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Management of Combined Severe Carotid and Coronary Artery Disease

  • Peripheral Vascular Disease (M Shishehbor, Section Editor)
  • Published:
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Abstract

Patients with severe carotid and coronary disease—especially if they require coronary artery bypass grafting (CABG)—are at high risk of cardiac events and stroke. Carotid revascularization should be considered for patients with symptomatic carotid disease and bilateral severe asymptomatic carotid stenosis. In patients with unilateral asymptomatic carotid stenosis, decision to proceed to revascularization should be based more on a perspective of long-term stroke prevention than of perioperative stroke reduction. Compared with endarterectomy, carotid artery stenting is associated with a lower incidence of periprocedural myocardial infarction, an event linked to long-term mortality. This observation may be particularly relevant for patients with advanced coronary artery disease such as those undergoing CABG. Irrespective of the carotid revascularization strategy, a broad disease management approach based on lifestyle modification and pharmacologic cardiovascular prevention is more likely to affect both the quality and duration of life than revascularization itself.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Alberts MJ, Bhatt DL, Mas JL, et al. Three-year follow-up and event rates in the international REduction of Atherothrombosis for Continued Health Registry. Eur Heart J. 2009;30(19):2318–26.

    Article  PubMed  Google Scholar 

  2. Steg PG, Bhatt DL, Wilson PW, et al. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA. 2007;297(11):1197–206.

    Article  PubMed  CAS  Google Scholar 

  3. Venkatachalam S, Gray BH, Mukherjee D, Shishehbor MH. Contemporary management of concomitant carotid and coronary artery disease. Heart. 2011;97(3):175–80.

    Article  PubMed  Google Scholar 

  4. Naylor AR, Mehta Z, Rothwell PM, Bell PR. Carotid artery disease and stroke during coronary artery bypass: a critical review of the literature. Eur J Vasc Endovasc Surg. 2002;23(4):283–94.

    Article  PubMed  CAS  Google Scholar 

  5. de Weerd M, Greving JP, Hedblad B, et al. Prevalence of asymptomatic carotid artery stenosis in the general population: an individual participant data meta-analysis. Stroke. 2010;41(6):1294–7.

    Article  PubMed  Google Scholar 

  6. Kurvers HA, van der Graaf Y, Blankensteijn JD, Visseren FL, Eikelboom BC. Screening for asymptomatic internal carotid artery stenosis and aneurysm of the abdominal aorta: comparing the yield between patients with manifest atherosclerosis and patients with risk factors for atherosclerosis only. J Vasc Surg. 2003;37(6):1226–33.

    Article  PubMed  CAS  Google Scholar 

  7. Aboyans V, Lacroix P. Indications for carotid screening in patients with coronary artery disease. Presse Med. 2009;38(6):977–86.

    Article  PubMed  Google Scholar 

  8. Berens ES, Kouchoukos NT, Murphy SF, Wareing TH. Preoperative carotid artery screening in elderly patients undergoing cardiac surgery. J Vasc Surg. 1992;15(2):313–21. discussion 322–313.

    Article  PubMed  CAS  Google Scholar 

  9. Qureshi AI, Janardhan V, Bennett SE, Luft AR, Hopkins LN, Guterman LR. Who should be screened for asymptomatic carotid artery stenosis? Experience from the Western New York Stroke Screening Program. J Neuroimaging. 2001;11(2):105–11.

    Article  PubMed  CAS  Google Scholar 

  10. Hillis LD, Smith PK, Anderson JL, et al. ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011; in print.

  11. • Tendera M, Aboyans V, Bartelink ML, et al. 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;32:2851–6. For the first time, the European Guidelines on the diagnosis and treatment of peripheral artery diseases include the management of patients with multilevel arterial disease, and specifically those with carotid and coronary disease.

    Article  PubMed  Google Scholar 

  12. Likosky DS, Caplan LR, Weintraub RM, et al. Intraoperative and postoperative variables associated with strokes following cardiac surgery. Heart Surg Forum. 2004;7(4):E271–6.

    Article  PubMed  Google Scholar 

  13. Likosky DS, Marrin CA, Caplan LR, et al. Determination of etiologic mechanisms of strokes secondary to coronary artery bypass graft surgery. Stroke; J Cereb Circ. 2003;34(12):2830–4.

    Article  Google Scholar 

  14. Bucerius J, Gummert JF, Borger MA, et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg. 2003;75(2):472–8.

    Article  PubMed  Google Scholar 

  15. Stamou SC, Hill PC, Dangas G, et al. Stroke after coronary artery bypass: incidence, predictors, and clinical outcome. Stroke; J Cereb Circ. 2001;32(7):1508–13.

    Article  CAS  Google Scholar 

  16. Tarakji KG, Sabik 3rd JF, Bhudia SK, Batizy LH, Blackstone EH. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA. 2011;305(4):381–90.

    Article  PubMed  CAS  Google Scholar 

  17. • Naylor AR, Bown MJ. Stroke after cardiac surgery and its association with asymptomatic carotid disease: an updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2011;41(5):607–24. This is a comprehensive review on stroke among patients undergoing CABG, especially those with carotid disease.

