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Managing asymptomatic carotid disease in patients undergoing coronary artery bypass grafting

Peripheral Arterial Diseases


In the absence of randomized data, the optimal management of patients with severe carotid and coronary artery disease (CAD), especially those undergoing open heart surgery (OHS) and coronary bypass grafting (CABG), remains undetermined. (1-3)

As a general rule (2), in patients with multilevel atherosclerotic disease, the symptomatic vascular area should be treated first. The entirely surgical approach with carotid endarterectomy (CEA) and CABG is associated with high event rates. Therefore, whenever severe carotid disease is identified in the work-up prior to cardiac surgery, the indication for CABG should be reassessed and the feasibility of percutaneous coronary intervention (PCI) as an alternative treatment should be explored. If PCI is not an option, carotid artery stenting (CAS) prior to open heart should be considered if the expertise is available.
 
Although perioperative stroke is multifactorial and the value of revascularization of asymptomatic carotid disease prior to open heart surgery remains controversial, treatment of patients with severe bilateral carotid stenosis appears reasonable for perioperative stroke prevention (2). The aim of carotid revascularization in patients with unilateral severe carotid stenosis should be more long-term stroke prevention than merely perioperative stroke reduction.
The main advantage of CAS compared with CEA in patients with advanced CAD is the reduction of perioperative myocardial infarction, an event associated with long term mortality.
One of the main points under discussion is whether we have to undergo a synchronous or staged intervention. Many data from non randomized trials support the concept that synchronous CEA and open heart surgery is better than staged interventions.

A recent study by Shishehbor et al. (3) has to be cited because it brings some new insights into this difficult matter that can help the cardiovascular team to define the correct individual treatment strategy in this very challenging patient subset.
This is a retrospective analysis of 350 patients treated at the Cleveland Clinic from 1997-2009 who presented with combined high grade coronary and carotid artery disease, and met indications for revascularization of both vascular territories.
This well managed study provides clarity regarding the management of patients with carotid and coronary disease requiring open heart surgery (OHS).
Using propensity analysis, authors demonstrated that staged CAS-OHS and combined CEA-OHS had similar early hazard phase composite outcomes, while staged CEA-OHS incurred the highest risk driven by inter-stage MI. Subsequently, staged CAS-OHS experienced significantly fewer late hazard phase events in comparison to both staged CEA-OHS (adjusted hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.15 to 0.77; p = 0.01) and combined CEA-OHS (adjusted HR: 0.35; 95% CI: 0.18 to 0.70; p = 0.003).
From a clinical standpoint, these findings could lead to some consequences in terms of treatment strategies:

  • For patients presenting with an acute coronary syndrome requiring urgent coronary revascularization in whom waiting 3-4 weeks is not safe, combined CEA-OHS is the optimum revascularization strategy, though associated with higher neurological ischemic events.
  • For patients with stable or accelerating anginal syndrome who can wait 3-4 weeks to complete dual antiplatelet therapy after carotid stenting, staged CAS followed by OHS leads to superior early and long term outcomes.
  • Staged CEA followed by OHS is associated with an increased short term (inter-stage myocardial infarction) and long term (mortality) hazard and should be avoided.

In conclusion, the management of concomitant severe coronary and carotid disease depends on the severity of the carotid stenosis, on the estimated complication rate for the carotid procedure as well as on whether the coronary disease is stable or unstable.
All these concepts have been discussed today in a very interactive joint session between the ESC and the European Association of Cardio-Thoracic Surgery.
According to the themes discussed during the specific session dedicated to this still unresolved issue, we can sum up the conclusions in the algorithm for managing both symptomatic and asymptomatic carotid disease in patients undergoing coronary bypass grafting recently suggested by Roffi M. et al. (2)
1 - Early and long-term outcomes after combined percutaneous revascularization in patients with carotid and coronary artery stenoses. Tomai F, Pesarini G, Castriota F, Reimers B, De Luca L, De Persio G, Spartà D, Aurigemma C, Pacchioni A, Spagnolo B, Cremonesi A, Ribichini F; Finalized Research in Endovascular Strategies Study Group. JACC Cardiovasc Interv. 2011 May;4(5):560-8. doi: 10.1016/j.jcin.2011.01.012.
2 - Current concepts on the management of concomitant carotid and coronary disease. Roffi M, Cremonesi A. J Cardiovasc Surg (Torino). 2013 Feb;54(1):47-54
3 - A Direct Comparison of Early and Late Outcomes with Three Approaches to Carotid Revascularization and Open Heart Surgery. Shishehbor MH, Venkatachalam S, Sun Z, Rajeswaran J, Kapadia SR, Bajzer C, Gornik HL, Gray BH, Bartholomew JR, Clair DG, Sabik JF 3rd, Blackstone EH. J Am Coll Cardiol. 2013 Jul 19. doi:pii: S0735-1097(13)02775-7. 10.1016/j.jacc.2013.03.094.

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Managing asymptomatic carotid disease in patients undergoing coronary artery bypass grafting

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.