1
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Caton MT, Narsinh KH, Baker A, Amans MR, Hetts SW, Rapp JH, Ianuzzi JC, Tseng E, Gasper WJ, Cooke DL. Eptifibatide bridging therapy for staged carotid artery stenting and cardiac surgery: Safety and feasibility. Vascular 2024; 32:433-439. [PMID: 35341420 PMCID: PMC11129521 DOI: 10.1177/17085381221084813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Prophylactic carotid artery stenting (CAS) is an effective strategy to reduce perioperative stroke in patients with severe carotid stenosis who require cardiothoracic surgery (CTS). Staging both procedures (CAS-CTS) during a single hospitalization presents conflicting demands for antiplatelet therapy and the optimal pharmacologic strategy between procedures is not established. The purpose of this study is to present our initial experience with a "bridging" protocol for staged CAS-CTS. METHODS A retrospective review of staged CAS-CTS procedures at a single referral center was performed. All patients had multivessel coronary and/or valvular disease and severe carotid stenosis (>70%). Patients not previously on aspirin were also started on aspirin prior to surgery, followed by eptifibatide during CAS (intraprocedural bolus followed by post-procedural infusion which was continued until the morning of surgery). Pre- and perioperative (30 days) neurologic morbidity and mortality was the primary endpoint. RESULTS 11 CAS procedures were performed in 10 patients using the protocol. The median duration of eptifibatide bridge therapy was 36 h (range 24-288 h). There was one minor bleeding complication (1/11, 9.1%) and no major bleeding complications during the bridging and post-operative period. There was one post-operative, non-neurologic death and zero perioperative ischemic strokes. CONCLUSIONS For patients undergoing staged CAS-CTS, Eptifibatide bridging therapy is a viable temporary antiplatelet strategy with a favorable safety profile. This strategy enables a flexible range of time-intervals between procedures.
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Affiliation(s)
- M Travis Caton
- Neurointerventional Radiology, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Kazim H Narsinh
- Neurointerventional Radiology, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Amanda Baker
- Neurointerventional Radiology, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Matthew R Amans
- Neurointerventional Radiology, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Steven W Hetts
- Neurointerventional Radiology, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Joseph H Rapp
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA, USA
| | - James C Ianuzzi
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Elaine Tseng
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Cardiothoracic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Warren J Gasper
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Daniel L Cooke
- Neurointerventional Radiology, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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2
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Aboyans V, Ricco JB, Bartelink MLEL, Björck M, Brodmann M, Cohnert T, Collet JP, Czerny M, De Carlo M, Debus S, Espinola-Klein C, Kahan T, Kownator S, Mazzolai L, Naylor AR, Roffi M, Röther J, Sprynger M, Tendera M, Tepe G, Venermo M, Vlachopoulos C, Desormais I. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 2019; 39:763-816. [PMID: 28886620 DOI: 10.1093/eurheartj/ehx095] [Citation(s) in RCA: 1904] [Impact Index Per Article: 380.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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3
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Extrakranielle Karotisstenose beim herzchirurgischen Patienten. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00398-018-0250-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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4
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Piątek J, Kędziora A, Dzierwa K, Konstanty-Kalandyk J, Wróżek M, Bryniarski KL, Musiałek P, Bartuś K, Kapelak B, Pieniążek P. Hybrid one-day coronary artery bypass grafting and carotid artery stenting - cardiac surgeons' perspective on the procedure's safety. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2018; 14:99-102. [PMID: 29743911 PMCID: PMC5939552 DOI: 10.5114/aic.2018.74362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 02/20/2018] [Indexed: 01/22/2023] Open
Affiliation(s)
- Jacek Piątek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Anna Kędziora
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Karolina Dzierwa
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Janusz Konstanty-Kalandyk
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Marcin Wróżek
- Cardiosurgical Students’ Scientific Group, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof L. Bryniarski
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Piotr Musiałek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Krzysztof Bartuś
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Bogusław Kapelak
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Piotr Pieniążek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
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5
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Long-Term Outcome After Carotid Endarterectomy in Patients with Ischemic Heart Disease. World Neurosurg 2017; 110:e806-e814. [PMID: 29180080 DOI: 10.1016/j.wneu.2017.11.092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 11/16/2017] [Accepted: 11/18/2017] [Indexed: 12/17/2022]
Abstract
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.
