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Cardiac damage after carotid intervention: a meta-analysis after a decade of randomized trials

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Abstract

Purpose

This study synthesizes evidence from randomized controlled trials of the past decade regarding the relative safety of carotid endarterectomy (CEA) versus carotid angioplasty and stenting (CAS) as concerns postoperative cardiac damage.

Methods

We searched Medline, Embase, and Cochrane Central through November 2013 to December 2013. We determined trial eligibility and extracted descriptive, methodological, and outcome data related to cardiac damage after open or endovascular treatment. Cardiac damage was defined as evidence of symptomatic or asymptomatic myocardial ischemia/infarction.

Results

Nine trials (5,959 patients) were eligible for enrollment in this review. CAS was associated with a decreased risk for cardiac damage in all trials (pooled RR = 0.37; 95 % CI = 0.22–0.61, I 2 = 11 %, P = 0.0001), and specifically in the latest two randomized trials that show fewer methodological flaws (RR = 0.39; 95 % CI = 0.23–0.69, P = 0.03). CAS was associated with 11.5 fewer cardiac events (from 14.7 fewer to 6.3 fewer) compared to CEA.

Conclusions

Compared to open surgery, CAS is associated with significantly decreased risk for symptomatic and asymptomatic cardiac damage postoperatively. Therefore, a standardized troponin measurement after CEA should be further evaluated in future studies.

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References

  1. Skerritt MR, Block RC, Pearson TA, Young KC. Carotid endarterectomy and carotid artery stenting utilization trends over time. BMC Neurol. 2012;12:17.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 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: executive summary. Stroke. 2011;42:420–63.

    Article  Google Scholar 

  3. Jordan WD Jr, Alcocer F, Wirthlin DJ, Fisher WS, Warren JA, McDowell HA Jr, Whitley WD. High-risk carotid endarterectomy: challenges for carotid stent protocols. J Vasc Surg. 2002;35:16–21.

    Article  PubMed  Google Scholar 

  4. Wholey MH, Wholey M, Mathias K, Roubin GS, Diethrich EB, Henry M, Bailey S, Bergeron P, Dorros G, Eles G, Gaines P, Gomez CR, Gray B, Guimaraens J, Higashida R, Ho DS, Katzen B, Kambara A, Kumar V, Laborde JC, Leon M, Lim M, Londero H, Mesa J, Musacchio A, Myla S, Ramee S, Rodriquez A, Rosenfield K, Sakai N, Shawl F, Sievert H, Teitelbaum G, Theron JG, Vaclav P, Vozzi C, Yadav JS, Yoshimura SI. Global experience in cervical carotid artery stent placement. Catheter Cardiovasc Interv. 2000;50(2):160–7.

    Article  CAS  PubMed  Google Scholar 

  5. CAVATAS Investigators. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet. 2001;357:1729–37.

    Article  Google Scholar 

  6. International Carotid Stenting Study Investigators, Ederle J, Dobson J, Featherstone RL, Featherstone RL, Bonati LH, van der Worp HB, de Borst GJ, Lo TH, Gaines P, Dorman PJ, Macdonald S, Lyrer PA, Hendriks JM, McCollum C, Nederkoorn PJ, Brown MM. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet. 2010;375:985–97.

    Article  PubMed  Google Scholar 

  7. Hoffmann A, Engelter S, Taschner C, Mendelowitsch A, Merlo A, Radue EW, Lyrer P, Kirsch EC. Carotid artery stenting versus carotid endarterectomy: a prospective randomised controlled single-centre trial with long-term follow-up (BACASS). Schweiz Arch Neurol Psychiatry. 2008;159:84–9.

    Google Scholar 

  8. Ling F, Jiao LQ. Preliminary report of trial of endarterectomy versus stenting for the treatment of carotid atherosclerotic stenosis in China (TESCAS-C). Chin J Cerebrovasc Dis. 2006;3:4–8.

    Google Scholar 

  9. Steinvil A, Sadeh B, Arbel Y, Justo D, Belei A, Borenstein N, Banai S, Halkin A. Prevalence and predictors of concomitant carotid and coronary artery atherosclerotic disease. J Am Coll Cardiol. 2011;57:779–83.

    Article  PubMed  Google Scholar 

  10. Hallerstam S, Larsson PT, Zuber E, Rosfors S. Carotid atherosclerosis is correlated with extent and severity of coronary artery disease evaluated by myocardial perfusion scintigraphy. Angiology. 2004;55:281–8.

    Article  PubMed  Google Scholar 

  11. Altinbas A, Algra A, Brown MM, Featherstone RL, Kappelle LJ, de Borst GJ, Mali WP, van der Worp HB; International Carotid Stenting Study Investigators. Effects of carotid endarterectomy or stenting on hemodynamic complications in the International Carotid Stenting Study: a randomized comparison. Int J Stroke 2013; doi: 10.1111/ijs.12089. (Epub ahead of print).

  12. Ashton CM, Petersen NJ, Wray NP, Kiefe CI, Dunn JK, Wu L, Thomas JM. The incidence of perioperative myocardial infarction in men undergoing noncardiac surgery. Ann Intern Med. 1993;118:504–10.

