Early results of percutaneous intervention for severe coexisting carotid and coronary artery disease

Carotid Restenosis Rate After Stenting for Primary Lesions Versus Restenosis After Endarterectomy With Creation of Risk Index

PURPOSE

Carotid artery stenting (CAS) is an option for carotid restenosis (CR) treatment with favorable outcomes. However, CAS has also emerged as an alternative to carotid endarterectomy (CEA) for the management of patients with primary carotid stenosis. This study aimed to report CR rates after CAS was performed in patients with primary lesions versus restenosis after CEA, to identify predictors of CR, and to report both neurological and overall outcomes.

MATERIALS AND METHODS

From January 2000 to September 2018, a total of 782 patients were divided into 2 groups: The CAS (prim) group consisted of 440 patients in whom CAS was performed for primary lesions, and the CAS (res) group consisted of 342 patients with CAS due to restenosis after CEA. Indications for CAS were symptomatic stenosis/restenosis >70% and asymptomatic stenosis/restenosis >85%. A color duplex scan (CDS) of carotid arteries was performed 6 months after CAS, after 1 year, and annually afterward. Follow-up ranged from 12 to 88 months, with a mean follow-up of 34.6±18.0 months.

RESULTS

There were no differences in terms of CR rate between the patients in the CAS (prim) and CAS (res) groups (8.7% vs 7.2%, χ²=0.691, p=0.406). The overall CR rate was 7.9%, whereas significant CR (>70%) rate needing re-intervention was 5.6%, but there was no difference between patients in the CAS (prim) and CAS (res) groups (6.4% vs 4.7%, p=0.351). Six independent predictors for CR were smoking, associated previous myocardial infarction and angina pectoris, plaque morphology, spasm after CAS, the use of FilterWire or Spider Fx cerebral protection devices, and time after stenting. A carotid restenosis risk index (CRRI) was created based on these predictors and ranged from -7 (minimal risk) to +10 (maximum risk); patients with a score >-4 were at increased risk for CR. There were no differences in terms of neurological and overall morbidity and mortality between the 2 groups.

CONCLUSIONS

There was no difference in CR rate after CAS between the patients with primary stenosis and restenosis after CEA. A CRRI score >-4 is a criterion for identifying high-risk patients for post-CAS CR that should be tested in future randomized trials.

Association between circle of Willis and ischemic stroke: a systematic review and meta-analysis

Background

Circle of Willis is the main structure that provides constant and regular blood flow to the brain, protects the brain from ischemia. Stroke has remained the second leading cause of death globally in the last fifteen years. It is the fifth leading cause of death in the United States. It is also the leading cause of serious adult disability. Interlinked problems related to ischemic stroke are become increasing nowadays. Strong evidence is needed about the pooled measure of association between the circle of Willis (COW) and ischemic stroke. Therefore, this systematic review and meta-analysis were intended to provide compressive and up to date evidence on the association between the variations of COW and ischemic stroke using the available studies.

Methods

PubMed, Google Scholar, Science Direct, and Cochrane Library databases were systematically searched. All essential data were extracted using a standardized data extraction template. The heterogeneity across studies was assessed by using the Cochrane Q test statistic, I² test statistic, and P-values. A fixed-effect model was used to estimate the pooled effect of the measure association between COW and ischemic stroke.

Results

In this meta-analysis, 2,718 participants were involved. The pooled measure of association between COW and ischemic stroke was 1.38 (95% CI 0.87, 2.19). Therefore, this indicated that the presence of any variation in COW was 1.38 times more likely to develop ischemic stroke as compared to the patent COW. The presence of hypoplasia/incompleteness in a posterior communicating artery (PcomA) [Pooled OR: 1.34 (95% CI 0.80, 2.25)] and anterior communicating artery (AcomA) [Pooled OR: 1.32 (95% CI 0.81, 2.19)] were a contributing factor for the development of ischemic stroke. Hypertension was the most common comorbid condition, followed by diabetes mellitus, smoking, coronary artery disease, and hyperlipidemia.

