Management of carotid disease in patients undergoing coronary artery bypass surgery: is it time to change our approach?

Association of carotid duplex ultrasonography screening with stroke and mortality among patients undergoing coronary artery bypass grafting

OBJECTIVE

Selection criteria for carotid duplex ultrasonography screening (DUS) before coronary artery bypass grafting (CABG) is primarily based on limited observational analysis, and the risks associated with carotid artery stenosis (CAS) detected by this approach to preoperative DUS are uncertain. This study aimed to determine the association of carotid DUS with stroke and mortality among patients undergoing CABG.

METHODS

Adult patients with coronary artery disease who underwent isolated CABG or CABG with concomitant valvular or congenital procedure were identified. CHA2DS2-VASc score was assessed before CABG, and patients were recorded as high risk if they had a score of 3 or higher. The primary outcomes were stroke and all-cause mortality. Secondary outcomes included ischemic stroke, non-ischemic stroke, transient ischemic attack, and cardiovascular mortality.

RESULTS

Among 8958 patients who underwent CABG, 70.9% (n = 6347) received carotid DUS preoperatively (low-risk, 57.3%; high-risk, 42.7%). In the low-risk cohort, there was no significant difference in the risk of stroke (20.7 per 1000 patient-years for CAS vs 13.1 per 1000 patient-years for no CAS; adjusted hazard ratio [aHR], 1.14; 95% confidence interval [CI], 0.78-1.68) or mortality (20.5 per 1000 patient-years for CAS vs 16.8 per 1000 patient-years for no CAS; aHR, 1.33; 95% CI, 0.97-1.83) at 15 years. In the high-risk cohort, CAS was associated with significantly higher risks of stroke at 30 days (433.2 vs 279.5 per 1000 patient-years; aHR, 1.92; 95% CI, 1.00-3.70) and mortality at 15 years (38.4 vs 32.7 per 1000 patient-years; aHR, 1.25; 95% CI, 1.01-1.57) compared with no CAS.

CONCLUSIONS

CAS did not impact the incidence of stroke or mortality in the low-risk cohort who underwent CABG. However, in the high-risk cohort, CAS was associated with a significant increase in the risks of 30-day stroke and 15-year mortality, indicating selective carotid DUS is necessarily recommended for these patients.

The role of carotid artery stenosis in predicting stroke after coronary artery bypass grafting in a Chinese cohort study

Current guidelines give priority to surgical treatment of carotid artery stenosis (CAS) before coronary artery bypass grafting (CABG), especially in symptomatic patients. Carotid artery stenting is an alternative treatment for narrowing of the carotid arteries. This study sought to demonstrate the role of severe CAS in predicting stroke after CABG and assess the efficacy of carotid artery stenting in preventing postoperative stroke in a Chinese cohort. From 2015 to 2021, 1799 consecutive patients undergoing isolated CABG surgery were retrospectively recruited in a Chinese cohort. The predictive value of severe CAS in postoperative stroke and carotid stenting in preventing postoperative stroke was statistically analyzed. The incidence of postoperative stroke was 1.67%. The incidence of CAS with stenosis ≥ 50% and ≥ 70% was 19.2% and 6.9%. After propensity matching, the incidence of stroke was 8.0% in the severe CAS group and 0% in the non-severe CAS group. We successfully established an optimal predictive nomogram for predicting severe CAS in patients undergoing CABG. Carotid artery stenting was found ineffective in preventing postoperative stroke. The present study provides the incidence of CAS and postoperative stroke in a Chinese cohort, identifies severe CAS as an independent risk factor for postoperative stroke after CABG, constructs a nomogram predicting the incidence of severe CAS, and evaluates the effectiveness of carotid artery stenting in preventing postoperative stroke after CABG.

