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Interact CardioVasc Thorac Surg 2009;9:278-281. doi:10.1510/icvts.2009.204354 © 2009 European Association of Cardio-Thoracic Surgery
Combined carotid stenting and urgent coronary artery surgery in unstable angina patients with severe carotid stenosis
a Department of Cardiothoracic Surgery, Centro Hospitalar de Vila Nova de Gaia/Espinho, EPE, Portugal Received 3 February 2009; received in revised form 6 April 2009; accepted 16 April 2009
*Corresponding author. Serviço de Cirurgia Cardiotorácica, Centro Hospitalar de Vila Nova de Gaia/Espinho, EPE, Rua Conceição Fernandes, s/n, 4434-502 Vila Nova de Gaia, Portugal. Tel.: (+351) 227865100; Tlm: (+351) 933734217; fax: (+351) 227865170.
Staged or combined carotid endarterectomy (CEA) offers the potential benefit of decreased neurological morbidity during and after cardiac surgery; however, the strategy for treating unstable high-risk patients, who need urgent coronary artery surgery, remains unresolved. We report in-hospital and 30-day outcomes of 23 consecutive patients admitted with unstable angina, who underwent carotid angioplasty and stenting (CAS) immediately prior to urgent coronary artery surgery, from October 2007 to October 2008. Aspirin and unfractioned heparin were administrated during carotid stenting and clopidogrel was only started after cardiac surgery. All patients remained event-free during and immediately after the carotid stenting procedure. One patient died due to sepsis 22 days after cardiac surgery. There was neither stroke nor myocardial infarction at follow-up. No patient needed a cardiac or carotid re-intervention. This new approach (combined carotid stenting and coronary artery surgery) provides a less radical intervention, can be performed with a low periprocedural complication rate and may become a valuable alternative in the treatment of high-risk patients with combined carotid and cardiac disease.
Key Words: Carotid stenting; Urgent coronary surgery; Stroke; Myocardial infarction; Mortality
Perioperative stroke is a well-recognized major complication of cardiac surgery. The presence of carotid disease in patients undergoing coronary artery bypass surgery (CABG) has been shown to increase this risk of perioperative stroke from the cardiac procedure 3-fold [1, 2]. Despite the limited available evidence regarding the benefit of prophylactic carotid re-vascularization, carotid endarterectomy (CEA) is often recommended for patients with asymptomatic but hemodynamically significant carotid stenosis, especially those having major cardiac surgery [3]. The rationale being that this strategy will reduce perioperative mortality and neurological morbidity. However, the overall effectiveness of this approach is ultimately dependent on the procedural risk. As a consequence, there has been considerable interest in establishing whether carotid angioplasty and stenting (CAS) might be a safer and better alternative. Although recent studies have shown that CAS is a feasible and effective minimally invasive technique, the effect of CAS on the incidence of death and stroke after cardiac surgery remains unclear [4, 5]. Another important issue is how one had to balance the optimal antiplatelet therapy required for CAS against not leaving the patient too long before undergoing CABG. In practice, the delay between performing CAS and cardiac surgery will inevitably be determined by the urgency of the cardiac disease. In patients with unstable angina requiring urgent cardiac surgery, the time between procedures should be very short. The concept of performing CAS and then immediately transfer the patient to the operating room (‘synchronous’ CASCABG) is not novel, but very few studies have reported their outcomes [6]. We reviewed our recent experience and outcome of this combined approach.
The studied population included 23 consecutive patients admitted with unstable angina who underwent CAS immediately prior to urgent CABG over a period of 12 months from October 2007 to October 2008. Patient informed consent was always obtained and the study was approved by hospital Ethics Committee. Clinical records and database were reviewed while clinical evolution was prospectively obtained by a medical interview. Patients were hospitalized because of coronary disease presented as unstable angina and a clinical status which required urgent cardiac surgery. Unstable angina included new-onset angina, accelerating angina, rest angina, early post-infarct angina, and early post-revascularization angina. We also included non-Q-wave MI. Urgent operations were defined as operative procedures performed in patients whose accelerated symptoms prompted urgent hospital admission for evaluation and who were judged to be too unstable for discharge before surgery. Patients found to have a significant carotid artery stenosis on duplex ultrasound (26.1%; 6 patients) or angiography during pre-assessment for cardiac surgery were included. All patients with critical stenosis on duplex underwent a diagnostic carotid angiography before CAS. Patients admitted with Q-wave or transmural myocardial infarction were excluded. It should be noted that in our hospital, carotid disease screening before cardiothoracic procedures was performed only in patients older than 65 years. Significant carotid artery disease was defined as luminal diameter reduction of >80%, according to North American Symptomatic Carotid Endarterectomy Trial criteria [7]. Valve disease was checked out by bidimensional echography and treated when indicated. Carotid angioplasty was done by femoral approach under local anesthesia and as previously described [8]. Cervical-cerebral angiography was previously performed according to the standard technique with intracranial views to determine patency and the completeness of the circle of Willis. Distal protection devices (ANGIOGUARD®) were routinely used and all patients received stenting (PRECISE®). To maximize stent deployment and vessel scaffolding, post-dilation was performed with a balloon (5.5–7.0 mm) after atropine (0.5 mg IV) was administered to prevent bradycardia and hypotension. Procedural success was defined as successful stent deployment with a residual diameter stenosis <30%, as determined by post-procedural quantitative carotid angiography. Cardiac surgery was performed immediately after CAS. Aspirin and unfractioned heparin were administrated during CAS and clopidogrel was started after CABG. The primary end point of the present study was the combined incidence of death and stroke from time of CAS to 30 days after cardiac surgery. Fatal stroke was defined as death attributed to an ischemic or hemorrhagic stroke. Minor stroke was defined as a new neurological deficit lasting >24 h but <7 days. Major stoke was defined as a new neurological deficit that persists >7 days. All patients were assessed before treatment, at discharge, and 30 days after the procedure by an independent stoke neurologist. Formal postoperative neurology consultation was obtained if there was any clinical suspicion of neurological event. Outcome events and complications from both the stenting and cardiac bypass procedures were registered. Absolute numbers and percentages were reported to describe the patient population.