Conclusions

There was a non-significant positive association between COW variation and ischemic stroke in this meta-analysis.

Long-Term Outcome After Carotid Endarterectomy in Patients with Ischemic Heart Disease

BACKGROUND

The long-term outcome after carotid endarterectomy (CEA) is determined by many confounding factors. Ischemic heart disease (IHD) is linked to atherosclerotic stroke, and it is an important cause of death during the perioperative and follow-up periods after CEA. We aimed to investigate mortality and long-term major adverse cardiovascular events (MACEs) in patients with IHD compared with patients who do not have IHD.

METHODS

We consecutively enrolled 229 patients who underwent CEA procedures from 2000 to 2011. Of these patients, 45 had known or probable IHD defined by history or medical record of myocardial infarction, stable/unstable angina, previous coronary revascularization such as percutaneous coronary intervention or coronary artery bypass graft, or positive stress test. Long-term outcome was identified by using death certificates from the Korean National Statistical Office and telephone interviews by June 2013. We investigated predictors of early (≤30 days) and long-term mortality and MACEs (stroke, myocardial infarction, and death).

RESULTS

Mean follow-up period was 49 months. Cox proportional analysis adjusted for potent predictors revealed symptomatic stenosis (hazard ratio, 1.72; 95% confidence interval, 1.02-2.88; P = 0.042) and presence of IHD (hazard ratio, 1.93; 95% confidence interval, 1.09-3.42; P = 0.025) as significant predictors of long-term MACEs. Kaplan-Meier analysis showed a significantly lower rate of survival (P = 0.030) and MACE-free survival (P = 0.003) in the IHD group.

CONCLUSIONS

In this study, a poor long-term outcome was observed in patients with IHD and symptomatic stenosis but not in patients with conventional high-risk factors for surgery. Therefore, appropriate evaluation and treatment of IHD before and after CEA might be helpful for better outcome.

Low prevalence of collateral cerebral circulation in the circle of Willis in patients with severe carotid artery stenosis and recent ischemic stroke

INTRODUCTION

The circle of Willis is thought to play a key role in development of collateral flow in patients with internal carotid artery stenosis (ICAS).

AIM

To assess flow in the circle of Willis in patients with recent ischemic stroke (IS).

MATERIAL AND METHODS

The study included 371 patients, 102 symptomatic with severe ICAS and recent IS (within the last 3 months) (group I) and 269 asymptomatic with severe ICAS (group II). Flow in the middle (MCA), anterior (ACA) and posterior (PCA) cerebral arteries and pattern of the cross-flow through anterior (ACoA) and posterior (PCoA) communicating arteries were assessed with transcranial color-coded Doppler ultrasonography (TCCD).

RESULTS

The ACoA or PCoA was less prevalent in group I than in group II (54% vs. 78%, p < 0.001 and 20% vs. 42%, p < 0.001, respectively), resulting in lower peak-systolic velocity (PSV) in the MCA in group I vs. group II (p = 0.015). Any collateral pathway was present in 67% of patients in group I, compared to 86% in group II (p < 0.001). Both PSV and end-diastolic (EDV) flow velocity in the ACA were lower in patients with recent IS, compared to asymptomatic subjects (71 ±24 cm/s vs. 86 ±34 cm/s, p < 0.001 and 32 ±12 cm/s vs. 37 ±17 cm/s, p = 0.038, respectively). Presence of ACoA or PCoA and higher PSV in the MCA and ACA were associated with significant risk reduction of IS (RR = 0.28 (95% CI = 0.16-0.49, p < 0.001), RR = 0.28 (95% CI = 0.15-0.52, p < 0.001), RR = 0.97 (95% CI = 0.96-0.99, p < 0.001), RR = 0.99 (95% CI = 0.98-0.99, p < 0.032), respectively). However, ROC curves failed to show reliable MCA or ACA PSV cut-offs for IS risk assessment.

CONCLUSIONS

The ACoA and PCoA seem to play a key role in the evaluation of IS risk in subjects with severe ICAS.