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Editor's Choice - 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2017; 55:305-368. [PMID: 28851596 DOI: 10.1016/j.ejvs.2017.07.018] [Citation(s) in RCA: 655] [Impact Index Per Article: 93.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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7
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Carotid Stenting Prior to Coronary Bypass Surgery: An Updated Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2017; 53:309-319. [DOI: 10.1016/j.ejvs.2016.12.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 12/08/2016] [Indexed: 12/30/2022]
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8
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Guía de práctica clíníca de la ESC sobre diagnóstico y tratamiento de las enfermedades arteriales periféricas. Rev Esp Cardiol 2012. [DOI: 10.1016/j.recesp.2011.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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9
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Open and Endovascular Management of Concomitant Severe Carotid and Coronary Artery Disease: Tabular Review of the Literature. Ann Vasc Surg 2012; 26:125-40. [DOI: 10.1016/j.avsg.2011.02.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 01/10/2011] [Accepted: 02/09/2011] [Indexed: 11/20/2022]
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10
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Okamoto Y, Minakata K, Yunoki T, Katsu M, Chino SI, Matsumoto M. Two-staged treatment strategy in patients with severe carotid or cerebrovascular diseases undergoing coronary artery bypass grafting. Gen Thorac Cardiovasc Surg 2011; 59:730-6. [DOI: 10.1007/s11748-011-0825-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 04/19/2011] [Indexed: 10/15/2022]
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Van der Heyden J, Van Neerven D, Sonker U, Bal ET, Kelder JC, Plokker HW, Suttorp MJ. Carotid Artery Stenting and Cardiac Surgery in Symptomatic Patients. JACC Cardiovasc Interv 2011; 4:1190-6. [DOI: 10.1016/j.jcin.2011.07.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 06/29/2011] [Accepted: 07/07/2011] [Indexed: 11/27/2022]
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12
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Don CW, House J, White C, Kiernan T, Weideman M, Ruggiero N, McCann A, Rosenfield K. Carotid Revascularization Immediately Before Urgent Cardiac Surgery. JACC Cardiovasc Interv 2011; 4:1200-8. [DOI: 10.1016/j.jcin.2011.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 09/19/2011] [Accepted: 09/19/2011] [Indexed: 10/15/2022]
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Mahmoudi M, Hill PC, Xue Z, Torguson R, Ali G, Boyce SW, Bafi AS, Corso PJ, Waksman R. Patients With Severe Asymptomatic Carotid Artery Stenosis Do Not Have a Higher Risk of Stroke and Mortality After Coronary Artery Bypass Surgery. Stroke 2011; 42:2801-5. [PMID: 21817149 DOI: 10.1161/strokeaha.111.618082] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Stroke development is a major concern in patients undergoing coronary artery bypass grafting (CABG). Whether asymptomatic severe carotid artery stenosis (CAS) contributes to the development of stroke and mortality in such patients remains uncertain.
Methods—
A retrospective analysis of 878 consecutive patients with documented carotid duplex ultrasound who underwent isolated CABG in our institution from January 2003 to December 2009 was performed. Patients with severe CAS (n=117) were compared with those without severe CAS (n=761) to assess the rates of stroke and mortality during hospitalization for CABG. The 30-day mortality rate was also assessed.
Results—
Patients with severe CAS were older and had a higher prevalence of peripheral arterial disease and heart failure. Patients with severe CAS had similar rates of in-hospital stroke (3.4% versus 3.6%;
P
=1.0) and mortality (3.4% versus 4.2%;
P
=1.0) compared with patients without severe CAS. The 30-day rate of mortality was also similar between the 2 cohorts (3.4% versus 2.9%;
P
=0.51).
Conclusions—
Severe CAS alone is not a risk factor for stroke or mortality in patients undergoing CABG. The decision to perform carotid imaging and subsequent revascularization in association with CABG must be individualized and based on clinical judgment.
