Management of patients with concomitant coronary and carotid artery disease

Endovascular carotid revascularization under open-chest extracorporeal circulation combined with cardiac surgery in unstable patients at increased risk of carotid-related stroke: SIMultaneous urgent cardiac surgery and MicroNet-covered stent carotid revascularization in extreme-risk patients-SIMGUARD Study

BACKGROUND

In patients at urgent need for cardiac surgery coexisting with increased-stroke-risk carotid stenosis, any staged intervention increases the risk of complications from the primarily unaddressed pathology. In this challenging cohort, we assessed safety and feasibility of endovascular carotid revascularization under open-chest extracorporeal circulation (ECC) combined with cardiac surgery (hybrid-room true simultaneous treatment).

METHODS

Per-protocol (PP), after general anesthesia induction, chest-opening and ECC stand-by installation, carotid stenting (CAS) was performed (femoral/radial or direct carotid access) with ad-hoc/on-hand switch to ECC cardiac surgery.

RESULTS

Over 78 months, 60 patients (70.7±6.9years, 85% male, all American Society of Anesthesiology grade IV) were enrolled. All were at increased carotid-related stroke risk (ipsilateral recent stroke/transient ischemick attack, asymptomatic cerebral infarct, increased-risk lesion morphology, bilateral severe stenosis). Majority of study procedures involved CAS+coronary bypass surgery or CAS+valve replacement±coronary bypass. 45 (75%) patients were PP- and 15 (25%) not-PP (NPP-) managed (context therapy). CAS was 100% neuroprotected (transient flow reversal-64.4%, filters-35.6%) and employed micronet-covered plaque-sequestrating stents with routine post-dilatation optimization/embedding. 4 deaths (6.7%) and 7 strokes (11.7%) occurred by 30-days. Despite CAS+surgery performed on aspirin and unfractionated heparin-only (delayed clopidogrel-loading), no thrombosis occurred in the stented arteries, and 30-days stent patency was 100%. NPP-management significantly increased the risk of death/ipsilateral stroke (OR 38.5; P<0.001) and death/any stroke (OR 12.3; P=0.002) by 30-days.

CONCLUSIONS

In cardiac unstable patients at increased carotid-related stroke risk who require urgent cardiac surgery, simultaneous cardiac surgery and CAS with micronet-covered stent lesion sequestration is feasible and safe and shows efficacy in minimizing stroke risk. Larger-scale, multicentric evaluation is warranted. (SIMGUARD NCT04973579).

Systematic review and meta-analysis of the treatment strategies for coronary artery bypass graft patients with concomitant carotid artery atherosclerotic disease

OBJECTIVE

Stroke is one of the devastating complications after coronary artery bypass graft (CABG). Underlying carotid artery atherosclerotic disease is reported to be an independent risk factor. The optimal treatment strategy for these patients remains under debate.

METHODS

We aimed to perform a network meta-analysis to evaluate the safety and efficacy of additional carotid interventions for patients with concomitant carotid artery atherosclerotic disease who require CABG by comparing perioperative adverse event rates. All articles through February 2022 were searched using MEDLINE and EMBASE to identify studies that investigated outcomes of CABG only as well as additional staged vs combined carotid interventions by both carotid endarterectomy (CEA) and carotid artery stenting (CAS).

RESULTS

Two randomized controlled trials and 23 observational studies were included, yielding a total of 32,473 patients who underwent combined CEA and CABG (n = 20,204), CEA and staged CABG (n = 6882), CABG and staged CEA (n = 340), CAS and CABG regardless of timing and sequences (n = 1224), and CABG only (n = 3823). No strategy showed a significant advantage over CABG only in all perioperative outcomes. CEA and staged CABG was associated with the lowest perioperative stroke/transient ischemic attack (TIA) rate, significantly lower compared with CAS and CABG (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.36-0.76) as well as CABG and staged CEA (OR, 0.41; 95% CI, 0.23-0.74), but was also associated with the highest perioperative mortality (OR, 2.50; 95% CI, 1.67-3.85, vs CAS and CABG) and myocardial infarction rate (OR, 3.70 [95% CI, 1.16-12.5] and OR, 2.50 [95% CI, 1.35-4.55] vs CAS and CABG, vs combined CEA and CABG, respectively).