Simultaneous stenting of the left main coronary stem and internal carotid artery in a hemodynamically unstable patient

INTRODUCTION

Combined endovascular interventions on carotid and coronary arteries are rare. Stenting of the unprotected coronary left main stem is a high risk procedure. We presented hemodynamically unstable patient with combined carotid artery and left main stem coronary artery stenting.

CASE REPORT

A 78-year-old female patient was admitted to our institution for right carotid endaterectomy. The patient had 80% stenosis of the right carotid artery and occlusion of the left carotid artery. Coronary angiography revealed 70% ostial left main stenosis, occlusion of the right coronary artery and the left circumflex artery, and 80% stenosis of the left anterior descending artery. Simultaneous carotid artery endaterectomy and coronary artery by-pass grafting were considered. Due to high perioperative risk, surgery was rejected, and the patient was treated endovascularly with stenting of arteries occluded. The procedure was completed without complications and the patient was hemodynamically stabilised.

CONCLUSION

This report illustrates simultaneous coronary and carotid stenting as a successfull lifesaving procedure.

Determinants of embolic risk during angioplasty and stenting: neurologic symptoms and coronary artery disease increase embolic risk

BACKGROUND

Carotid angioplasty and stenting (CAS) has proven to be a potential alternative to carotid endarterectomy in the treatment of severe carotid disease. Patient selection has emerged as a means of optimizing the outcomes of CAS.

OBJECTIVE

To determine whether the presence of preprocedural neurologic symptoms and having a history of coronary artery disease (CAD) are associated with greater embolic risk during CAS through analysis of the embolic debris captured within protective filters.

METHODS

A total of 233 consecutive CAS procedures were performed between 2003 and 2009. Particles of embolic debris within the filters were quantified by photomicroscopy and video imaging software. Particulate size was determined by measuring the length along the longest axis. Preprocedural neurologic symptoms included transient ischemic attack, cerebrovascular accident, and amaurosis fugax. History of CAD included prior myocardial infarction, coronary artery bypass grafting, congestive heart failure, or abnormal stress test.

RESULTS

Of the 137 (58.8%) filters that were analyzed (mean age, 71.3 ± 9.1 years, 56.9% male), 52 (38.0%) and 80 (58.4%) filters were from symptomatic and CAD patients, respectively. Filters of symptomatic (S) patients contained both a greater number and larger mean particle size compared with those of asymptomatic (AS) patients (S: 15.8 ± 13.5 particles vs. AS: 9.8 ± 8.7 particles, P = 0.002; S: 507 ± 389 μm vs. AS: 398 ± 181 μm, P = 0.03; respectively). Filters from CAD patients also had a greater number of particles, but trended toward smaller minimum size than those in non-CAD patients (CAD: 14.4 ± 12.8 particles vs. non-CAD: 8.8 ± 7.4 particles, P = 0.002; CAD: 167 ± 172 μm vs. 228 ± 203 μm, P = 0.06).

CONCLUSIONS

These findings suggest that the presence of preprocedural neurologic symptoms and a history of CAD are associated with increased embolization during CAS. Therefore, the benefit of carotid stenting should be tempered by the potential for increased perioperative events in both symptomatic and CAD patients.

The brain first or the heart: the approach to revascularizing severe co-existing carotid and coronary artery disease

Combined symptomatic severe cerebralvascular disease and significant obstructive coronary artery disease frequently exist. For the past few decades, clinicians have debated the various treatment strategies for these high-risk patients including staged procedures and hybrid revascularization. While some recommend addressing the more unstable vascular territory first, others prefer to intervene on the carotids prior to performing coronary revascularization. Both surgical and percutaneous options have been explored in various clinical settings, but there are no treatment guidelines to date. Given the frequency and magnitude of this problem, we performed an extensive review of the literature in an attempt to add some much needed clarity. An illustrative case and recommendations are provided.