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Affiliation(s)
- Michael Mahmoudi
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Peter C. Hill
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Zhenyi Xue
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Gholam Ali
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Steven W. Boyce
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Ammar S. Bafi
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Paul J. Corso
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
| | - Ron Waksman
- From the Department of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
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Tendera M, Aboyans V, Bartelink ML, Baumgartner I, Clément D, Collet JP, Cremonesi A, De Carlo M, Erbel R, Fowkes FGR, Heras M, Kownator S, Minar E, Ostergren J, Poldermans D, Riambau V, Roffi M, Röther J, Sievert H, van Sambeek M, Zeller T. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:2851-906. [PMID: 21873417 DOI: 10.1093/eurheartj/ehr211] [Citation(s) in RCA: 1035] [Impact Index Per Article: 79.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
-
- 3rd Division of Cardiology, Medical University of Silesia, Ziolowa 47, 40-635 Katowice, Poland.
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15
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Synchronous carotid artery stenting and open heart surgery. J Vasc Surg 2011; 53:1237-41. [DOI: 10.1016/j.jvs.2010.11.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 11/01/2010] [Accepted: 11/06/2010] [Indexed: 11/20/2022]
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16
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Current outcomes of simultaneous carotid endarterectomy and coronary artery bypass graft surgery in North America. World J Surg 2011; 34:2292-8. [PMID: 20645099 DOI: 10.1007/s00268-010-0506-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Management of patients with concomitant carotid and coronary artery disease has been controversial. Divergent strategies have been employed, including simultaneous carotid endarterectomy and coronary bypass (SCC) versus various staged procedures. Although no strict comparison group is available, this study defines current outcomes of SCC, compared qualitatively to two reference categories. METHODS Utilizing the STS database from 2003 to 2007, patients who had SCC were compared with patients with cerebrovascular disease who had coronary bypass (CABG) with prior carotid endarterectomy (CEA), and those with carotid Doppler stenosis >75% and no carotid intervention. Logistic regression analysis adjusted for differences in baseline characteristics and operative mortality (OM), and a composite of neurological complications (NC) was assessed. RESULTS Of 745,769 patients who underwent isolated CABG with/without CEA, 108,212 (14%) had cerebrovascular disease. Of this group, 5,732 (5%) underwent SCC. The SCC group had more males and lower preoperative risk factors. After statistical adjustment for all baseline differences, SCC had clinically and statistically higher OM and NC compared with any of the reference groups, with 20-40% higher event risk. CONCLUSIONS Although no quantitative control group exists for comparison, SCC as recently performed in North America has a high risk compared with any of the reference groups. Suboptimal results associated with the SCC strategy suggest a need for quality improvement and research on the optimal management of patients with simultaneous carotid and coronary disease.
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Yoda M, Hata M, Sezai A, Minami K. Surgical outcome of simultaneous carotid and cardiac surgery. Surg Today 2010; 41:67-71. [PMID: 21191693 DOI: 10.1007/s00595-009-4238-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2008] [Accepted: 03/31/2009] [Indexed: 10/18/2022]
Abstract
PURPOSE The surgical outcome of a simultaneous carotid endarterectomy and cardiac surgery has not been clarified. This study retrospectively reviewed short- and mid-term outcomes after a carotid endarterectomy combined with valvular surgery or coronary artery bypass grafting (CABG). METHODS Fifteen patients (12 males and 3 females, mean age 68.9 ± 6.7, range 59-86 years) underwent a carotid endarterectomy combined with cardiac surgery. The main indication for carotid endarterectomy was more than 75% carotid stenosis with or without cerebral ischemic symptom. Eight patients had a history of stroke or transient ischemic attack. Endarterectomy was performed under mild hypothermia and controlled hemodynamics with pulsatile perfusion with cardiopulmonary bypass in all cases. Concomitant cardiac procedures were aortic valve replacement in 1 patient and CABG in 14 patients. RESULTS There was no early death. Early neurological complications occurred in only 1 patient (6.7%). The ratio of heart-type fatty acid binding protein increased significantly in those that suffered postoperative neurological complications. One patient died 6 months after the operation due to pneumonia. There was no myocardial infarction, and no events were observed in the late postoperative periods. CONCLUSIONS Carotid endarterectomy can be safely performed in combination with cardiac surgery. Furthermore, the heat-type fatty acid binding protein levels might be useful for predicting early neurological complications.
