Multivessel Disease and Severe Carotid Stenosis: How to Proceed

Myocardial revascularization surgery (CABG) is the most frequent of all cardiovascular surgeries and is still the gold standard to treat multivessel disease.  Between 6 and 8% of these patients present concomitant carotid stenosis and it is associated with increased peri and post procedural stroke rates during and after surgery.

To prevent carotid stenosis, either PCI or endarterectomy can be carried out, prior CABG or simultaneously.

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All data come from case series with different inclusion criteria or end point definitions, which is why no definite evidence from randomized and controlled studies show any advantage of endarterectomy over CABG, neither simultaneous nor staged, vs. isolated CABG.

Patients with severe asymptomatic stenosis to the internal carotid – ≥80% according to ECST (European Carotid Surgery Trial), or ≥70% by ECG, according to NASCET (North American Symptomatic Carotid Endarterectomy Trial)- requiring CABG were randomized to synchronous endarterectomy + CABG vs. isolated CABG. Randomization was stratified by center, age, sex and modified Rankin scale. Primary end point was rate of stroke and death at 30 days.

Between 2010 and 2014 a total 129 patients in 17 centers of Germany and the Czech Republic were enrolled. Poor recruitment and funding terminated enrolment earlier.

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At 30 days, the rate of any stroke or death was 12/65 (18.5%) in those receiving synchronous endarterectomy + CABG compared to 6/62 (9.7%) in patients undergoing isolated CABG (absolute risk reduction 8.8%; p=0.12).

Secondary end points saw no significant difference between the groups both at 30 days and a year, even though there was a tendency in favor of isolated CABG.

Conclusion

These outcomes are not definite, due to the study’s low statistical power, but combining endarterectomy and CABG in the same procedure seems unlikely to be the best treatment strategy. The 5 year follow up is still ongoing. 

Editorial Comment

Carotid stenting is an alternative to endarterectomy, though most studies have shown higher periprocedural stroke rate with stenting (mostly minor stroke). This happens mostly in elderly men, who typically present with both concomitant problems. 

A systematic version of cohort studies has showed a stroke and death rate of 9.1% with PCI and staged CABG. Some observational studies have also favored this strategy even more.  The problem is the need of at least one month of dual antiaggregation, which postpones surgery and exposes patients to coronary events while they wait.

Another possible strategy is to perform PCI and, if there were no complications, take patients straight to surgery, right after the cath lab. The procedure has to be carried out without dual antiaggregation, and after surgery, if there is no bleeding, the patient can receive clopidogrel by nasogastric tube. There is no randomized evidence for this last recommendation.

Original title: Safety of Simultaneous Coronary Artery Bypass Grafting and Carotid Endarterectomy Versus Isolated Coronary Artery Bypass Grafting. A Randomized Clinical Trial.

Reference: Christian Weimar et al. Stroke. 2017 Oct;48(10):2769-2775.

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