NY
| | - Nkiruka Arinze
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Denis Rybin
- Department of Biostatistics, Boston University School of Public Health, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
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Paraskevas KI. Carotid artery stenting versus carotid endarterectomy for patients requiring combined carotid and coronary revascularization procedures. J Vasc Surg 2019; 70:1727. [PMID: 31653391 DOI: 10.1016/j.jvs.2019.04.450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/11/2019] [Indexed: 11/25/2022]
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Wang LJ, Mohebali J, Goodney PP, Patel VI, Conrad MF, Eagleton MJ, Clouse WD. The effect of clinical coronary disease severity on outcomes of carotid endarterectomy with and without combined coronary bypass. J Vasc Surg 2019; 71:546-552. [PMID: 31401112 DOI: 10.1016/j.jvs.2019.03.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 03/26/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The management of patients with carotid stenosis and symptomatic coronary artery disease (CAD) is challenging. This study assessed the impact of clinical coronary disease severity on carotid endarterectomy (CEA) with and without combined coronary artery bypass (CCAB). METHODS Using the Vascular Quality Initiative, patients with symptomatic CAD who underwent CCAB or isolated CEA (ICEA) from 2003 to 2017 were identified. Patients were stratified by CAD severity: stable angina (SA) and recent myocardial infarction/unstable angina (UA). Primary outcomes, including perioperative stroke, myocardial infarction (MI), and stroke/death/MI (SDM), were assessed between procedures within each CAD cohort. RESULTS There were 9098 patients identified: 887 CCAB patients (215 [24%] SA, 672 [76%] UA) and 8211 ICEA patients (6385 [78%] SA, 1826 [22%] UA). Overall, CCAB patients had higher rates of stroke (2.6% vs 1.3%; P = .002) and SDM (7.3% vs 3.5%, P < .001) but similar rates of MI (0.9% vs 1.6%; P = .12) compared with ICEA patients. In SA patients, no difference was seen in stroke (ICEA 1.2% vs CCAB 1.9%; P = .36), MI (1.3% vs 1.4%; P = .95), or SDM (2.9% vs 4.7%; P = .13). In UA patients, no difference was seen in stroke (ICEA 1.6% vs CCAB 2.8%; P = .06), but ICEA patients had higher rates of MI (2.4% vs 0.7%; P = .01) and CCAB patients had higher rates of SDM (8.2% vs 5.5%; P = .01). After logistic regression in the UA cohort, predictors of MI included ICEA (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.1-7.0; P = .04) and carotid symptomatic status (OR, 2.1; 95% CI, 1.1-3.8; P = .01); carotid symptomatic status also predicted stroke (OR, 2.0; 95% CI, 1.1-3.6; P = .03), but CCAB did not. CONCLUSIONS In patients with symptomatic CAD, both clinical CAD severity and operative strategy affect outcomes. In SA patients, CCAB does not increase perioperative morbidity. However, CCAB in UA patients prevents MI while not appreciably increasing stroke risk. This suggests that coronary revascularization before or concomitant with CEA should be considered in UA patients but that prioritizing coronary intervention is less important in SA patients.
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Affiliation(s)
- Linda J Wang
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, New York, NY
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
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