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Affiliation(s)
- Masataka Yoda
- Department of Cardiovascular Surgery, The Cardiovascular Institute Hospital, 7-3-10 Roppongi, Minato-ku, Tokyo 106-0032, Japan
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18
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Rabellino M, Garcia-Nielsen L, Baldi S, Zander T, Casasola C, Estigarribia A, Llorens R, Maynar M. Non-protected carotid artery stent without angioplasty in high-risk patients with carotid and coronary artery disease undergoing cardiac surgery. MINIM INVASIV THER 2010; 19:184-8. [DOI: 10.3109/13645701003644194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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19
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Yuan SM, Wu HW, Jing H. Treatment strategy for combined carotid artery stenosis and coronary artery disease: staged or simultaneous surgical procedure? TOHOKU J EXP MED 2009; 219:243-50. [PMID: 19851053 DOI: 10.1620/tjem.219.243] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Patients with combined carotid and coronary arterial diseases pose a high risk of cerebrovascular events, and the treatment of choice with either a simultaneous or a staged surgical procedure remains controversial. The literature of combined carotid and coronary arterial diseases of a recent decade in English was retrieved. Totally 41,901 patients undergoing simultaneous or staged carotid and coronary procedures from 53 reports were included. As a result, carotid endarterectomy plus coronary artery bypass remained the most commonly used procedure for the intervention of combined carotid artery stenosis and coronary artery disease, and was associated with higher incidences of perioperative transient ischemic attack, stroke and hospital mortality, but with less perioperative myocardial infarction comparing with the staged procedures. Patients with a simultaneous carotid endarterectomy and coronary artery bypass were generally related more to an advanced atherosclerotic coronary artery disease, so that a pure comparison between the two strategies was not always possible. To compare the efficacy of different surgical methods for combined carotid and coronary arterial diseases is of pronounced importance. The new hybrid approach consisting of the simultaneous carotid artery stenting and subsequent on-pump coronary artery bypass can be a safe approach, with the aim to reduce the surgical trauma as compared to surgical procedures, and to reduce the risk of myocardial infarction in the interval period required for the staged operations. Thus, for patients with combined carotid artery stenosis and coronary artery disease, the simultaneous surgical procedure, rather than the staged procedure, is recommended.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Nanjing University, Nanjing, Jiangsu Province, People's Republic of China
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20
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Anastasiadis K, Karamitsos TD, Velissaris I, Makrygiannakis K, Kiskinis D. Preoperative screening and management of carotid artery disease in patients undergoing cardiac surgery. Perfusion 2009; 24:257-62. [PMID: 19755466 DOI: 10.1177/0267659109347404] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Carotid artery stenosis (CAS) is a well-known risk factor for perioperative stroke in cardiac surgery. It is unclear whether preoperative carotid screening should be applied to all patients. Carotid intervention concomitantly with cardiac operations is also controversial. Our objective was to identify the prevalence of significant CAS and its related risk factors by applying a protocol of preoperative carotid screening to all patients undergoing cardiac surgery. METHODS We studied 307 patients who were primarily screened preoperatively by duplex Doppler ultrasonography. Catheter carotid angiography or transcranial Doppler was performed on equivocal cases. Univariate and multivariate analyses were applied across selected parameters to identify risk factors for significant CAS (> 70%). The prevalence of CAS and perioperative stroke rates were determined. RESULTS Twenty-two patients with severe and 18 with moderate carotid stenosis were identified. Further radiological evaluation with catheter carotid angiography and transcranial Doppler confirmed the presence of significant CAS in 20 patients who underwent carotid stenting or endarterectomy before the open heart surgery. The cardiac surgeon was free to modify the surgical technique according to the preoperative assessment. No patient had major stroke perioperatively, while two minor strokes with complete neurologic recovery have been documented. The history of stroke and the presence of bruit on clinical examination were the only significant predictors of severe carotid disease. CONCLUSION Careful clinical examination together with detailed previous history taking can identify the majority of patients with CAS. Further data are required for the construction of a scientifically valid policy as a guideline.
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Affiliation(s)
- Kyriakos Anastasiadis
- Department of Cardiovascular Surgery, Kyanous Stavros Hospital, Thessaloniki, Greece.