Outcomes of simultaneous carotid endarterectomy and coronary artery bypass grafting: A single centre experience

OBJECTIVE

Stroke following a coronary artery bypass surgery is a well-known complication often predisposed by carotid artery disease. Perioperative risk of stroke after on-pump cardiac surgery can overall affect 2% of patients. Patients with 80-99% unilateral carotid artery stenosis carry a 4% risk of stroke. Significant carotid artery stenosis is present in 3-10% of patients who are candidates for coronary artery bypass grafting (CABG). Those patients might be considered for either simultaneous or staged carotid endarterectomy and CABG to reduce the risk of stroke and death. The purpose of this study was to evaluate preoperative and intraoperative risk factors for myocardial infarction (MI), stroke and death and assess complications occurring during the early postoperative period after simultaneous CABG/CAE procedure.

METHODS

A single centre retrospective analysis of 134 patients from 2015 to 2019 who underwent simultaneous CABG/CEA was performed. At the same period, a total of 2827 CABG were performed, of which 4.7% were simultaneous interventions. We excluded staged CEA/CABG procedures, off-pump CABG and urgent CABG patients. All patients included in the study met the criteria for elective CABG for triple-vessel or left main trunk symptomatic coronary artery disease (CAD) with asymptomatic >70% carotid stenosis or symptomatic ipsilateral >50% carotid stenosis regardless of the degree of contralateral carotid artery stenosis. Patient demographics, comorbidities and operative details were reviewed. The primary endpoint was to assess the intraoperative and 30-day risk of stroke and death after simultaneous CEA/CABG procedure.

RESULTS

Simultaneous CEA/CABG is effective procedure that can be performed in high-risk symptomatic patients with acceptable results. Predictors of postoperative stroke were smoking (P = 0.011), history of MI (P = 0.046), history of CABG (P = 0.013), and history of stroke/TIA (P = 0.005). Significant risk factors for adverse major postoperative complications after simultaneous CEA/CABG procedure were cardiac arrhythmia (AF or AFL) (P = 0.045), previous MI (P < 0.001), and smoking (P = 0.001).

CONCLUSIONS

Synchronous CEA/CABG procedure can be performed with acceptable results in patients having a high risk of stroke, septuagenarians and older.

SOCIETY FOR VASCULAR SURGERY CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF EXTRACRANIAL CEREBROVASCULAR DISEASE

Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were published. Since that publication, several studies and a few systematic reviews comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2011 guidelines with specific emphasis on five areas: is carotid endarterectomy recommended over maximal medical therapy in low risk patients; is carotid endarterectomy recommended over trans-femoral carotid artery stenting in low surgical risk patients with symptomatic carotid artery stenosis of >50%; timing of carotid Intervention in patients presenting with acute stroke; screening for carotid artery stenosis in asymptomatic patients; and optimal sequence for intervention in patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) approach, as has been done with other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin 0-2), carotid revascularization is considered appropriate in symptomatic patients with greater than 50% stenosis and is recommended and performed as soon as the patient is neurologically stable after 48 hours but definitely before 14 days of onset of symptoms. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients who are at increased risk for carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. In patients with symptomatic carotid stenosis 50-99%, who require both CEA and CABG, we suggest CEA before or concomitant with CABG to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on clinical presentation and institutional experience.

Prevalence of extracranial carotid atherosclerosis in the patients with coronary artery disease in a tertiary hospital in Malaysia

