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Extrakranielle Karotisstenose beim herzchirurgischen Patienten

Diagnostik und Therapie

Carotid artery stenosis in patients undergoing cardiac surgery

Diagnostics and treatment

  • CME
  • Published:
Zeitschrift für Herz-,Thorax- und Gefäßchirurgie Aims and scope

Zusammenfassung

Die optimale Therapie von herzchirurgischen Patienten mit koexistierender schwerer koronarer und karotidaler Atherosklerose zur Reduzierung des Schlaganfallrisikos wird kontrovers diskutiert. Bis heute besteht keine hohe Evidenz für einen Vorteil der kombinierten Karotisrevaskularisation und koronaren Bypassoperation („coronary artery bypass grafting“, CABG) gegenüber der isolierten CABG. Während eine Karotisrevaskularisation bei symptomatischer Karotisstenose, unilateralen asymptomatischen Karotisstenosen mit aufgehobener zerebraler Reservekapazität, hochgradiger asymptomatischer Karotisstenose mit kontralateralem Verschluss oder hochgradigen asymptomatischen bilateralen Karotisstenosen (kumulativ >140 %) vorteilhaft sein kann, ist dies für die überwiegende Mehrheit der asymptomatischen Karotisstenosen nicht gesichert. Bislang wird daher empfohlen, die Indikation zur Karotisrevaskularisation bei Herzoperationen zurückhaltend zu stellen.

Abstract

The optimal treatment for reduction of the risk of stroke in cardiac surgery patients with concurrent severe coronary and carotid artery atherosclerosis is controversially discussed. To date, no high-level evidence exists that combined carotid artery revascularization and coronary bypass grafting (CABG) confer any benefit over isolated CABG. While carotid artery revascularization can be beneficial in cases of symptomatic carotid stenosis, unilateral asymptomatic carotid stenosis with good cerebral reserve capacity, high-grade asymptomatic carotid stenosis with contralateral occlusion or high-grade bilateral carotid artery stenosis (cumulative >140%), there is no proven benefit for the large majority of patients with asymptomatic carotid disease. It is therefore recommended that the indications for carotid revascularization in patients undergoing CABG should be considered with caution.

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Literatur

  1. Arning C et al (2010) Revision of DEGUM ultrasound criteria for grading internal carotid artery stenoses and transfer to NASCET measurement. Ultraschall Med 31(3):251–257

    Article  PubMed  CAS  Google Scholar 

  2. Eckstein HH (2012) S3-Leitlinie zur Diagnostik, Therapie und Nachsorge der extracraniellen Carotisstenose. AWMF-Register Nr. 004/028, S 1–217

    Google Scholar 

  3. Naylor AR, Bell PRF (2002) Carotid artery disease and stroke during coronary artery bypass: a critical review of the literature. Eur J Vasc Endovasc Surg 23:283–294

    Article  PubMed  CAS  Google Scholar 

  4. Wardlaw JM et al (2006) Non-invasive imaging compared with intra-arterial angiography in the diagnosis of symptomatic carotid stenosis: a meta-analysis. Lancet 367:1503–1512

    Article  PubMed  CAS  Google Scholar 

  5. Daneault B, Kirtane AJ, Kodall SK et al (2011) Stroke associated with surgical and transcatheter treatment of aortic stenosis. A comprehensive review. J Am Coll Cardiol 58:2143–2150

    Article  PubMed  Google Scholar 

  6. Rankin J (1957) Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J 2:200–215

    Article  PubMed  CAS  Google Scholar 

  7. Barnett HJ, Taylor DW, Eliasziw M et al (1998) Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 339:1415–1425

    Article  PubMed  CAS  Google Scholar 

  8. Naylor R, Cuffe RL, Rothwell PM, Loftus IM, Bell PR (2003b) A systematic review of outcome following synchronous carotid endarterectomy and coronary artery bypass: influence of surgical and patient variables. Eur J Vasc Endovasc Surg 26:230–241

    Article  PubMed  CAS  Google Scholar 

  9. Tarakji KG, Sabik JF III, Bhudia SK, Batizy LH, Blackstone EH (2011) Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA 305:381–390

    Article  PubMed  CAS  Google Scholar 

  10. Ricotta JJ, Faggioli GL, Castiloni A, Hasset JM (1995) Risk factors for stroke after cardiac surgery. Buffalo cardiac-cerebral study group. J Vasc Surg 21:359–363

    Article  PubMed  CAS  Google Scholar 

  11. Roach GW, Kangucher M, Mangano CM et al (1996) Adverse cerebral outcomes after coronary bypass surgery: multicenter study of perioperative ischemia research group and the ischemia research and education foundation investigators. N Engl J Med 335:1857–1863

    Article  PubMed  CAS  Google Scholar 

  12. McKhann GM, Grega MA, Borowicz LM Jr et al (2006) Stroke and encephalopathy after cardiac surgery: an update. Stroke 37:562–571

    Article  PubMed  Google Scholar 

  13. Lloyed-Jones D, Adams R, Carnethon M et al (2009) Heart Disease and stroke statistics 2009 update. A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 119:480–486

    Article  Google Scholar 

  14. Hogue CW, Murphy SF, Schechtman KB, Davila-Roman VG (1999) Risk factors for early or delayed stroke after cardiac surgery. Circulation 100:642–647

    Article  PubMed  Google Scholar 

  15. Likosky DS, Leavitt BJ, Marrin CA et al (2003) Intra- and postoperative predictors of stroke after coronary artery bypass grafting. Ann Thorac Surg 76:428–434

