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

A meta-analysis supporting the superiority of staged carotid artery stenting and coronary artery bypass grafting in patients with concurrent severe coronary and carotid artery stenosis

BACKGROUND

This study sought to ascertain whether a staged approach involving carotid artery stenting (CAS) and coronary artery bypass grafting (CABG) holds superiority over the synchronous (Syn) strategy of CAS or carotid endarterectomy (CEA) and CABG in patients necessitating combined revascularization for concurrent carotid and coronary artery disease.

METHOD

Studies were identified through 3 databases: PubMed, EMBASE, and the Cochrane Library. Statistical significance was defined as a P value of less than .05 for all analyses, conducted using STATA version 12.0.

RESULTS

In the comparison between staged versus Syn CAS and CABG for patients with concomitant severe coronary and carotid stenosis, 4 studies were analyzed. The staged procedure was associated with a lower rate of 30-day stroke (OR = 8.329, 95% CI = 1.017-69.229, P = .048) compared to Syn CAS and CABG. In the comparison between staged CAS and CABG versus Syn CEA and CABG for patients with concomitant severe coronary and carotid stenosis, 5 studies were examined. The staged CAS and CABG procedure was associated with a lower rate of mortality (OR = 2.046, 95% CI = 1.304-3.210, P = .002) compared to Syn CEA and CABG.

CONCLUSION

The Syn CAS and CABG was linked to a higher risk of peri-operative stroke compared to staged CAS and CABG. Additionally, patients undergoing staged CAS and CABG exhibited a significantly decreased risk of 30-day mortality compared to Syn CEA and CABG. Future randomized trials or prospective cohorts are essential to confirm and validate these findings.

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.

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.

A Systematic Review Supporting the Society for Vascular Surgery Guidelines on the Management of Carotid Artery Disease

BACKGROUND

To support the development of guidelines on the management of carotid disease, a writing committee from the Society for Vascular Surgery has commissioned this systematic review.

METHODS

We searched multiple data bases for studies addressing 5 questions: medical management vs. carotid revascularization (CEA) in asymptomatic patients, CEA vs. CAS in symptomatic low surgical risk patients, the optimal timing of revascularization after acute stroke, screening high risk patients for carotid disease, and the optimal sequence of interventions in patients with combined coronary and carotid disease. Studies were selected and appraised by pairs of independent reviewers. Meta-analyses were performed when feasible.

RESULTS

Medical management compared to carotid interventions in asymptomatic patients was associated with better early outcome during the first 30 days. However, CEA was associated with significantly lower long-term rate of stroke/death at 5 years. In symptomatic low risk surgical patients, CEA was associated with lower risk of stroke, but a significant increase in MI compared to CAS during the first 30 days. When the long-term outcome of transfemoral CAS vs. CEA in symptomatic patients were examined using pre-planned pooled analysis of individual patient data from four randomized trials, the risk of death or stroke within 120 days of the index procedure was 5.5% for CEA and 8.7% for CAS, which lends support that over the long-term, CEA has superior outcome than transfemoral CAS. When managing acute stroke, the comparison of CEA during the first 48 hours to that between day 2 and day14 did not reveal a statistically significant difference on outcomes during the first 30 days. Registry data show good results with CEA performed in the first week, but not within the first 48 hours. A single risk factor, aside from PAD, was associated with low carotid screening yield. Multiple risk factors greatly increase the yield of screening. Evidence on the timing of interventions in patients with combined carotid and coronary disease was sparse and imprecise. Patients without carotid symptoms, who had the carotid intervention first, compared to a combined carotid intervention and CABG, had better outcomes.

CONCLUSIONS

This updated evidence summary will support the SVS clinical practice guidelines for commonly raised clinical scenarios. CEA was superior to medical therapy in long-term prevention of stroke/death over medical therapy. CEA was also superior to transfemoral CAS in minimizing long-term stroke/death for symptomatic low risk surgical patients. CEA should optimally be performed between 2-14 days from the onset of acute stroke. Having multiple risk factors increases the value of carotid screening.

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.

Safety of different carotid artery revascularization strategies in the coronary artery bypass graft population: study protocol for a systematic review and network meta-analysis

BACKGROUND

Concomitant significant carotid artery occlusive diseases (CAOD) increase the risk of perioperative stroke and death in patients who undergo coronary artery bypass graft (CABG). Although several surgical strategies can be used in the management of such patients, controversy still surrounds which is the best option for CABG patients with accompanying CAOD.

METHODS

Literature searches will be conducted covering articles published in PubMed, the Cochrane Central Register of Controlled Trials, Web of Science, and Embase between January 1989 and December 2019. Search results will be limited to articles published in English. Six surgical strategies using carotid endarterectomy (CEA) or carotid artery stenting (CAS) with different timings (i.e., before, after, or combined with CABG) will be evaluated. Randomized controlled trials and non-randomized studies comparing these strategies will be included. The quality of studies will be critically appraised using the Cochrane risk-of-bias tool or ROBINS-I tool. Since CEA and CAS have comparable effectiveness for the treatment of significant CAOD, we will integrate direct and indirect evidence using network meta-analysis (NMA) to create hierarchies of the six surgical strategies based on their perioperative safety. The primary outcomes will be the probability of perioperative stroke and the probability of perioperative death. Additionally, we will analyze the probability of perioperative myocardial infarction (MI) as a secondary outcome. Pairwise meta-analyses and Bayesian network meta-analyses will be performed for all related outcome measures. Subgroup analyses, sensitivity analyses, and network meta-regression will be conducted to assess the robustness of the findings.

DISCUSSION

This NMA will summarize the direct and indirect evidence of perioperative safety with the aim of providing a ranking of the various surgical strategies. The results of this meta-analysis will provide useful information on optimal surgical management of CABG patients with concomitant significant CAOD.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42020162611.

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.

Prevalence of carotid artery stenosis in ischaemic heart disease patients in Bangladesh

Background:

Concurrent carotid artery stenosis and ischaemic heart disease rates are increasing day by day in Bangladesh. Moreover, carotid artery stenosis has been identified as a high-risk factor for postoperative ischaemic cerebral inconvenience following coronary artery bypass graft surgery.

Methods:

This observational cross-sectional study was performed to evaluate 200 study patients from July 2017 to June 2018. Patients with coronary artery disease scheduled for isolated elective coronary artery bypass graft surgery were included in the study, excluding those with coexisting valvular or congenital heart disease and emergency coronary artery bypass graft surgery.

Results:

About two-thirds of the study patients were 50–59 years old, with a mean age of 57.7 ± 3.06 years. Approximately 70% patients were male; the male:female ratio was 2.1:1. Most of the patients (74.5%) were Muslim. The majority of patients (59.0%) were overweight, and severe carotid artery stenosis was significantly higher in obese patients (p ⩽ 0.05). Furthermore, hypertension and diabetes mellitus were significantly associated with moderate to severe carotid artery stenosis (p ⩽ 0.05). Multi-vessel coronary artery disease was significantly associated with the severity of carotid artery stenosis. Bilateral carotid artery stenosis was significantly associated with the severity of carotid artery stenosis (p ⩽ 0.05).

Conclusion:

Routine duplex screening will identify significant carotid artery disease and will subsequently reduce the risk of perioperative stroke in ischaemic heart disease patients undergoing coronary artery bypass graft surgery.