    Article  PubMed  CAS  Google Scholar 

  18. Selim M. Perioperative stroke. N Engl J Med. 2007;356(7):706–13.

    Article  PubMed  CAS  Google Scholar 

  19. Kronzon I, Tunick PA. Aortic atherosclerotic disease and stroke. Circulation. 2006;114(1):63–75.

    Article  PubMed  Google Scholar 

  20. Borger MA. Preventing stroke during coronary bypass: are we focusing on the wrong culprit? J Card Surg. 2005;20(1):58–9.

    Article  PubMed  Google Scholar 

  21. Roach GW, Kanchuger M, Mangano CM, et al. Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med. 1996;335(25):1857–63.

    Article  PubMed  CAS  Google Scholar 

  22. Kurra V, Lieber ML, Sola S, et al. Extent of thoracic aortic atheroma burden and long-term mortality after cardiothoracic surgery: a computed tomography study. JACC Cardiovasc Imaging. 2010;3(10):1020–9.

    Article  PubMed  Google Scholar 

  23. Dubinsky RM, Lai SM. Mortality from combined carotid endarterectomy and coronary artery bypass surgery in the US. Neurology. 2007;68(3):195–7.

    Article  PubMed  Google Scholar 

  24. Timaran CH, Rosero EB, Smith ST, et al. Trends and outcomes of concurrent carotid revascularization and coronary bypass. J Vasc Surg. 2008;48(2):355–60. discussion 360–351.

    Article  PubMed  Google Scholar 

  25. • Venkatachalam S, Gray BH, Shishehbor MH. Open and endovascular management of concomitant severe carotid and coronary artery disease: tabular review of the literature. Ann Vasc Surg 2011; in print. This is an extensive review with a tabular summary of outcome data of patients with carotid and coronary disease.

  26. Roffi M, Mukherjee D, Clair DG. Carotid artery stenting vs. endarterectomy. Eur Heart J. 2009;30(22):2693–704.

    Article  PubMed  Google Scholar 

  27. Economopoulos KP, Sergentanis TN, Tsivgoulis G, Mariolis AD, Stefanadis C. Carotid artery stenting versus carotid endarterectomy: a comprehensive meta-analysis of short-term and long-term outcomes. Stroke; J Cereb Circ. 2011;42(3):687–92.

    Article  Google Scholar 

  28. Roffi M, Sievert H, Gray WA, et al. Carotid artery stenting versus surgery: adequate comparisons? Lancet Neurol. 2010;9(4):339–41. author reply 341–332.

    Article  PubMed  Google Scholar 

  29. 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):2036–42.

    Article  PubMed  Google Scholar 

  30. Roffi M. Management of patients with concomitant severe coronary and carotid artery disease: is there a perfect solution? Circulation. 2007;116(18):2002–4.

    Article  PubMed  Google Scholar 

  31. Velissaris I, Kiskinis D, Anastasiadis K. Synchronous carotid artery stenting and open heart surgery. J Vasc Surg. 2011;53(5):1237–41.

    Article  PubMed  Google Scholar 

  32. 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.

    Article  PubMed  Google Scholar 

  33. Blackshear JL, Cutlip DE, Roubin GS, et al. Myocardial infarction after carotid stenting and endarterectomy: results from the carotid revascularization endarterectomy versus stenting trial. Circulation. 2011;123(22):2571–8.

    Article  PubMed  Google Scholar 

  34. Landesberg G, Shatz V, Akopnik I, et al. Association of cardiac troponin, CK-MB, and postoperative myocardial ischemia with long-term survival after major vascular surgery. J Am Coll Cardiol. 2003;42(9):1547–54.

    Article  PubMed  CAS  Google Scholar 

  35. Kertai MD, Boersma E, Klein J, Van Urk H, Bax JJ, Poldermans D. Long-term prognostic value of asymptomatic cardiac troponin T elevations in patients after major vascular surgery. Eur J Vasc Endovasc Surg. 2004;28(1):59–66.

    Article  PubMed  CAS  Google Scholar 

  36. • Brott TG, Halperin JL, Abbara S, et al. ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation 2011;124(4):e54–130. This is the latest American guidelines on the management of patients with carotid disease.

    Article  PubMed  Google Scholar 

  37. Spence JD. Is there a role for revascularisation in asymptomatic carotid stenosis? No. BMJ. 2010;341:c4900.

    Article  PubMed  Google Scholar 

  38. Roffi M. Is there a role for revascularisation in asymptomatic carotid stenosis? Yes. BMJ. 2010;341:c4898.

    Article  PubMed  Google Scholar 

  39. Aichner FT, Topakian R, Alberts MJ, et al. High cardiovascular event rates in patients with asymptomatic carotid stenosis: the REACH Registry. Eur J Neurol. 2009;16(8):902–8.