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Aqel R, Dorfman TA. The brain first or the heart: the approach to revascularizing severe co-existing carotid and coronary artery disease. Clin Cardiol 2009; 32:418-25. [PMID: 19685511 DOI: 10.1002/clc.20443] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Raed Aqel
- Division of Cardiovascular Disease, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama 35233, USA.
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22
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Simultaneous Hybrid Revascularization by Carotid Stenting and Coronary Artery Bypass Grafting. JACC Cardiovasc Interv 2009; 2:393-401. [DOI: 10.1016/j.jcin.2009.02.010] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Revised: 01/21/2009] [Accepted: 02/07/2009] [Indexed: 11/17/2022]
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Naylor A, Mehta Z, Rothwell P. A Systematic Review and Meta-analysis of 30-Day Outcomes Following Staged Carotid Artery Stenting and Coronary Bypass. Eur J Vasc Endovasc Surg 2009; 37:379-87. [DOI: 10.1016/j.ejvs.2008.12.011] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Accepted: 12/16/2008] [Indexed: 10/21/2022]
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Das P, Clavijo LC, Nanjundappa A, Dieter RS. Revascularization of carotid stenosis before cardiac surgery. Expert Rev Cardiovasc Ther 2009; 6:1393-6. [PMID: 19018692 DOI: 10.1586/14779072.6.10.1393] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Carotid artery stenosis is often associated with advanced coronary artery disease. The coexistence of carotid and coronary artery disease adds complexity to the medical decision process and brings increasing challenge to the perioperative management of coronary artery bypass graft (CABG) surgery. Postoperative stroke remains one of the most devastating complications of CABG, thereby contributing to the increased risk of mortality following CABG. Carotid artery disease causes approximately a third of post-CABG stroke and thus needs to be addressed while preparing a patient for CABG. While carotid endarterectomy (CEA) has been the gold standard of carotid artery revascularization, carotid artery stenting may be noninferior to CEA in patients with increased surgical risks. Thus, a consensus as how to best revascularize patients with carotid artery stenosis before CABG is yet to emerge. We have reviewed the current literature and have addressed the pros and cons of the two modalities of carotid artery revascularization. Based on the current literature, the best management strategy for patients with concomitant surgical coronary artery disease in need of CABG and significant carotid artery stenosis should be based on individual patient characteristics, urgency of revascularization, prioritization based on the symptomatic vascular territory, local expertise with an integrated team approach by interventionalists, neurologists and cardiothoracic surgeons, preferably in high-volume centers.
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Affiliation(s)
- Pranab Das
- Department of Internal Medicine, Division of Cardiology, University of Tennessee Health Sciences Center, Memphis, TN 38104, USA.
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Casserly IP. Optimizing outcomes for patients with severe carotid and coronary disease. Catheter Cardiovasc Interv 2009; 73:143-4. [DOI: 10.1002/ccd.21951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Song MH, Nakayama T, Hattori K, Miyachi S. Asymptomatic severe carotid stenosis undergoing staged carotid artery stent and coronary artery bypass grafting: decisive role of brain single photon emission computed tomography. Gen Thorac Cardiovasc Surg 2009; 57:40-2. [PMID: 19160011 DOI: 10.1007/s11748-008-0323-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Accepted: 08/17/2008] [Indexed: 10/21/2022]
Abstract
Effort angina of a 70-year-old man was diagnosed as due to triple coronary vessel disease, and he was scheduled to undergo coronary artery bypass surgery. Preoperative carotid duplex scan revealed more than 75% stenosis of the right internal carotid artery, which was functionally proven to be significantly ischemic on brain single photon emission computed tomography. Although he was neurologically asymptomatic, we chose staged surgery for fear of stroke during coronary artery bypass surgery. He had successful carotid artery stenting first by neurosurgeons; then, 2 months later he underwent uneventful coronary artery bypass surgery. This experience prompted us to report the case.
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Affiliation(s)
- Min-Ho Song
- Department of Cardiovascular Surgery, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan.