Thirty-one CAS procedures in 23 patients were included in this study. The mean age was 77.0 years (range 65–86) and only 17.4% were women. CAS was performed pre-dominantly in the proximal right (n=14) and left (n=11) internal carotid artery but also included the common carotid artery (n=6). Bilateral carotid stenting was done in two patients and cerebral protection devices were used in all patients. Carotid stenting technical success was achieved in all patients. Additional history obtained at the time of stenting revealed that 13.0% (3 of 23) of our patients had neurological symptoms within the preceding six months. Patient demographics and clinical and procedural characteristics are summarized in Tables 1 and 2. One patient had restenosis post CEA.
All patients remained event-free during and immediately after CAS. After carotid stenting procedures, all patients immediately underwent CABG, in whom 16 procedures (69.6%) were off-pump, 4 (17.4%) were on-pump and 3 (13%) were combined with valve surgery. Thirty-day follow-up was performed in all patients. Table 3 summarizes outcome events and complications from both the stenting and cardiac bypass procedures. Rate complications reveal high-risk patients profile. One patient died due to sepsis with multiorgan failure at 22 days. There was no evidence of neurologic deficit in any patient. Overall in-hospital death rate was 4.3% (one patient) related to cardiac surgery complications. There was neither stroke nor myocardial infarction at follow-up. No patient needed a cardiac or carotid reintervention. No stent restenoses were diagnosed at Doppler follow-up evaluation.
The optimal management of patients with concomitant carotid and coronary artery disease who are scheduled to CABG remains controversial. Despite the limited available evidence regarding the benefit of prophylactic carotid re-vascularization, many cardiac surgery patients with advanced carotid and coronary disease are currently treated with staged or synchronous carotid/coronary interventions. The rationale being that this strategy will reduce perioperative mortality and neurological morbidity [9]. Risk factors for stroke during CABG that are frequently quoted in the literature, in addition to carotid artery stenosis, are ascending aortic atherosclerosis, previous stroke or transient ischemic attack, age, hypertension, diabetes, smoking, peripheral vascular disease, left ventricular dysfunction, left main coronary artery disease, renal failure, and increased cardiopulmonary bypass time [10, 11]. Several therapeutic options exist for patients with concomitant carotid and coronary artery disease: CABG alone, staged CEA and CABG, reversed staged CEA and CABG, and combined procedure during the same anesthesia. However, the overall effectiveness of those approaches are ultimately dependent on the procedural risk [9]. The use of carotid angioplasty or stenting as an alternative to CEA before cardiac surgery has been proposed as a less risky carotid re-vascularization strategy [12–14], mainly in acute situations who need urgent surgery and where staged strategies are not feasible [5]. Furthermore, the optimal strategy for the discontinuation of antiplatelet agents, which takes into account both adequate timing for complete carotid stent endothelialization with decreased platelet activation and a brief waiting period for cardiac surgery to reduce the incidence of cardiac events, is inconceivable [15]. Inevitably, a compromise is required. Hemodynamic instability, dynamic ST-T changes on electrocardiography, refractory angina despite optimal medical therapy or severe left main disease warrant immediate action. In the present study, all patients were immediately transferred to the operating room under aspirin and unfractionated heparin, but they only received clopidogrel after CABG. A staged CAS-CABG approach has been proposed, but need of an aggressive antiplatelet therapy for approximately one month after stenting represents an important limitation due to the risk of coronary events during this period. The ideal strategy for treating patients with severe asymptomatic carotid artery stenosis and coronary disease remains unclear, because the complication rates for procedures are not statistically different from the natural history data available [9, 12]. However, CAS immediately followed by CABG may provide a valuable treatment for patients with combined carotid and coronary disease, given the low periprocedural complication rates observed in the present study. The theoretical advantage of CAS is that it is less invasive and does not require a general anesthesia, therefore decreasing myocardial risks and cerebral ischemia of hemodynamic cause. Our strategy may have some additional advantages as compared with staged CEA-CABG or CAS-CABG approaches, by reducing the risk of acute myocardial infarction in the time elapsing between the two procedures as the interval between them is virtually eliminated. Therefore, in patients with combined carotid and coronary disease at high surgical risk, the proposed combined hybrid approach seems to be a possible therapeutic strategy. It should, however, be emphasized that carotid stenting is relatively new and that the long-term results are unknown. Therefore, in our opinion, only patients who are considered at unacceptable risk for CABG plus CEA, either by synchronous or delayed procedures, should currently be considered for carotid stenting. However, indications for carotid stenting could potentially be enlarged in the future if long-term results are good.
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Abstract
1. Introduction