Procedural outcome and midterm result of carotid stenting in high-risk patients

Carotid endarterectomy is the standard treatment for carotid stenosis, but carotid artery stenting has emerged as a potential alternative. Elective carotid artery stenting was performed in 42 patients aged 42 to 79 years (mean, 67.05 +/- 8.67 years) after ultrasonography, computed tomography, magnetic resonance angiography and a neurological evaluation. There was bilateral carotid stenosis in 23 patients (55%), with > 90% stenosis in 18 vessels. All patients had significant associated coronary lesions. An emboli protection device and self-expanding stents were used. One year later, the patients were evaluated by Doppler sonography and selective angiography. Technical success was achieved in all procedures. During follow-up, 1 (2.4%) patient died from myocardial infarction, 1 underwent coronary artery bypass and 14 (40%) had minor complaints including occasional dizziness. No other neurological events were noted. Restenosis was found in one case, but selective angiography ruled out a significant lesion. One patient suffered embolization, but recovered completely within 24 hours. In 7 (17%) patients with type C arch interruption and a tortuous carotid course, stenting was successful and they had no embolization or restenosis. Carotid artery stenting is recommended in high-risk patients.

Stent-supported angioplasty versus endarterectomy for carotid artery stenosis: evidence from current randomized trials

BACKGROUND

Carotid artery stenting (CAS) for carotid artery stenoses is evolving as an alternative to carotid endarterectomy (CEA). However, the value of CAS is still a matter of debate. Therefore, we performed a metaanalysis of the randomized controlled clinical trials (RCT) on this issue.

METHODS

RCTs were identified through searching MEDLINE, textbooks and by personal communication.

RESULTS

Six finished RCTs on this issue could be identified, including 1263 patients, 628 randomized to CAS and 635 to CEA. The 30-day death or stroke rate was 8.0% (50/628) in patients treated with CAS compared to 6.1% (39/635) in CEA patients (OR=1.36, 95% CI: 0.88-2.11; p=0.17; p for heterogeneity=0.009). The rate of cranial nerve palsy was 7.1% in the CEA compared to 0% in the CAS group (p<0.0001). The rate of myocardial infarctions was reduced from 3.1 to 1% (OR=0.32, 95% CI: 0.12- 0.81; p=0.02; p for heterogeneity=0.49). The death or stroke rate during follow-up was 12.1% in patients treated with CAS compared to 12.2% in CEA patients (OR=0.99, 95% CI: 0.70-1.42; p=0.98; p for heterogeneity=0.02).

CONCLUSION

The available RCT data on CAS vs. CEA suggest that both methods seem to be equally effective concerning short- and medium-term results, while CAS is associated with lower minor complications than CEA. However, because of the significant heterogeneity between the study outcomes, the results of the large RCTs underway should be awaited before it can be advised to use CAS in a broader perspective.

Coronary angiography in patients undergoing carotid artery stenting shows a high incidence of significant coronary artery disease

OBJECTIVE

To assess the incidence, morphology, and associated clinical symptoms of coronary artery disease in patients undergoing elective carotid artery stenting.

METHODS

In a prospective observational study at a tertiary care centre (university teaching hospital) 444 consecutive patients underwent elective stenting of the carotid artery. Twenty four patients had to be ruled out because of urgent carotid intervention for severe neurological symptoms, lack of compliance, complications from vascular puncture, or renal failure. In 390 patients, the coronary angiography was performed together with carotid artery stenting in a single session; the remaining 30 patients have had a recent coronary angiography.

RESULTS

One, two, and three vessel disease and left main stenoses were found in 70 (17%), 64 (15%), 93 (22%), and 31 (7%) patients, respectively. Sixty six (16%) patients had a history of coronary artery disease but no current significant stenosis. Only 39% of the patients with significant stenoses (n = 258) had clinical cardiac symptoms.

CONCLUSIONS

For patients undergoing elective stenting of the carotid, routine coronary angiography reliably discloses morphologically significant coronary artery disease and enables consecutive treatment in 61% and 29%. This safe measure is useful because a majority of patients with a significant stenosis are asymptomatic.