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Van der Heyden J, Lans H, van Werkum J, Schepens M, Ackerstaff R, Suttorp M. Will Carotid Angioplasty Become the Preferred Alternative to Staged Or Synchronous Carotid Endarterectomy in Patients Undergoing Cardiac Surgery? Eur J Vasc Endovasc Surg 2008; 36:379-84. [DOI: 10.1016/j.ejvs.2008.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Accepted: 06/05/2008] [Indexed: 11/28/2022]
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Wakayama K, Shimamura M, Sata M, Koibuchi N, Sato N, Ogihara T, Morishita R. A model of cerebrovascular injury in rats. J Neurosci Methods 2008; 175:187-95. [PMID: 18786566 DOI: 10.1016/j.jneumeth.2008.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2007] [Revised: 07/27/2008] [Accepted: 08/04/2008] [Indexed: 12/01/2022]
Abstract
Although the pathophysiology of post-angioplasty restenosis has been extensively studied in extracranial arteries using transluminal vascular injury model in rodents, it is still not well known in the intracranial arteries, which have quite different structures from extracranial arteries. Here, we examined whether 1-min placement of modified intraluminal suture could induce an injury in the internal carotid artery (ICA) in rats and observed temporal profile of histological change after the injury. HE staining showed that the injured intracranial ICA was dilated, while the media was markedly thinned at 1 day after injury. The internal elastic lamina was not observed, and the media contained few cells. At 1 week after injury, a thin layer of neointimal hyperplasia was observed on the luminal side of the internal elastic lamina. Neointimal hyperplasia developed until at least 4 weeks after injury. Morphometric analysis demonstrated that the healing process of the injury was related to arterial remodeling. Immunohistochemical staining for alpha-smooth muscle actin and electron microscopic analysis showed that the neointima was composed of smooth muscle cells. Re-endothelialization was observed from 1 to 4 weeks after injury by immunohistochemical staining for von Willebrand's factor and electron microscopic analysis. Vascular endothelial growth factor was expressed in neointima on days 7 and 14. Interestingly, superoxide anion was not increased in injured arteries on day 3, when the infiltration of macrophages was intensive, but increased on day 7, when infiltrating macrophages almost disappeared. These findings might shed new light on pathophysiology of post-angioplasty restenosis in intracranial arteries.
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Affiliation(s)
- Kouji Wakayama
- Department of Advanced Clinical Science and Therapeutics, Graduate School of Medicine, University of Tokyo, Japan
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29
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Trends and outcomes of concurrent carotid revascularization and coronary bypass. J Vasc Surg 2008; 48:355-360; discussion 360-1. [DOI: 10.1016/j.jvs.2008.03.031] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Revised: 03/08/2008] [Accepted: 03/13/2008] [Indexed: 11/23/2022]
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Guzman LA, Costa MA, Angiolillo DJ, Zenni M, Wludyka P, Silliman S, Bass TA. A Systematic Review of Outcomes in Patients With Staged Carotid Artery Stenting and Coronary Artery Bypass Graft Surgery. Stroke 2008; 39:361-5. [PMID: 18174484 DOI: 10.1161/strokeaha.107.495010] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Luis A. Guzman
- From the Division of Cardiology (L.A.G., M.A.C., D.J.A., M.Z., T.A.B.), the Division of Neurology (S.S.), and the Office of Research Affairs (P.W.), University of Florida College of Medicine–Jacksonville, Jacksonville, Fla
| | - Marco A. Costa
- From the Division of Cardiology (L.A.G., M.A.C., D.J.A., M.Z., T.A.B.), the Division of Neurology (S.S.), and the Office of Research Affairs (P.W.), University of Florida College of Medicine–Jacksonville, Jacksonville, Fla
| | - Dominick J. Angiolillo
- From the Division of Cardiology (L.A.G., M.A.C., D.J.A., M.Z., T.A.B.), the Division of Neurology (S.S.), and the Office of Research Affairs (P.W.), University of Florida College of Medicine–Jacksonville, Jacksonville, Fla
| | - Martin Zenni