There is limited information regarding the prevalence of extracranial carotid atherosclerosis in the patients with coronary artery disease (CAD) undergoing coronary artery bypass graft (CABG) surgery in South East Asia. The primary objective was to assess the prevalence of extracranial carotid stenosis, raised carotid intima media thickness (CIMT), and plaques in the patients with CAD undergoing elective CABG. The secondary objective was to evaluate the risk factors for extracranial carotid atherosclerosis.A total of 119 consecutive patients with CAD undergoing elective CABG in a tertiary hospital in Malaysia were recruited. Data on the demographic characteristics and risk factors were collected. The ultrasound carotid Doppler findings comprising of raised CIMT, plaques, and stenosis in the extracranial carotid vessels were recorded.The mean age of the patients was 64.26 ± 10.12 (range 42-89). Most of the patients were men (73.1%). The patients consisted of 44 (37%) Malays, 26 (21.8%) Chinese, and 49 (41.2%) Indians.A total of 67 (56.3%) patients had raised CIMT, 89 (74.8%) patients had plaques, and 10 (8.4%) patients had stenosis in the internal and common carotid arteries. The mean age of patients with plaques was higher compared to those without plaques (66.00 ± 9.63 vs 59.10 ± 9.92, P = .001). The body mass index (BMI) of patients with stenosis was higher compared to those without stenosis (28.35 ± 4.92 vs 25.75 ± 3.16, P = .02).The patients with plaques were more likely to be older, whereas the patients with carotid stenosis were more likely to have higher BMI.

Contemporary Management of Patients with Concomitant Coronary and Carotid Artery Disease

The ideal management of concomitant carotid and coronary artery occlusive disease remains elusive. Although researchers have advocated the potential benefits of varying treatment strategies based on either concomitant or staged surgical treatment, there is no consensus in treatment guidelines among national or international clinical societies. Clinical studies show that coronary artery bypass grafting (CABG) with either staged or synchronous carotid endarterectomy (CEA) is associated with a high procedural stroke or death rate. Recent clinical studies have found carotid artery stenting (CAS) prior to CABG can lead to superior treatment outcomes in asymptomatic patients who are deemed high risk of CEA. With emerging data suggesting favorable outcome of CAS compared to CEA in patients with critical coronary artery disease, physicians must consider these diverging therapeutic options when treating patients with concurrent carotid and coronary disease. This review examines the available clinical data on therapeutic strategies in patients with concomitant carotid and coronary artery disease. A treatment paradigm for considering CAS or CEA as well as CABG and percutaneous coronary intervention is discussed.

Bedside screening with the use of pocket-size imaging device can be useful for ruling out carotid artery stenosis in patients scheduled for cardiac surgery

BACKGROUND

Patients (pts) scheduled for coronary artery bypass grafting, burdened with high risk of carotid stenosis, are recommended to undergo duplex ultrasonography (DUS) of carotid arteries.

PURPOSE

To validate pocket-size imaging device (PSID) equipped with linear probe as an easily accessible tool enabling bedside screening for carotid artery stenosis (CAS).

METHODS

A total of 100 pts (60 men, mean age 69±11 years) with multivessel coronary artery disease underwent bedside DUS of carotid arteries with the use of PSID performed by a cardiology resident trained in DUS. Subsequently, DUS with the use of stationary high-end ultrasound system was performed in all pts to verify findings of PSID examination.

RESULTS

Initial diagnosis of atherosclerotic plaque presence obtained with PSID in 59 patients was confirmed by high-end ultrasound system examination in all cases. There was a statistically significant correlation of intima-media thickness measurements between PSID and stationary system (r=.58; 95% CI: 0.48-0.66; P<.0001), but the coefficient of agreement (κ) between the two methods in classification of intima-media as normal or thickened (>0.9 mm) was only .38 (95% CI: 0.299-0.459). During PSID examination, turbulent flow was observed in 21 pts-CAS was confirmed in all these pts-5 pts were diagnosed with significant CAS, the rest with CAS ranging from 30% to 70%.

CONCLUSIONS

Pocket-size imaging device equipped with linear probe allows for identification of patients with atherosclerotic plaques and turbulent flow in carotid arteries; however, the degree of CAS cannot be reliably determined. The measurement accuracy of intima-media thickness is insufficient for a diagnostic purpose.

Association between the Gensini Score and Carotid Artery Stenosis

Background and Objectives

The aim of this study was to evaluate the association between the extent of coronary artery disease assessed by the Gensini score and/or the SYNTAX score and the significant carotid stenosis in patients undergoing coronary artery bypass grafting (CABG).