Association of increased carotid intima-media thickness with the extent of coronary artery disease

OBJECTIVE

To investigate (a) the relation between intima-media thickness (IMT) in carotid arteries and the extent of coronary artery disease (CAD); and (b) whether IMT is predictive of coronary atherosclerosis. The coexistence of severe extracranial atherosclerosis in patients with CAD was also analysed.

METHODS

Coronary angiography and carotid ultrasound evaluation were performed in 558 consecutive patients (438 men), with a mean (SD) age of 58.8 (9.2) years and suspected CAD. Mean IMT was measured at both carotid arteries and expressed as the mean aggregate value. The relation between IMT and severity of CAD was determined.

RESULTS

A significant correlation between mean IMT and advancing CAD (p < 0.0001) was found. Four independent predictors of CAD were found in the discriminant analysis: age (p = 0.0193), hyperlipidaemia (p < 0.0001), smoking (p = 0.0032), and IMT (p < 0.0001). A significant increase in IMT was observed among patients with one, two, and three vessel CAD. A log normal distribution of IMT values showed that if mean IMT was over 1.15 mm, patients had a 94% probability of having CAD, with sensitivity of 65% and specificity of 80% in the patients with a high risk of CAD. The number of critically stenosed extracranial arteries increased with advancing CAD. None of the patients with normal coronary arteries had severe stenosis of the extracranial arteries. Severe carotid, vertebral, or subclavian stenosis was found in 16.6% of patients with three vessel CAD.

CONCLUSIONS

IMT increases with advancing CAD, patients with mean IMT over 1.15 mm have a 94% likelihood of having CAD, and the coexistence of CAD with severe stenosis of aortic arch arteries is relatively high and was found in 16.6% of patients with three vessel CAD.

Simultaneous stenting of the carotid artery and other coronary or extracoronary arteries: does a combined procedure increase the risk of interventional therapy?

Simultaneous interventions in carotid and other extracarotid arteries are not performed on a routine basis up to now. In 67 out of 295 consecutive patients (23%) undergoing elective stenting of the internal carotid artery, additional interventions in the coronary arteries (n = 65), the iliac artery (n = 3), renal artery (n = 1), left subclavian artery (n = 3), vertebral artery (n = 4), or a combination thereof were performed. Primary stenting was done in 51 (74%) out of 69 carotid arteries, in 48 (74%) of 65 coronary arteries, and in 10 (91%) of 11 other targeted vessels. Neurological complications consisted of two (2.9%) transient ischemic attacks and one (1.5%) minor stroke. In addition, one (1.5%) myocardial infarction occurred during coronary artery intervention. In comparison, 16 (6.6%) transient ischemic attacks, 1 minor stroke (0.4%), 5 (2.2%) major strokes, and 3 (1.2%) deaths were observed in 228 patients without combined procedures. Simultaneous percutaneous interventions including carotid arteries and other extracarotid arteries are feasible, relatively safe, and cost-effective.

Feasibility of simultaneous bilateral carotid artery stenting

Due to the progressive aging of the population, severe bilateral carotid stenosis has become a more frequent condition. On occasion, simultaneous revascularization may be appropriate. There is increased evidence that for these high-risk patients, a percutaneous revascularization may be the best approach. However, there are concerns that simultaneous bilateral carotid stenting may be associated with cerebral hyperperfusion, excessive bradycardia, and hypotension. We report a series of 10 consecutive patients who underwent simultaneous bilateral carotid stenting. All of these patients were not deemed to be surgical candidates due to high-risk comorbidities. All but one of the lesions were successfully stented. There were no procedural deaths, myocardial infarctions, or strokes. Thus, among carefully selected patients, simultaneous bilateral carotid artery stenting is a promising, technically feasible option.

Operative management of carotid artery in-stent restenosis: first experiences and duplex follow-up

OBJECTIVES

Carotid Artery Stenting (CAS) may be comparable to Carotid Endarterectomy (CEA) as a durable and effective procedure in stroke prevention. Concern remains about the incidence of restenosis after stenting and its management. We evaluated the surgical management of restenosis after CAS.