- From the Division of Cardiology (L.A.G., M.A.C., D.J.A., M.Z., T.A.B.), the Division of Neurology (S.S.), and the Office of Research Affairs (P.W.), University of Florida College of Medicine–Jacksonville, Jacksonville, Fla
| | - Peter Wludyka
- From the Division of Cardiology (L.A.G., M.A.C., D.J.A., M.Z., T.A.B.), the Division of Neurology (S.S.), and the Office of Research Affairs (P.W.), University of Florida College of Medicine–Jacksonville, Jacksonville, Fla
| | - Scott Silliman
- From the Division of Cardiology (L.A.G., M.A.C., D.J.A., M.Z., T.A.B.), the Division of Neurology (S.S.), and the Office of Research Affairs (P.W.), University of Florida College of Medicine–Jacksonville, Jacksonville, Fla
| | - Theodore A. Bass
- From the Division of Cardiology (L.A.G., M.A.C., D.J.A., M.Z., T.A.B.), the Division of Neurology (S.S.), and the Office of Research Affairs (P.W.), University of Florida College of Medicine–Jacksonville, Jacksonville, Fla
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Maharaj R. A review of recent developments in the management of carotid artery stenosis. J Cardiothorac Vasc Anesth 2008; 22:277-89. [PMID: 18375336 DOI: 10.1053/j.jvca.2007.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Ritesh Maharaj
- Department of Anaesthesia, University of Natal, Congella, South Africa
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Versaci F, Del Giudice C, Scafuri A, Zeitani J, Gandini R, Nardi P, Salvati A, Pampana E, Sebastiano F, Romagnoli A, Simonetti G, Chiariello L. Sequential Hybrid Carotid and Coronary Artery Revascularization: Immediate and Mid-Term Results. Ann Thorac Surg 2007; 84:1508-13; discussion 1513-4. [DOI: 10.1016/j.athoracsur.2007.05.048] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 05/18/2007] [Accepted: 05/21/2007] [Indexed: 11/16/2022]
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Türköz A, Türköz R, Gülcan O, Sener M, Kiziltan T, Calişkan E, Bozdoğan N, Arslan G. Wake-Up Test After Carotid Endarterectomy for Combined Carotid–Coronary Artery Surgery: A Case Series. J Cardiothorac Vasc Anesth 2007; 21:540-6. [PMID: 17678781 DOI: 10.1053/j.jvca.2006.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Indexed: 11/11/2022]
Abstract
OBJECTIVE In combined carotid-coronary artery surgery, it is important to determine patients' neurologic status after carotid endarterectomy (CEA). An initial stroke could be exacerbated by cardiopulmonary bypass required for coronary artery bypass graft (CABG) surgery. Various monitoring methods (eg, electroencephalogram) have been used to reduce neurologic deficits during CEA under general anesthesia. However, none of the methods of determining neurologic status of patients are ideal during the time between the end of CEA and the beginning of CABG surgery. In this study, patient's neurologic status was assessed after CEA with a wake-up test to identify stroke before CABG surgery. DESIGN A prospective nonrandomized case series. SETTING Single institution, university hospital. PARTICIPANTS Forty-four patients with carotid artery stenosis and coronary artery disease underwent combined carotid-coronary artery surgery. INTERVENTIONS After CEA, propofol and remifentanil anesthesia was discontinued, the wake-up test was performed, and then anesthesia was reinstituted for CABG surgery. MEASUREMENTS AND RESULTS A total of 48 wake-up tests were performed in 43 patients. Two wake-up tests were performed in each of the 5 patients who underwent bilateral CEA. Postoperative stroke were seen in 2 patients. In the first patient, despite a normal wake-up test, the stroke occurred in the cerebral hemisphere contralateral to the CEA, and the patient recovered within 12 days. In the second patient, there was a positive wake-up test after CEA, and he recovered within 3 days. One patient died postoperatively because of ventricular failure. CONCLUSIONS Although this is a case series, the authors believe that performing a neurologic examination using a wake-up test may make a contribution and increases the safety of combined surgical procedures in patients with coronary and carotid artery disease.
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Affiliation(s)
- Ayda Türköz
- Department of Anesthesiology, Başkent University Adana Teaching and Medical Research Center, Adana, Turkey.
