Mid-term outcome after carotid artery stenting depends on presence of coronary artery disease

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.

Coronary artery bypass grafting for left main disease and the risk of stroke: Incidence, aetiology and prevention

This review explores the association between left main disease and the increased risk of perioperative stroke following coronary artery bypass grafting, specifically addressing the potential underlying mechanisms and its potential prevention. In particular, this correlation appears stronger for patients with left main disease when compared to patients with isolated triple vessel disease. Even though evidence on this topic is limited and of modest quality, there appears to be a significant association between ascending aorta atherosclerosis and coronary artery disease. Furthermore, there seems to be a relationship between the severity and extent of carotid artery stenosis and coronary artery disease. Carotid artery disease is itself associated with atherosclerosis of the ascending aorta, a well-recognised risk factor for postoperative atheroembolic stroke. The association between left main disease, ascending aorta atherosclerosis and carotid artery stenosis may reflect an increased systemic atherosclerotic burden and hence explain, at least partially, the higher risk of perioperative cerebrovascular events. Potential pre-, intra- and post-operative strategies for stroke prevention are discussed.

History of transient ischaemic attack, myocardial infarction and hyperlipidaemia affects outcome following carotid artery stenting

AIMS

This prospective registry study was intended to evaluate outcomes and predictors of adverse events following carotid artery stenting (CAS).

METHODS AND RESULTS

Patients received neurological and duplex exams before CAS, prior to discharge and at 30- and 180-day follow-up. Multiple regression analysis included patient- and procedure-related characteristics. The MACCE endpoint comprised stroke, myocardial infarction and death. Three hundred and seventy-five consecutive patients underwent CAS between 1998 and 2011. Mean age was 69±9.1 years; 53% were symptomatic within the preceding six months. Mean time to CAS was 23 days in patients with TIA and 31 days with stroke (p=0.029). The MACCE rate was 1.6% during intervention and 4.0%, 5.6% and 5.9% at discharge, day 30 and day 180, respectively. TIA occurred in 31 cases (9.6%) within 30 days. A history of TIA was independently associated with MACCE (OR: 2.88; p=0.04). Furthermore, a history of hyperlipidaemia (OR: 4.02, p=0.029), MI (OR: 2.93, p=0.007) and age ≥70 (OR: 1.89, p=0.033) were independent predictors for the combined endpoint MACCE plus TIA.

CONCLUSIONS

TIA is an underappreciated adverse event following CAS. Pre-procedural TIA was an independent risk factor for adverse outcomes, while stroke was not, probably related to the timing of the procedure relative to the index event.

Impact of coexisting coronary artery disease on the occurrence of cerebral ischemic lesions after carotid stenting

Background

Coronary artery disease (CAD) may coexist with extracranial carotid artery stenosis (ECAS), but the influence of CAD on procedure-related complications after carotid artery stenting (CAS) has not been well investigated. The study aimed to determine the impact of CAD on the occurrence of peri-CAS cerebral ischemic lesions on diffusion-weighted imaging (DWI) scanning.

Methods

Coronary angiography was performed within six months before CAS. DWI scanning was repetitively done within 1 week before and after CAS. Clinical outcome measures were stroke, angina, myocardial infarction and death within 30 days.

Results

Among 126 patients (69.5±9.0 years) recruited for unilateral protected CAS, 33 (26%) patients had peri-CAS DWI-positive lesions. CAD was noted in 79% (26 in 33) and 48% (45 in 93) of patients with and without peri-CAS DWI-positive lesions (OR, 4.0; 95% CI, 1.6–10.0; P = .0018), and the number of concomitant CAD on coronary angiography was positively correlated with the risk for peri-CAS DWI-positive lesions (P = .0032). In patients with no CAD (n = 55), asymptomatic CAD (n = 41) and symptomatic CAD (n = 30), the occurrence rates of peri-CAS DWI-positive lesions were 13%, 41% and 30% (P = .0048), and the peri-CAS stroke rates were 2%, 7% and 0% (P = .2120).

Conclusions

The severity of morphological CAD and the presence of either symptomatic or asymptomatic CAD are associated with the occurrence of peri-CAS cerebral ischemic lesions.

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.

Comparison of carotid artery stenting in patients with single versus bilateral carotid artery disease and factors affecting midterm outcome

BACKGROUND

Carotid artery stenting (CAS) is the method of choice for carotid artery revascularization of patients at high risk for carotid endarterectomy. In this study, we compared the midterm results of CAS in patients with unilateral versus bilateral carotid artery disease.

METHODS AND RESULTS

This is a retrospective analysis of 1-year outcome of 273 consecutive patients in whom 342 CAS procedures were performed. The incidence of periprocedural transient ischemic attacks (TIAs) differed significantly (8% vs. 1%; p = 0.01) among patients with and without bilateral internal carotid disease, and a tendency to a lower occurrence of early adverse events (death, stroke, periprocedural TIA, periprocedural myocardial infarction) was subsequently shown (11% vs. 5%; p = 0.12). At 1-year follow-up, there was a high incidence of adverse events (death, stroke, periprocedural TIA, periprocedural myocardial infarction, restenosis) in patients with bilateral carotid artery disease (40% vs. 14%; p < 0.01), which was mainly driven by a higher incidence of death, periprocedural TIA, and restenosis (p ≤ 0.02 for all). According to multivariate analysis, the independent predictors of midterm adverse events were left ventricular dysfunction, male gender, bilateral carotid artery disease, renal insufficiency, cerebral symptoms within the last 6 months before the intervention, and low-density lipoprotein cholesterol level.

CONCLUSIONS

At midterm follow-up, patients with bilateral carotid artery disease treated by CAS have significantly more adverse events than those with unilateral disease.

Long-Term Results of Carotid Artery Stents to Manage Symptomatic Carotid Artery Stenosis and Factors That Affect Outcome

Background— Limited data are available about the long-term outcomes of the use of carotid artery stents in symptomatic patients and the impact of patient variables on the durability of endovascular carotid procedures. Outcome data previously reported from registry series mix symptomatic and asymptomatic patients. We present analysis of long-term follow-up, with independent neurological assessment, for patients with symptomatic high-grade carotid lesions undergoing stenting to identify patients at risk of recurrence.

Methods and Results— Prospectively collected data on 563 carotid stenting procedures in a single center were analyzed. Univariate and multivariate techniques were used to identify risk groups and beneficial technical adaptations. Ipsilateral stroke rates for all patients were 4.8%, 7.0%, and 9.5% at 30 days, 1 year, and 4 years, respectively. The rates improved to 2.7%, 4.1%, and 4.5% when patients were treated with optimal therapy. Retinal events had a lower risk of long-term recurrent ipsilateral stroke (hazard ratio=0.228, CI=0.082 to 0.632, P =0.004) than cerebral events. A recurrent or residual stenosis of >50% had a statistically significant effect on long-term stroke recurrence in multivariate analysis (hazard ratio=2.187, CI=1.173 to 4.078, P =0.014).

Conclusions— Patients with retinal presentations are a lower risk group to treat. Residual stenosis or restenosis >50% has a statistically significant trend to an increased risk of recurrence for ipsilateral stroke in the long term in this population. In our patients, a combination of procedural modifications and pharmacological changes seems to improve outcomes.