    Article  CAS  PubMed  Google Scholar 

  13. Pasternack PF, Grossi EA, Baumann FG, Riles TS, Lamparello PJ, Giangola G, Primis LK, Mintzer R, Imparato AM. The value of silent myocardial ischemia monitoring in the prediction of perioperative myocardial infarction in patients undergoing peripheral vascular surgery. J Vasc Surg. 1989;10:617–25.

    Article  CAS  PubMed  Google Scholar 

  14. Hobson RW 2nd, Mackey WC, Ascher E, Murad MH, Calligaro KD, Comerota AJ, Montori VM, Eskandari MK, Massop DW, Bush RL, Lal BK, Perler BA. Management of atherosclerotic carotid artery disease: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2008;48:480–6.

    Article  PubMed  Google Scholar 

  15. Feringa HH, Hendriks JM, Karagiannis S, Schouten O, Vidakovic R, van Sambeek MR, Klein J, Noordzij P, Bax JJ, Poldermans D. Carotid artery stenting versus endarterectomy in relation to perioperative myocardial ischemia, troponin T release and major cardiac events. Coron Artery Dis. 2007;18:483–7.

    Article  PubMed  Google Scholar 

  16. Blackshear JL, Cutlip DE, Roubin GS, Hill MD, Leimgruber PP, Begg RJ, Cohen DJ, Eidt JF, Narins CR, Prineas RJ, Glasser SP, Voeks JH, Brott TG, CREST Investigators. Myocardial infarction after carotid stenting and endarterectomy. Results from the carotid revascularization endarterectomy versus stenting trial (CREST). Circulation. 2011;123:2571–8.

    Article  PubMed Central  PubMed  Google Scholar 

  17. Mas JL, Chatellier G, Beyssen B, EVA-3S Investigators. Carotid angioplasty and stenting with and without cerebral protection: clinical alert from the endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis (EVA-3S) trial. Stroke. 2004;35:18–20.

    Google Scholar 

  18. Steinbauer MG, Pfister K, Greindl M, Schlachetzki F, Borisch I, Schuirer G, Feuerbach S, Kasprzak PM. Alert for increased long-term follow-up after carotid artery stenting: results of a prospective, randomized, single-center trial of carotid artery stenting vs. carotid endarterectomy. J Vasc Surg. 2008;48:93–8.

    Article  PubMed  Google Scholar 

  19. Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK, Whitlow P, Strickman NE, Jaff MR, Popma JJ, Snead DB, Cutlip DE, Firth BG, Ouriel K. 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;351:1493–501.

    Article  CAS  PubMed  Google Scholar 

  20. Motamed C, Motamed-Kazerounian G, Merle JC, Dumérat M, Yakhou L, Vodinh J, Kouyoumoudjian C, Duvaldestin P, Becquemin JP. Cardiac troponin I assessment and late cardiac complications after carotid stenting or endarterectomy. J Vasc Surg. 2005;41:769–74.

    Article  PubMed  Google Scholar 

  21. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined: a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol. 2000;36:959–69.

    Article  CAS  PubMed  Google Scholar 

  22. Hsu J, Brożek JL, Terracciano L, Kreis J, Compalati E, Stein AT, Fiocchi A, Schünemann HJ. Application of GRADE: making evidence-based recommendations about diagnostic tests in clinical practice guidelines. Implement Sci. 2011;6:62.

    Article  PubMed Central  PubMed  Google Scholar 

  23. Murad MH, Shahrour A, Shah ND, Montori VM, Ricotta JJ. A systematic review and meta-analysis of randomized trials of carotid endarterectomy vs. stenting. J Vasc Surg. 2011;53:792–7.

    Article  PubMed  Google Scholar 

  24. Yavin D, Roberts DJ, Tso M, Sutherland GR, Eliasziw M, Wong JH. Carotid endarterectomy versus stenting: a meta-analysis of randomized trials. Can J Neurol Sci. 2011;38:230–5.

    PubMed  Google Scholar 

  25. Liu ZJ, Fu WG, Guo ZY, Shen LG, Shi ZY, Li JH. Updated systematic review and meta-analysis of randomized clinical trials comparing carotid artery stenting and carotid endarterectomy in the treatment of carotid stenosis. Ann Vasc Surg. 2012;26:576–90.

    Article  CAS  PubMed  Google Scholar 

  26. Wang L, Liu XZ, Liu ZL, Lan FM, Shi WC, Liu J, Zhang JN. A meta-analysis of carotid endarterectomy versus stenting in the treatment of symptomatic carotid stenosis. Chin Med J. 2013;126:532–5.

    PubMed  Google Scholar 

  27. Timaran CH, Mantese VA, Malas M, Brown OW, Lal BK, Moore WS, Voeks JH, Brott TG, CREST Investigators. Differential outcomes of carotid stenting and endarterectomy performed exclusively by vascular surgeons in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). J Vasc Surg. 2013;57(2):303–8.

    Article  PubMed Central  PubMed  Google Scholar 

  28. 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. 2011;42:687–92.