Subjects and Methods

A total of 225 patients who had carotid doppler ultrasonography prior to CABG were included retrospectively. Significant coronary artery disease was assumed as a lumen diameter stenosis of ≥50% in any of the major epicardial coronary arteries. The severity of carotid stenosis was determined by B-mode and duplex ultrasonography. Clinically significant carotid stenosis was defined as peak systolic velocity greater than 125 cm/s.

Results

The mean value of SYNTAX score and Gensini score was highest in patients allocated to significant carotid stenosis (22.98±7.32, p<0.001 and 77.40±32.35, p<0.001, respectively). The other risk factors for significant carotid stenosis were found to be male gender (p=0.029), carotid bruit (p<0.001), diabetes (p=0.021), left main disease (p=0.002), 3-vessel disease (p=0.008), chronic total coronary occlusion (p=0.001), and coronary artery calcification (p=0.001) in univariate analysis. However, only the Gensini score (odds ratio[OR]=1.030, p=0.004), carotid bruit (OR=0.068, p<0.001), and male gender (OR=0.190, p=0.003) were the independent predictors. The Gensini score cut off value predicting significant carotid stenosis was 50.5 with 77% sensitivity (p<0.001).

Conclusion

The Gensini score may be used to identify patients at high risk for significant carotid stenosis prior to CABG.

The effects of the metabolic syndrome on coronary artery bypass grafting surgery

Background

The metabolic syndrome (MS) is a clustering of factors that are associated with increased cardiovascular risk. A low-grade inflammatory process acts as the underlying pathophysiology, which suggests that the MS may have a detrimental effect on coronary interventions, including coronary artery bypass grafting (CABG) surgery performed with cardiopulmonary bypass (CPB). We aimed to evaluate the effect of the MS on morbidity and mortality rates in the early postoperative period in patients undergoing CABG.

Methods

We prospectively included 152 patients (109 males and 43 females; mean age 60.1 ± 8.6 years) who underwent elective CABG on CPB between January and September 2011. Early postoperative morbidity and mortality rates were compared between subjects with and without the MS. Diagnosis of the MS was based on the American National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria.

Results

Of the study group, 64 patients (42%) had the MS. The two groups were similar in age and gender. In the postoperative period, rates of atrial fibrillation, wound infection, pulmonary complications, and lengths of intubation, hospitalisation and intensive care unit stay were significantly higher in MS patients (p < 0.01). The MS was significantly associated with wound infection (OR 6.64, 95% CI: 1.72–25.75), pulmonary complications (OR 6.44, 95% CI: 1.58–26.33), arrhythmia (OR 5.47, 95% CI: 1.50–19.97) and prolonged intubation (OR 1.17, 95% CI: 1.05–1.32). The mortality rate was 3.1% in the MS group and 1.1% in the non-MS group, with no significant difference (p > 0.05).

Conclusion

The MS was associated with a higher rate of early postoperative morbidity following CABG, without having a significant effect on the mortality rate.

Risk Factors for Carotid Artery Stenosis in Chinese Patients Undergoing Coronary Artery Bypass Graft Interventions

Current guidelines established in the USA and Europe for coronary artery bypass graft (CABG) suggest that patients ≥65 and ≥70 years of age, or with certain atherosclerotic-risk factors, should be screened preoperatively for extracranial carotid artery stenosis (CAS) to assess their risk of perioperative stoke. We sought factors that should be taken into consideration when treating Chinese CABG patients using CABG guidelines based on an analysis of CAS in a large cohort of Chinese CABG patients. We analyzed data for 1558 Chinese CABG patients who were screened preoperatively for CAS using duplex ultrasonography at a single institution. We defined significant and severe CAS as ≥50% and ≥70% stenosis, respectively, in one or more common or internal carotid arteries. We investigated the prevalence of CAS, the incidence of perioperative stroke, and the risk factors for CAS in the CABG cohort. The prevalence of CAS in the CABG cohort was 21.2%. Multivariate stepwise logistic regression analysis showed that an age ≥50 years and a history of smoking (odds ratios = 8.36 and 1.83, respectively) were independent risk factors for CAS (P < 0.05 for both). The incidence of perioperative stroke among CABG patients with significant or severe CAS was significantly higher (2.4% and 2.9%, respectively) than in CABG patients with <50% stenosis (0.5%; P = 0.004 and 0.029, respectively). Chinese CABG patients with a history of smoking or ≥50 years of age should undergo preoperative screening for CAS to assess their risk of perioperative stroke.