    Article  PubMed  CAS  Google Scholar 

  40. Kakkos SK, Sabetai M, Tegos T, et al. Silent embolic infarcts on computed tomography brain scans and risk of ipsilateral hemispheric events in patients with asymptomatic internal carotid artery stenosis. J Vasc Surg. 2009;49(4):902–9.

    Article  PubMed  Google Scholar 

  41. Markus HS, King A, Shipley M, et al. Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observational study. Lancet Neurol 9(7):663-71.

  42. Inzitari D, Eliasziw M, Gates P, et al. The causes and risk of stroke in patients with asymptomatic internal-carotid-artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators [see comments]. N Engl J Med. 2000;342(23):1693–700.

    Article  PubMed  CAS  Google Scholar 

  43. Gurm HS, Yadav JS, Fayad P, et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med. 2008;358(15):1572–9.

    Article  PubMed  CAS  Google Scholar 

  44. Eckstein HH, Ringleb P, Allenberg JR, et al. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Lancet Neurol. 2008;7(10):893–902.

    Article  PubMed  Google Scholar 

  45. Mas JL, Trinquart L, Leys D, et al. Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial. Lancet Neurol. 2008;7(10):885–92.

    Article  PubMed  Google Scholar 

  46. Brott TG, Hobson 2nd RW, Howard G, Roubin GS, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11–23.

    Article  PubMed  CAS  Google Scholar 

  47. 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):379–87.

    Article  PubMed  CAS  Google Scholar 

  48. Maatz W, Kohler J, Botsios S, John V, Walterbusch G. Risk of stroke for carotid endarterectomy patients with contralateral carotid occlusion. Ann Vasc Surg. 2008;22(1):45–51.

    Article  PubMed  Google Scholar 

  49. Mehta RH, Zahn R, Hochadel M, et al. Effectiveness and safety of carotid artery stenting for significant carotid stenosis in patients with contralateral occlusion (from the German ALKK-CAS Registry experience). Am J Cardiol. 2009;104(5):725–31.

    Article  PubMed  Google Scholar 

  50. Feng ZZ, Shi J, Zhao XW, Xu ZF. Meta-analysis of on-pump and off-pump coronary arterial revascularization. Ann Thorac Surg. 2009;87(3):757–65.

    Article  PubMed  Google Scholar 

  51. Shroyer AL, Grover FL, Hattler B, et al. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med. 2009;361(19):1827–37.

    Article  PubMed  CAS  Google Scholar 

  52. Sharony R, Bizekis CS, Kanchuger M, et al. Off-pump coronary artery bypass grafting reduces mortality and stroke in patients with atheromatous aortas: a case control study. Circulation. 2003;108 Suppl 1:II15–20.

    PubMed  Google Scholar 

  53. Tomai F, Pesarini G, Castriota F, et al. Early and long-term outcomes after combined percutaneous revascularization in patients with carotid and coronary artery stenoses. JACC Cardiovasc Interv. 2011;4(5):560–8.

    Article  PubMed  Google Scholar 

  54. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360(10):961–72.

    Article  PubMed  CAS  Google Scholar 

  55. Kapur A, Hall RJ, Malik IS, et al. Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients. 1-year results of the CARDia (Coronary Artery Revascularization in Diabetes) trial. J Am Coll Cardiol. 2010;55(5):432–40.

    Article  PubMed  Google Scholar 

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Disclosure

Conflicts of interest: M. Roffi: none; F. Ribichini: none; F. Castriota: has received grant support from Medtronic and Boston Scientific; has received a consulting fee or honorarium from Medtronic and Boston Scientific; and has received travel/accommodations expenses covered or reimbursed from Medtronic and Boston Scientific; A. Cremonesi: has received grant support from Medtronic and Boston Scientific; has received a consulting fee or honorarium from Medtronic and Boston Scientific; and has received travel/accommodations expenses covered or reimbursed from Medtronic and Boston Scientific.

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Authors and Affiliations

  1. Interventional Cardiology Unit, Division of Cardiology, University Hospital, Rue Gabrielle Perret-Gentil 4, 1211, Geneva 14, Switzerland

    Marco Roffi

  2. Department of Medicine, Catheterisation Laboratories, University of Verona, Verona, Italy

    Flavio Ribichini

  3. GVM Care and Research, Interventional Cardio-Angiology Unit, Cotignola, Italy

    Fausto Castriota & Alberto Cremonesi

  4. Cardiovascular Interventional Unit, Piazzale A. Stefani 1, 37126, Verona, Italy

    Flavio Ribichini

  5. Maria Cecilia Hospital—GVM Care and Research Cotignola, 48010 Via Corriera 1, Cotignola, RA, Italy

    Fausto Castriota & Alberto Cremonesi

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  1. Marco Roffi
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  2. Flavio Ribichini
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  3. Fausto Castriota
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  4. Alberto Cremonesi
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Correspondence to Marco Roffi.

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Roffi, M., Ribichini, F., Castriota, F. et al. Management of Combined Severe Carotid and Coronary Artery Disease. Curr Cardiol Rep 14, 125–134 (2012). https://doi.org/10.1007/s11886-012-0246-1

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