    Article  PubMed  Google Scholar 

  29. Guay J. Endovascular stenting or carotid endarterectomy for treatment of carotid stenosis: a meta-analysis. J Cardiothorac Vasc Anesth. 2011;25:1024–9.

    Article  PubMed  Google Scholar 

  30. Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, Mackey A, Hill MD, Leimgruber PP, Sheffet AJ, Howard VJ, Moore WS, Voeks JH, Hopkins LN, Cutlip DE, Cohen DJ, Popma JJ, Ferguson RD, Cohen SN, Blackshear JL, Silver FL, Mohr JP, Lal BK, Meschia JF, CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363:11–23.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  31. Thygesen K, Alpert JS, White HD, Jaffe AS, Katus HA, Apple FS, Lindahl B, Morrow DA, Chaitman BA, Clemmensen PM, Johanson P, Hod H, Underwood R, Bax JJ, Bonow RO, Pinto F, Gibbons RJ, Fox KA, Atar D, Newby LK, Galvani M, Hamm CW, Uretsky BF, Steg PG, Wijns W, Bassand JP, Menasché P, Ravkilde J, Ohman EM, Antman EM, Wallentin LC, Armstrong PW, Simoons ML, Januzzi JL, Nieminen MS, Gheorghiade M, Filippatos G, Luepker RV, Fortmann SP, Rosamond WD, Levy D, Wood D, Smith SC, Hu D, Lopez-Sendon JL, Robertson RM, Weaver D, Tendera M, Bove AA, Parkhomenko AN, Vasilieva EJ, Mendis S, ESC Committee for Practice Guidelines (CPG), Writing Group on the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction, ESC Committee for Practice Guidelines (CPG). Third universal definition of myocardial infarction. Eur Heart J. 2012;33:2551–67.

    Article  PubMed  Google Scholar 

  32. Galyfos G, Sigala F, Tsioufis K, Bakoyiannis C, Lagoudiannakis E, Manouras A, Zografos G, Filis K. Postoperative cardiac damage after standardized carotid endarterectomy procedures in low- and high-risk patients. Ann Vasc Surg. 2013;27(4):433–40.

    Article  PubMed  Google Scholar 

  33. Carotid Stenting Trialists’ Collaboration, Bonati LH, Dobson J, Algra A, Branchereau A, Chatellier G, Fraedrich G, Mali WP, Zeumer H, Brown MM, Mas JL, Ringleb PA. Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned meta-analysis of individual patient data. Lancet. 2010;376:1062–73.

    Article  PubMed  Google Scholar 

  34. Liapis CD, Bell PR, Mikhailidis D, Mikhailidis D, Sivenius J, Nicolaides A, Fernandes e Fernandes J, Biasi G, Norgren L, ESVS Guidelines Collaborators. ESVS Guidelines. Invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg. 2009;37(4):1–19.

    Article  CAS  PubMed  Google Scholar 

  35. Bunt TJ. The role of a defined protocol for cardiac risk assessment in decreasing perioperative myocardial infarction in vascular surgery. J Vasc Surg. 1992;15:626–34.

    Article  CAS  PubMed  Google Scholar 

  36. Mohler ER 3rd, Mantha S, Miller AB, Poldermans D, Cropp AB, St. Aubin LB, Billing CB Jr, Fleisher LA, Perioperative Myocardial Ischemic Injury Investigators. Should troponin and creatinine kinase be routinely measured after vascular surgery? Vasc Med. 2007;12:175–81.

    Article  PubMed  Google Scholar 

  37. McFalls EO, Ward HB, Moritz TE, Apple FS, Goldman S, Pierpont G, Larsen GC, Hattler B, Shunk K, Littooy F, Santilli S, Rapp J, Thottapurathu L, Krupski W, Reda DJ, Henderson WG. Predictors and outcomes of a perioperative myocardial infarction following elective vascular surgery in patients with a documented coronary artery disease: results of the CARP trial. Eur Heart J. 2008;29:394–401.

    Article  CAS  PubMed  Google Scholar 

  38. Flu WJ, Schouten O, van Kuijk JP, Poldermans D. Perioperative cardiac damage in vascular surgery patients. Eur J Vasc Endovasc Surg. 2010;40:1–8.

    Article  PubMed  Google Scholar 

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Acknowledgments

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Conflict of interest

There was no conflict of interest.

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Authors and Affiliations

  1. First Department of Propedeutic Surgery, University of Athens Medical School, Ippokrateion Hospital, Athens, Greece

    George Galyfos, Fragiska Sigala, Evridiki Karanikola, Konstantinos Toutouzas & Konstantinos Filis

  2. Department of Anesthesiology, Ippokrateion Hospital, Athens, Greece

    Chrisoula Loizou

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  1. George Galyfos
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  2. Fragiska Sigala
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  3. Evridiki Karanikola
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  6. Konstantinos Filis
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Correspondence to George Galyfos.

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Galyfos, G., Sigala, F., Karanikola, E. et al. Cardiac damage after carotid intervention: a meta-analysis after a decade of randomized trials. J Anesth 28, 866–872 (2014). https://doi.org/10.1007/s00540-014-1843-5

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  • DOI: https://doi.org/10.1007/s00540-014-1843-5

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