DESIGN

prospective study.

METHODS

between December 1997 and April 2001, 217 CAS procedures were performed in 217 patients (155 men and 62 women; age 70 years +/- 8.2). After a mean of 8 months post-stenting four patients (two symptomatic, two asymptomatic with contralateral occlusion) with severe haemodynamic in-stent restenosis (90-99%) had surgical reintervention.

RESULTS

standard CEA with removal of the stent was performed in all four patients. No major complications occurred. Intima hyperplasia showed to be the predominant mechanism leading to in-stent restenosis. All four surgically treated patients remained asymptomatic and without recurrent restenosis over a mean follow-up time of 13 months (range 3-20 months).

CONCLUSION

the optimal treatment of in-stent restenosis has yet to be defined, but standard CEA with removement of the stent appears to be feasible.

Controversies in carotid stenting

Endovascular therapies are now commonly used in many vascular sites. However, the role for carotid angioplasty and stenting (CAS) remains an unproven therapy with some potential benefits. Initial results of CAS were worse than the surgical standard of carotid endarterectomy (CEA) and did not meet American Heart Association guidelines. However, recent improvements have resulted in improved stroke morbidity rate that may approach that of CEA. Specifically, the embolic problem associated with CAS has been reduced with embolic protection devices, but the ultimate effect of these protection devices remains uncertain. Initial comparison studies of CAS to CEA showed an unacceptably high stroke morbidity rate in the CAS group. As a result, multiple randomized clinical trials have been initiated to compare the results of CAS with embolic protection to that of CEA. While these studies are underway, the authors advocate a careful application of CAS to be used as a complementary tool for the carotid surgeon to use in special circumstances when CEA cannot be undertaken with acceptable morbidity. Furthermore, since the reported stroke morbidity rate of CAS exceeds the AHA recommendation for treatment of asymptomatic patients, most nonsurgical patients with asymptomatic disease should be treated with medical therapy.

Carotid artery stenting in the first 100 consecutive patients: results and follow up

BACKGROUND

Carotid artery stenting is now used as an alternative to surgical endarterectomy. The availability of cerebral protection systems has expanded the area of application of this procedure.

OBJECTIVE

To assess the feasibility, safety, and immediate and late clinical outcome in patients undergoing percutaneous carotid interventions.

METHODS

Between January 1999 and December 2000, 100 consecutive patients with 102 carotid artery stenoses were treated (71 men, 29 women, mean (SD) age 67 (8) years): 49 had coronary artery disease, 28 had previous stroke or transient ischaemic attack (TIA). On the basis of the Mayo Clinic carotid endarterectomy risk scale, 73 patients were grade III-IV and 13 grade VI.

RESULTS

Baseline diameter stenosis was 78.8 (10)%, with a mean lesion length of 12.6 (5.8) mm. Angiographic success was obtained in 99 lesions (97.0%) with a final diameter stenosis of 2.4 (3.5)%. Procedural success was obtained in 96 patients (96%). Selective cannulation of three carotid arteries was impossible owing to severe vessel tortuosity. Carotid stenting was performed in 97 of the treated lesions, and protection devices were used in 67 lesions. In-hospital complications occurred in seven patients (six TIA, one (category 1) minor stroke). No major stroke or death occurred. All patients were discharged from the hospital after an average of 2.5 days. At 12 (6.2) months of follow up restenosis occurred in three patients (3.4%) (one patient with carotid occlusion had TIA). Six patients had died: two from cerebrovascular events (5 and 11 months after the procedure) and four from cardiovascular causes.

CONCLUSIONS

Carotid stenting appears feasible and safe, with few major complications. Long term follow up is affected by a high incidence of cardiovascular mortality.

Carotid stenting and endarterectomy: a clinical and cost comparison of revascularization strategies

BACKGROUND AND PURPOSE

Investigational carotid stenting for extracranial carotid stenosis has demonstrated procedural results approaching those reported with endarterectomy, but with limited cost and long-term data. This study compared the in-hospital outcomes and costs of these 2 revascularization strategies at a single institution and the long-term effectiveness of carotid stenting.