Does preoperative carotid stenosis screening reduce perioperative stroke in patients undergoing coronary artery bypass grafting?

A number of institutions routinely perform carotid artery ultrasound screening before coronary artery bypass grafting (CABG) to identify carotid artery disease requiring revascularization before or during CABG, with the expectation of reducing perioperative neurologic events. The assumptions are that carotid disease is causally related to perioperative stroke and that prophylactic carotid revascularization decreases the risk of post-CABG neurologic events. Although carotid artery stenosis is a known risk factor for perioperative stroke in patients undergoing CABG, it might be a surrogate marker for diffuse atherosclerotic disease rather than a direct etiologic factor. Moreover, the benefit of prophylactic carotid revascularization in patients with asymptomatic unilateral carotid disease is uncertain. Therefore, we have reviewed the literature for evidence that preoperative carotid artery screening, by identifying patients with significant carotid artery stenosis and altering their management, reduces perioperative neurologic events in those undergoing CABG.

Perioperative management of combined carotid and coronary artery bypass grafting procedures

The objective of this review is to provide a high level overview on current thinking for treatment of patients with combined carotid and coronary artery disease given that these patients are at higher risk of adverse cardiac events, stroke, and death. This review discusses (1) the current literature addressing perioperative stroke risk in the setting of coronary artery bypass graft, (2) the literature regarding different surgical approaches when both carotid and coronary revascularization are being considered, and (3) the data available to guide optimal management of this complex patient population to minimize complications regardless of the surgical approach taken.

Asymptomatic carotid stenosis: immediate revascularization or watchful waiting?

Based on several randomized clinical trials, carotid revascularization has been shown to reduce future stroke risk among individuals with severe asymptomatic carotid stenosis. However, a well-recognized problem with such prophylactic intervention is the risk of periprocedural stroke, death, or myocardial infarction. If actual stroke risk with asymptomatic carotid stenosis can be reduced significantly by aggressive medical management, carotid revascularization may yield marginal benefit or even cause harm especially in those with limited life expectancy. Based on recent observational data, it is becoming apparent that the stroke risk in this population has been declining with better medical management alone. This has prompted a few to avoid carotid revascularization for asymptomatic carotid stenosis altogether. Others feel such conclusions cannot be made with observational data alone. In the midst of this controversy, it is important that clinicians perform carotid revascularization on a case by case basis while ensuring optimal medical management in all patients. An algorithmic approach to decision making based on available evidence will enable clinicians to personalize patient management with efficiency.

Advances in the management of carotid artery disease: focus on recent evidence and guidelines

Recent landmark randomized trials and society guidelines have significantly revised the management of carotid artery disease. Duplex ultrasonography is the recommended initial diagnostic test for the assessment of extracranial carotid artery stenosis. Carotid artery imaging is reasonable in select patients scheduled for coronary artery bypass graft (CABG) surgery. Carotid revascularization can be achieved safely and effectively with carotid endarterectomy or carotid artery stenting. Because each procedure has a different risk/benefit profile, the optimal approach is to match the particular patient to the intervention that maximizes outcome benefit. Carotid revascularization is recommended in patients scheduled for CABG surgery when the carotid artery stenosis is symptomatic and/or bilateral. Further trials are required to guide the management of asymptomatic unilateral carotid artery stenosis in patients undergoing CABG surgery. Aggressive medical therapy remains the gold standard for intracranial carotid artery disease because landmark trials have shown no outcome improvement with vascular bypass or percutaneous angioplasty and stenting. A large recent trial showed that local anesthesia, as compared with general anesthesia, for carotid endarterectomy has no major clinical outcome advantage. Although carotid artery stenting is associated with a reduced risk of myocardial ischemia, it still has important risks of stroke and hemodynamic instability that significantly affect clinical outcome. The timing and choice of carotid revascularization technique ultimately depends on multiple clinical factors.

