A Systematic Review of Early Results Following Synchronous or Staged Carotid Artery Stenting and Coronary Artery Bypass Grafting

Abstract

Background The optimal management of patients with concomitant coronary artery disease (CAD) and severe carotid artery stenosis remains a controversy. We performed a systematic review of studies comparing early outcomes of synchronous or staged carotid artery stenting (CAS) and coronary artery bypass grafting (CABG) in the treatment of patients with concomitant CAD and severe carotid artery stenosis.

Methods Multiple databases were systematically searched to identify studies of synchronous or staged CAS and CABG in the treatment of concomitant severe carotid and coronary artery disease published from 2005 to 2015. The quality of studies was assessed using the MINORS scale. The demographic data, risk factors, 30-day outcomes, and antiplatelet strategy were extracted.

Results 23 studies were identified with a total of 873 and 459 patients in the staged and synchronous group, respectively. The observed overall death/stroke/MI rate was 8.5% (95% CI: 7.6–9.4%) in staged group and 4.8% (95% CI: 3.8–5.8%) in synchronous group. It seems that the synchronous group has better 30-day outcomes, but these data could not be compared statistically.

Conclusion Our systematic review suggests either synchronous or staged CAS and CABG can be chosen for the treatment of concomitant carotid and coronary artery disease. It seems that the synchronous approach is relatively convenient and the antiplatelet strategy is relatively definite. For these patients, hybrid revascularization by synchronous CAS and CABG might be a feasible and promising therapeutic strategy. Our conclusions and the quality of the existing data suggest that a randomized controlled trial is needed to define the best treatment for patients with concomitant carotid and coronary artery disease.