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Cleveland T. Carotid intervention 1: who should be treated? Semin Intervent Radiol 2007; 24:221-5. [PMID: 21326799 DOI: 10.1055/s-2007-980044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Stroke is a major cause of morbidity and mortality in the modern world. Carotid artery atheromatous disease is responsible for a significant number of these events. The effects of carotid artery disease may be prevented by appropriate treatment. All patients with known atheromatous disease should be treated with medical therapy. Despite this, some patients remain at high risk of stroke, which may be reduced by the selective use of additional therapies such as carotid endarterectomy or carotid stenting. Patients who have had recent neurological symptoms, attributable to their carotid disease, may benefit most from these additional treatments, particularly if the treatment is performed soon after the event. The operation needs to be performed with low complication rates. Some groups of patients who have been free of neurological symptoms may also benefit from these additional therapies, but these patients have a much lower inherent risk of stroke, and so the potential benefits are less. In such circumstances it is even more important that the operations are performed with minimal morbidity. Patients undergoing coronary artery bypass grafts, who also have carotid disease, are at elevated risk of stroke, and it is common practice to treat both conditions. There is no strong data to support this practice.
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Affiliation(s)
- Trevor Cleveland
- Sheffield Vascular Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, United Kingdom
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Giorgetti PL, Odero A, Poletto GL, Franciosi E. Combined carotid endarterectomy and coronary artery bypass: a still-feasible procedure? Stroke 2007; 38:e51. [PMID: 17510460 DOI: 10.1161/strokeaha.106.476515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Pocar M, Moneta A, Mattioli R, Assaghi A, Donatelli F. Benefits of Staged Carotid Stenting Before Cardiac Surgery: a Randomized Trial Is Unwise. Stroke 2006; 37:2208; author reply 2209. [PMID: 16917089 DOI: 10.1161/01.str.0000237128.98571.e9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Randall MS, McKevitt FM, Venables GS, Cleveland TJ, Gaines PA. Response to Letter by Kramer et al. Stroke 2006. [DOI: 10.1161/01.str.0000223012.02184.b5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marc S. Randall
- Neurology Department, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, National Health Service Foundation Trust
| | - Fiona M. McKevitt
- Neurology Department, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, National Health Service Foundation Trust
| | - Graham S. Venables
- Neurology Department, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, National Health Service Foundation Trust
| | - Trevor J. Cleveland
- Sheffield Vascular Institute, Northern General Hospital, Sheffield Teaching Hospitals, National Health Service Foundation Trust
| | - Peter A. Gaines
- Sheffield Vascular Institute, Northern General Hospital, Sheffield Teaching Hospitals, National Health Service Foundation Trust
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Kramer J, Abraham J, Jones PA. Carotid Artery Stenting Before CABG: A Better Alternative to Treat Concomitant Coronary and Carotid Artery Disease. Stroke 2006; 37:1359; author reply 1360. [PMID: 16645126 DOI: 10.1161/01.str.0000223011.40166.ba] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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39
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Dalainas I, Nano G. Compatibility of carotid stenting and cardiac surgery. Stroke 2006; 37:1153-4; author reply 1154. [PMID: 16574917 DOI: 10.1161/01.str.0000217460.70676.fd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Mendiz O, Oscar M, Fava C, Carlos F, Valdivieso L, León V, Dulbecco E, Eduardo D, Raffaelli H, Héctor R, Lev G, Gustavo L, Favaloro R, Roberto F. Synchronous carotid stenting and cardiac surgery: An initial single-center experience. Catheter Cardiovasc Interv 2006; 68:424-8. [PMID: 16892442 DOI: 10.1002/ccd.20883] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Concurrent severe carotid and cardiac disease is a challenging situation where staged surgery is probably the most common strategy, although it is still controversial. We report in-hospital and midterm outcome of 30 patients who received carotid stenting and synchronous cardiac surgery. All received carotid stenting under aspirin and regular unfractioned heparin (UFH) and were immediately transferred to the operating room for coronary and/or cardiac valve surgery. All patients received aspirin and clopidogrel once bleeding was ruled out, after surgery. In-hospital complications were: three surgical related deaths, one TIA, and no patient suffered stroke or myocardial infarction. Hospital stay was 14 +/- 11.8 days. Survivors were followed for 18.4 +/- 14 months. There were two non-related deaths, but no stroke nor cardiac or carotid reinterventions. In conclusion, this small series showed that synchronous carotid stenting and cardiac surgery was feasible with an acceptable complication rate in a high-surgical-risk population which could not undergo staged procedures.
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Affiliation(s)
- Oscar Mendiz
- Department of Interventional Cardiology, Fundación Favaloro, Buenos Aires, Argentina.
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