CONCLUSIONS

CEA and staged CABG are associated with low perioperative stroke/transient ischemic attack rates with a tradeoff of higher mortality and myocardial infarction rate. No strategy showed a significant advantage over the CABG-only strategy in all perioperative outcomes, outlining the importance of a tailored approach and determining proper indications for carotid intervention in these patients.

Strategy for endovascular treatment of a patient with combined coronary and carotid artery atherosclerosis: a case report

Treatment of patients with combined coronary and carotid artery atherosclerosis is a difficult task due to the increased risk of surgical intervention in this cohort of patients. Lack of timely treatment can lead to a decrease in the quality of life of patients, as well as to death. In some cases with combined coronary and carotid artery atherosclerosis, the choice of surgical intervention may depend on vascular bed involvement. In a case report, open surgery was associated with a very high risk of perioperative complications; so the only way of myocardial revascularization was minimally invasive endovascular surgery. The article presents a case of the treatment of a patient with a combined multivessel coronary and bilateral carotid artery atherosclerosis.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Extracellular vesicles carrying proinflammatory factors may spread atherosclerosis to remote locations

Most cells involved in atherosclerosis release extracellular vesicles (EVs), which can carry bioactive substances to downstream tissues via circulation. We hypothesized that EVs derived from atherosclerotic plaques could promote atherogenesis in remote locations, a mechanism that mimics the blood metastasis of cancer. Ldlr gene knockout (Ldlr KO) rats were fed on a high cholesterol diet and underwent partial carotid ligation to induce local atherosclerosis. EVs were separated from carotid artery tissues and downstream blood of carotid ligation by centrifugation. MiRNA sequencing and qPCR were then performed to detect miRNA differences in EVs from rats with and without induced carotid atherosclerosis. Biochemical analyses demonstrated that EVs derived from atherosclerosis could increase the expression of ICAM-1, VCAM-1, and E-selectin in endothelial cells in vitro. EVs derived from atherosclerosis contained a higher level of miR-23a-3p than those derived from controls. MiR-23a-3p could promote endothelial inflammation by targeting Dusp5 and maintaining ERK1/2 phosphorylation in vitro. Inhibiting EV release could attenuate atherogenesis and reduce macrophage infiltration in vivo. Intravenously administrating atherosclerotic plaque-derived EVs could induce intimal inflammation, arterial wall thickening and lumen narrowing in the carotids of Ldlr KO rats, while simultaneous injection of miR-23a-3p antagomir could reverse this reaction. The results suggested that EVs may transfer atherosclerosis to remote locations by carrying proinflammatory factors, particularly miR-23a-3p.

Early neurological deterioration in cardiogenic cerebral embolism due to nonvalvular atrial fibrillation: Predisposing factors and clinical implications

PURPOSE

The aim of the study was to investigate factors which may predispose patients to early neurological deterioration (END) and explore peripheral biomarkers for the prediction of END in cardiogenic cerebral embolism (CCE) patients.

METHODS

Patients diagnosed with CCE within 24 hr of onset between January 2017 and January 2019 were included in this study. END was defined as an increase of ≥2 on the National Institutes of Health Stroke Scale (NIHSS) or the emergence of new neurological symptoms within 3 days of admission. Binary logistic regression was used to investigate the factors associated with END. Receiver operating characteristic (ROC) curves were then generated to determine the predictive value of the potential biomarkers and the optimal cutoff values.

RESULTS

Of the 129 (male, 55.81%; mean age 71.85 ± 11.99 years) CCE patients, 55 patients with END were identified. Hemorrhage transformation (HT), coronary heart disease (CHD), diastolic blood pressure, cystatin C levels, NIHSS score, and platelet-to-lymphocyte ratio (PLR) at admission were independently associated with END. A peripheral cystatin C level ≥ 1.41 mg/L and a PLR ≥ 132.97 were predictive factors for END in CCE patients. The lymphocyte-to-monocyte ratio (LMR) was negatively independently associated with HT, and LMR < 2.31 may predict the occurrence of HT in patients with CCE.

CONCLUSIONS

Of the potential predisposing factors considered, increased cystatin C and PLR were associated with END within 3 days of CCE, and a decreased LMR may have predictive value for HT in CCE patients.

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

Background

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

Methods

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

Results

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

Conclusion

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