Courtesy of Dr. Carlos Fava.

Carotid artery disease is an important cause of stroke and is associated to coronary artery disease. When patients need myocardial revascularization surgery (Carotid Artery Bypass Graft) and cannot wait one month or more for carotid revascularization, the optimal management strategy is still controversial.

The aim of this study was to compare the evolution of three carotid revascularization strategies vs. CABG during the same hospitalization:

• carotid endarterectomy + simultaneous CABG (CEA+CABG),
• staged CEA + CABG (CEA+CABG2),
• staged carotid stenting + CABG (CAS+CABG2).

Data were obtained from the Nationwide Inpatient Sample database 2004 to 2012. 

The study included 22,501 patients, 15,402 (68.4%) received CEA+CABG, 6,297 (28%) CEA+CABG2 and 802 (3.6%) CAS+CABG2. Patients undergoing CAS+CABG2 more often presented high blood pressure, diabetes, diabetes related complications, anemia, chronic obstructive pulmonary disease, obesity, kidney failure and prior coronary PCI.

Adjusted death risk was higher in the groups receiving CEA, whereas the risk of stroke was higher in those undergoing CAS. Combined death/stroke risk was similar with all three strategies.

For the octogenarian and women subgroup, the CAS+CABG2 strategy presented lower mortality and stroke. For symptomatic patients, CAS+CABG2 was associated with better evolution than the other two, presenting 3 times less mortality and 4 times less stroke.

Conclusion

In patients with carotid artery disease and concomitant coronary artery disease undergoing combined revascularization, the most used strategy was carotid endarterectomy + CABG in the same procedure, followed by staged endarterectomy + CABG and, lastly, staged carotid stenting + CABG. 

The strategy combining carotid stenting and CABG was associated with lower mortality risk but higher risk of stroke. Further research is required to find out the risk benefit/ratio of the different revascularization strategies in high risk patients.

Editorial Comment

This analysis shows that carotid endarterectomy is the most used strategy. Carotid stenting presented lower mortality but globally had a higher rate of stroke, even though performed in high risk patients, which we should take into account.

When higher risk populations were analyzed, carotid stenting showed better results than carotid endarterectomy in patients with concomitant coronary artery disease.

Courtesy of Dr. Carlos Fava. Favaloro Foundation, Buenos Aires, Argentina.

Original Title: Comparison of trend and In-Hospital Outcomes of Concurrent carotid Artery Revascularization and Coronary Artery Bypass Graft Surgery. The United States Experience 2004 to 2012.

Reference: Feldman DN et al. J Am Coll Cardiol Interv 2017;10:286-98.

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