The links between complex coronary disease, cerebrovascular disease, and degenerative brain disease

Our appreciation of the complexity of cardiovascular disease is growing rapidly. Consistent with the fact that the vasculature is an omnipresent system that carries blood to every organ in the body, an expanding number of conditions are now known to be directly associated with disturbed cardiovascular function or vascular pathology. In particular, cardiovascular disease has recently been implicated as playing a major role in dementia and other forms of degenerative brain disease. Here, we explore some of the many emerging relationships between cardiovascular risk factors, complex coronary artery disease, cerebrovascular disease, and degenerative brain disease.

Regional use of combined carotid endarterectomy/coronary artery bypass graft and the effect of patient risk

INTRODUCTION

Although carotid artery stenosis and coronary artery disease often coexist, many debate which patients are best served by combined concurrent revascularization (carotid endarterectomy [CEA]/coronary artery bypass graft [CABG]). We studied the use of CEA/CABG in New England and compared indications and outcomes, including stratification by risk, symptoms, and performing center.

METHODS

Using data from the Vascular Study Group of New England from 2003 to 2009, we studied all patients who underwent combined CEA/CABG across six centers in New England. Our main outcome measure was in-hospital stroke or death. We compared outcomes between all patients undergoing combined CEA/CABG to a baseline CEA risk group comprised of patients undergoing isolated CEA at non-CEA/CABG centers. Further, we compared in-hospital stroke and death rates between high and low neurologic risk patients, defining high neurologic risk patients as those who had at least one of the following clinical or anatomic features: (1) symptomatic carotid disease, (2) bilateral carotid stenosis >70%, (3) ipsilateral stenosis >70% and contralateral occlusion, or (4) ipsilateral or bilateral occlusion.

RESULTS

Overall, compared to patients undergoing isolated CEA at non-CEA/CABG centers (n = 1563), patients undergoing CEA/CABG (n = 109) were more likely to have diabetes (44% vs 29%; P = .001), creatinine >1.8 mg/dL (11% vs 5%; P = .007), and congestive heart failure (23% vs 10%; P < .001). Patients undergoing CEA/CABG were also more likely to take preoperative beta-blockers (94% vs 75%; P < .001) and less likely to take preoperative clopidogrel (7% vs 25%; P < .001). Patients undergoing CEA/CABG had higher rates of contralateral carotid occlusion (13% vs 5%; P = .001) and were more likely to undergo an urgent/emergent procedure (30% vs 15%; P < .001). The risk of complications was higher in CEA/CABG compared to isolated CEA, including increased risk of stroke (5.5% vs 1.2%; P < .001), death (5.5% vs 0.3%; P < .001), and return to the operating room for any reason (7.6% vs 1.2%; P < .001). Of 109 patients undergoing CEA/CABG, 61 (56%) were low neurologic risk and 48 (44%) were high neurologic risk but showed no demonstrable difference in stroke (4.9% vs 6.3%; P = .76), death, (4.9 vs 6.3%; P = .76), or return to the operating room (10.2% vs 4.3%; P = .25).

CONCLUSIONS

Although practice patterns in the use of CEA/CABG vary across our region, the risk of complications with CEA/CABG remains significantly higher than in isolated CEA. Future work to improve patient selection in CEA/CABG is needed to improve perioperative results with combined coronary and carotid revascularization.