Original title: A Direct Comparison of Early and Late Outcomes with Three Approaches to Carotid Revascularization and Open Heart Surgery. Reference: Mehdi H. Shishehbor et al. J Am Coll Cardiol, article in press.
The prevalence of severe carotid stenosis (> 80%) in patients planning to have a Central Venous Catheter (CVC) is estimated at between 6 and 12%. The best management strategy is controversial because no randomized studies exist. Some of the options perform Carotid Angioplasty and Stenting (CAS) in stages or Carotid Endarterectomy (CEA) and then the Central Venous Catheter (CVC) or combining CEA and CVC in the same procedure. Both options run the risk of events occurring in the intervening period, especially for those patients with severe coronary disease. Performing all the procedures at once eliminates the risk of waiting but increases perioperative risk. Between 1997 and 2009, 350 patients at one center received carotid revascularization (within 90 days) prior to central venous catheter (CABG, valve or combined).
Of these, 45 were conducted in stages CEA-CVC, 195 in the same procedure CEA-CVC and 110 in stages CAS-CVC. Most of the population consisted of patients who had received carotid ultrasound as a part of preoperative routine before central venous catheter. The surgery was decided for 12% in the context of unstable angina and in 7% for an acute myocardial infarction. Regarding carotid lesions, 19% had a history of transient ischemic attack or ipsilateral stroke within six months.
Propensity score was used to balance baseline characteristics as the group that received CAS-CVC had significantly more prior stroke (p = 0.03) and more complex surgeries, [combined coronary and valvular (p = 0.02) or aortic arch repair (p = 0.003)]. The average time between the two procedures was 14 days for CEA-CVC and 47 days for CAS-CVC. The CEA-CVC group had significantly more heart attacks compared with CAS-CVC in the interim period (24% versus 3%, p <0.001) but an equal number of strokes. In the Propensity adjusted score analysis a significantly increased risk of combined events in the interim waiting time for CEA-CVC was observed, (adjusted odds ratio: 5.47, 95% CI: 1.98 to 15.17, P = 0.001) but this was not so for CAS-CVC group (adjusted odds ratio: 0.95, 95% CI: 0.37 to 2.48, P = .92). At 30 days post central venous catheter a similar rate of events between performing CAS-CVC staged or CEA-CVC combined was observed and both performed significantly better than in CEA-CVC staged (p = 0.003), mainly due to heart attacks observed in the interim period. Beyond a year, the group staged CAS-CVC showed a significantly lower risk of events compared to both CEA-CVC combined (adjusted odds ratio: 0.35, 95% CI: 0.18 to 0.70, P = 0.003) and CEA-CVC in stages (adjusted odds ratio: 0.33, 95% CI: 0.15-0.77, p = .01). There was no difference in mortality between the three groups.
Conclusion:
Performing carotid angioplasty and staged central venous catheter has a similar risk of short-term combined events compared with carotid endarterectomy and central venous catheter in the same procedure. Beyond one year, staged carotid angioplasty with central venous catheter had the best result. Carotid endarterectomy in stages with central venous catheter had the worst performance of the three groups, mainly by the number of strokes observed in the intervening period.
Commentary:
While the combined results of endarterectomy with central venous catheter in the same procedure were similar to those of carotid angioplasty and surgery in stages, when analyzing events separately we observe a higher rate of stroke for the combination endarterectomy-CVC and a higher rate of heart attack during the waiting period for angioplasty- CVC. Because mortality is the same, these differences should be discussed with the patient and the team given the greater disability that stroke causes. Another option to the above problem is to analyze the possibility of a fourth group not considered in this work. Carotid angioplasty and at the same time CVC, in this way we would be eliminating interim infarctions.
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