METHODS

Data for 136 endarterectomies and 136 carotid stent procedures at a tertiary-care community hospital were obtained. The primary clinical outcome measures were in-hospital major ipsilateral stroke and death. In-hospital direct variable costs and length of stay were the primary economic measures. Information on restenosis and late ipsilateral stroke for the stent group was available at 2-year follow-up.

RESULTS

These nonrandomized groups were similar, but the endarterectomy group had more symptomatic patients (42% versus 31%; P=0.0004), and the stent group had more NASCET-excluded patients (68% versus 35%; P<0.0001). In-hospital major ipsilateral stroke and death occurred more frequently in the surgical group, but the difference was not significant (2.9% versus 0%; P=0.1). Minor ipsilateral strokes were similar (2.2% versus 2.9%; P=NS). Cost ($5409 versus $3417; P<0.0001) and length of stay (3.0 versus 1.4 days; P<0.0001) were significantly greater for the surgical group. In the stent group, 6-month angiographic restenosis was 3.1%, and 2-year ipsilateral major stroke rate was 0%.

CONCLUSIONS

In-hospital outcomes with carotid stenting were similar to those with endarterectomy but were achieved in patients with significantly more comorbidities. Cost and resource utilization with stenting were substantially less than those with endarterectomy. At 2 years, carotid stenting appeared not only durable but also effective in stroke prevention.

Management of patients with concomitant coronary and carotid vascular disease

Stroke is a major complication of coronary artery bypass graft (CABG) surgery. Carotid stenosis is an important cause of stroke in certain CABG patients. Randomized trials have revealed that carotid endarterectomy (CEA) is clearly indicated in non-CABG patients with symptomatic severe carotid stenosis. CEA is also indicated in patients with symptomatic moderate stenosis and asymptomatic severe stenosis if the predicted incidence of perioperative morbidity and mortality is low. Therapeutic options for patients with concomitant coronary and carotid disease include CABG alone, CABG plus CEA, and CABG plus carotid stenting. In this article we discuss each of these management techniques in detail, and make recommendations regarding the preferred approach in specific patient populations.

Integrated minimally invasive approaches for the treatment of atherosclerotic vascular diseases: Hybrid procedures

Patients may develop simultaneous symptoms of atherosclerotic vascular disease from different arterial beds. A concurrent minimally invasive approach to the management of these clinical situations may be an advantage over conventional surgical procedures. This study describes two separate case series of patients undergoing coronary/peripheral (n = 38) and peripheral/peripheral procedures (n = 10). Technical and clinical success was achieved in all patients. There were two periprocedural complications (retroperitoneal bleed and septicemia) in the coronary/peripheral series and no complications in the peripheral/peripheral series. We also present five case reports to illustrate the utility of hybrid procedures in various clinical settings. This study suggests that the use of simultaneous or sequential minimally invasive procedures appears to be a safe and feasible strategy for the treatment of patients with symptoms from more than one vascular bed. Cathet Cardiovasc Intervent 2001;52:154-161.

Carotid artery stent placement for atherosclerotic disease: rationale, technique, and current status

Carotid arterial endarterectomy is considered to be the standard for the treatment of atherosclerotic carotid arterial occlusive disease. This has been validated with results of several randomized controlled trials in which its effectiveness has been demonstrated over that of the best nonsurgical therapy. In the past several years, however, carotid angioplasty with stent placement has emerged as a potential alternative to carotid endarterectomy. This article represents a critical examination of the rationale for carotid revascularization; the history of endovascular techniques for the treatment of carotid atherosclerosis, beginning with balloon angioplasty and evolving to the use of stents; and the evidence supporting the effectiveness of the endovascular approach. A brief description of the current technical aspects of carotid artery stent placement is presented. The future status of the endovascular approach will be determined with randomized trials in which carotid artery stent placement is directly compared with endarterectomy, as well as by the potential for further innovation and improvement in endovascular devices, technique, and safety.