Keywords

cardiac - carotid arteries - coronary artery bypass surgery - stents

• References

• 1 Borger MA, Fremes SE, Weisel RD , et al. Coronary bypass and carotid endarterectomy: does a combined approach increase risk? A metaanalysis. Ann Thorac Surg 1999; 68 (1) 14-20 , discussion 21
• 2 Steinvil A, Sadeh B, Arbel Y , et al. Prevalence and predictors of concomitant carotid and coronary artery atherosclerotic disease. J Am Coll Cardiol 2011; 57 (7) 779-783
• 3 MRC European Carotid Surgery Trialists. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998; 351 (9113): 1379-1387
• 4 Knipp SC, Scherag A, Beyersdorf F , et al; CABACS Study Group. Randomized comparison of synchronous CABG and carotid endarterectomy vs. isolated CABG in patients with asymptomatic carotid stenosis: the CABACS trial. Int J Stroke 2012; 7 (4) 354-360
• 5 Das SK, Brow TD, Pepper J. Continuing controversy in the management of concomitant coronary and carotid disease: an overview. Int J Cardiol 2000; 74 (1) 47-65
• 6 Naylor AR, Cuffe RL, Rothwell PM, Bell PR. A systematic review of outcomes following staged and synchronous carotid endarterectomy and coronary artery bypass. Eur J Vasc Endovasc Surg 2003; 25 (5) 380-389
• 7 Brott TG, Hobson II RW, Howard G , et al; CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010; 363 (1) 11-23
• 8 Gurm HS, Yadav JS, Fayad P , et al; SAPPHIRE Investigators. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med 2008; 358 (15) 1572-1579
• 9 Versaci F, Del Giudice C, Scafuri A , et al. Sequential hybrid carotid and coronary artery revascularization: immediate and mid-term results. Ann Thorac Surg 2007; 84 (5) 1508-1513 , discussion 1513–1514
• 10 Van der Heyden J, Suttorp MJ, Bal ET , et al. Staged carotid angioplasty and stenting followed by cardiac surgery in patients with severe asymptomatic carotid artery stenosis: early and long-term results. Circulation 2007; 116 (18) 2036-2042
• 11 Barrera JG, Rojas KE, Balestrini C , et al. Early results after synchronous carotid stent placement and coronary artery bypass graft in patients with asymptomatic carotid stenosis. J Vasc Surg 2013; 57 (2, Suppl): 58S-63S
• 12 Shishehbor MH, Venkatachalam S, Sun Z , et al. A direct comparison of early and late outcomes with three approaches to carotid revascularization and open heart surgery. J Am Coll Cardiol 2013; 62 (21) 1948-1956
• 13 Kassaian SE, Abbasi K, Hakki Kazazi E , et al. Staged carotid artery stenting and coronary artery bypass surgery versus isolated coronary artery bypass surgery in concomitant coronary and carotid disease. J Invasive Cardiol 2013; 25 (1) 8-12
• 14 Versaci F, Reimers B, Del Giudice C , et al. Simultaneous hybrid revascularization by carotid stenting and coronary artery bypass grafting: the SHARP study. JACC Cardiovasc Interv 2009; 2 (5) 393-401
• 15 Chiariello L, Nardi P, Pellegrino A , et al. Simultaneous carotid artery stenting and heart surgery: expanded experience of hybrid surgical procedures. Ann Thorac Surg 2015; 99 (4) 1291-1297
• 16 Velissaris I, Kiskinis D, Anastasiadis K. Synchronous carotid artery stenting and open heart surgery. J Vasc Surg 2011; 53 (5) 1237-1241
• 17 Mendiz O, Fava C, Valdivieso L , et al. Synchronous carotid stenting and cardiac surgery: an initial single-center experience. Catheter Cardiovasc Interv 2006; 68 (3) 424-428 [Erratum in Catheter Cardiovasc Interv 2007;69(6):931]
• 18 Guerra M, Mota JC, Veloso M, Gama V, Vouga L. Combined carotid stenting and urgent coronary artery surgery in unstable angina patients with severe carotid stenosis. Interact Cardiovasc Thorac Surg 2009; 9 (2) 278-281
• 19 Palombo G, Stella N, Faraglia V , et al. Safety and effectiveness of combining carotid artery stenting with cardiac surgery: preliminary results of a single-center experience. J Cardiovasc Surg (Torino) 2009; 50 (1) 49-54
• 20 Dzierwa K, Pieniazek P, Musialek P , et al. Treatment strategies in severe symptomatic carotid and coronary artery disease. Med Sci Monit 2011; 17 (8) RA191-RA197
• 21 Velissaris I, Kiskinis D, Anastasiadis K. One stage carotid artery stenting and open heart surgery: a novel approach. J Cardiovasc Surg (Torino) 2011; 52 (4) 539-543
• 22 Van der Heyden J, Van Neerven D, Sonker U , et al. Carotid artery stenting and cardiac surgery in symptomatic patients. JACC Cardiovasc Interv 2011; 4 (11) 1190-1196
• 23 Randall MS, McKevitt FM, Cleveland TJ, Gaines PA, Venables GS. Is there any benefit from staged carotid and coronary revascularization using carotid stents? A single-center experience highlights the need for a randomized controlled trial. Stroke 2006; 37 (2) 435-439
• 24 Rabellino M, Garcia-Nielsen L, Baldi S , et al. Non-protected carotid artery stent without angioplasty in high-risk patients with carotid and coronary artery disease undergoing cardiac surgery. Minim Invasive Ther Allied Technol 2010; 19 (3) 184-188
• 25 Ziada KM, Yadav JS, Mukherjee D , et al. Comparison of results of carotid stenting followed by open heart surgery versus combined carotid endarterectomy and open heart surgery (coronary bypass with or without another procedure). Am J Cardiol 2005; 96 (4) 519-523
• 26 Kovacic JC, Roy PR, Baron DW, Muller DW. Staged carotid artery stenting and coronary artery bypass graft surgery: initial results from a single center. Catheter Cardiovasc Interv 2006; 67 (1) 142-148
• 27 Abbasi K, Fadaei Araghi M, Zafarghandi M , et al. Concomitant carotid endarterectomy and coronary artery bypass grafting versus staged carotid stenting followed by coronary artery bypass grafting. J Cardiovasc Surg (Torino) 2008; 49 (2) 285-288
• 28 Ranaweera PS, Bigelow BC, Leary MC, de la Torre R, Sellke F, Garcia LA. Endovascular carotid artery stenting and early coronary artery bypass grafting for asymptomatic carotid artery stenosis: long-term outcomes and neurologic events. Catheter Cardiovasc Interv 2009; 73 (2) 139-142
• 29 Polydorou AD, Megaloikonomos P, Moutiris JA , et al. Carotid angioplasty in asymptomatic patients undergoing CABG surgery. Int Angiol 2010; 29 (3) 239-243
• 30 Dzierwa K, Pieniazek P, Tekieli L , et al. Simultaneous or staged carotid artery stenting and coronary artery bypass grafting as the revascularization strategy for severe, concurrent carotid and coronary disease in TARGET-CAS study population. Eur Heart J 2013; 34 (Suppl. 01)
• 31 Zhang LG, Wu HC. Simultaneous hybrid or staged carotid artery stenting and off-pump coronary artery bypass for treatment of coronary artery disease in patients with concomitant severe carotid artery stenosis. Chin J Thorac Cardiovas Surg 2012; 28 (1) 20-23
• 32 Sharma V, Deo SV, Park SJ, Joyce LD. Meta-analysis of staged versus combined carotid endarterectomy and coronary artery bypass grafting. Ann Thorac Surg 2014; 97 (1) 102-109
• 33 Fareed KR, Rothwell PM, Mehta Z, Naylor AR. Synchronous carotid endarterectomy and off-pump coronary bypass: an updated, systematic review of early outcomes. Eur J Vasc Endovasc Surg 2009; 37 (4) 375-378
• 34 Venkatachalam S, Gray BH, Mukherjee D, Shishehbor MH. Contemporary management of concomitant carotid and coronary artery disease. Heart 2011; 97 (3) 175-180
• 35 Yadav JS, Wholey MH, Kuntz RE , et al; Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy Investigators. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004; 351 (15) 1493-1501
• 36 Naylor AR, Mehta Z, Rothwell PM. 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 (4) 379-387
• 37 Choi JC, Johnston SC, Kim AS. Early outcomes after carotid artery stenting compared with endarterectomy for asymptomatic carotid stenosis. Stroke 2015; 46 (1) 120-125