    Article  PubMed  Google Scholar 

  16. Selim M (2007) Perioperative stroke. N Engl J Med 356:706–713

    Article  PubMed  CAS  Google Scholar 

  17. Nathan HJ, Wells GA, Munson JL, Wozny D (2001) Neuroprotective effect of mild hypothermia in patients undergoing coronary artery surgery with cardiopulmonary bypass. A randomized trial. Circulation 104(suppl I):I-85–I-91

    Article  CAS  Google Scholar 

  18. Ozen Y, Aksoy E, Sarikaya S et al (2015) Effect of hypothermia in patients undergoing simultaneous carotid endarterectomy and coronary artery bypass graft surgery. Cardiovasc J Afr 26:17–20

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  19. DeBakey ME, Crawford ES, Cooley DA et al (1965) Cerebral arterial insufficiency: one to 11-year results following arterial reconstructive operation. Ann Surg 161:921–945

    Article  PubMed  CAS  Google Scholar 

  20. Bernhard VM, Johnson WD, Peterson JJ (1972) Carotid artery stenosis. Association with surgery for coronary artery disease. Arch Surg 105:837–840

    Article  PubMed  CAS  Google Scholar 

  21. Das SK, Brow TD, Pepper J (2000) Continuing controversy in the management of concomitant coronary and carotid disease: an overview. Int J Cardiol 74:47–65

    Article  PubMed  CAS  Google Scholar 

  22. Naylor AR, Mehta Z, Rothwell PM (2009) A systematic review and meta-analysis of 30-day outcomes following staged carotid artery stenting and coronary bypass. Eur J Vasc Endovasc Surg 37:379–387

    Article  PubMed  CAS  Google Scholar 

  23. Ghosh J, Murray D, Khwaja N, Murphy MO, Walker MG (2005) The influence of asymptomatic significant carotid disease on mortality and morbidity in patients undergoing coronary artery bypass surgery. Eur J Vasc Endovasc Surg 29:88–90

    Article  PubMed  CAS  Google Scholar 

  24. Schoof J, Lubahn W, Baeumer M et al (2007) Impaired cerebral autoregulation distal to carotid stenosis/occlusion is associated with increased risk of stroke at cardiac surgery with cardiopulmonary bypass. J Thorac Cardiovasc Surg 134:690–696

    Article  PubMed  Google Scholar 

  25. Mahmoudi M, Hill PC, Xue Z et al (2011) Patients with severe asymptomatic carotid artery stenosis do not have a higher risk of stroke and mortality after coronary artery bypass surgery. Stroke 42:2801–2805

    Article  PubMed  Google Scholar 

  26. Ricotta JJ, Wall LP, Blackstone E (2005) The influence of concurrent carotid endarterectomy on coronary bypass: a case-controlled study. J Vasc Surg 41:397–401 (discussion: 401–402)

    Article  PubMed  Google Scholar 

  27. Hill MD, Shrive FM, Kennedy J, Feasby TE, Ghali WA (2005) Simultaneous carotid endarterectomy and coronary artery bypass surgery in Canada. Neurology 64:1435–1437

    Article  PubMed  CAS  Google Scholar 

  28. Dubinsky RM, Lai SM (2007) Mortality from combined carotid endarterectomy and coronary artery bypass surgery in the US. Neurology 68:195–197

    Article  PubMed  Google Scholar 

  29. Brown KR, Kresowik TF, Chin MH, Kresowik RA, Grund SL, Hendel ME (2003) Multistate population based outcomes of combined carotid endarterectomy and coronary artery bypass. J Vasc Surg 37:32–39

    Article  PubMed  Google Scholar 

  30. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study (1995) Endarterectomy for asymptomatic carotid artery stenosis. Executive committee for the asymptomatic carotid atherosclerosis study. JAMA 273:1421–1428

    Article  Google Scholar 

  31. Byrne J, Darling RCR, Roddy SP et al (2006) Combined carotid endarterectomy and coronary artery bypass grafting in patients with asymptomatic high-grade stenoses: an analysis of 758 procedures. J Vasc Surg 44:67–72

    Article  PubMed  Google Scholar 

  32. Ascher E, Hingorani A, Yorkovich W, Ramsey PJ, Salles-Cunha S (2001) Routine preoperative carotid duplex scanning in patients undergoing open heart surgery: is it worthwhile? Ann Vasc Surg 15:669–678

    Article  PubMed  CAS  Google Scholar 

  33. Durand DJ, Perler BA, Roseborough GS et al (2004) Mandatory versus selective preoperative carotid screening: a retrospective analysis. Ann Thorac Surg 78:159–166

    Article  PubMed  Google Scholar 

  34. Sheiman RG, d’Othee BJ (2007) Screening carotid sonography before elective coronary artery bypass graft surgery: who needs it. Am J Roentgenol 188:W475–W479

    Article  Google Scholar 

  35. North American Symptomatic Carotid Endarterectomy Trial Collaborators (1991) Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 325:445–453

    Article  Google Scholar 

  36. European Carotid Surgery Collaborative Trialists’Group (1998) Randomized trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid surgery Trial (ECST). Lancet 351:1379–1387

    Article  Google Scholar 

  37. Brott TG, Hobson RW 2nd, Howard G et al (2010) Stenting versus endarterectomy for treatment of carotid artery stenosis. N Engl J Med 363:11–23

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  38. Hill MD, Brooks W, Mackey A et al (2012) Stroke after carotid stenting and endarterectomy in the carotid revascularization endarterectomy versus stenting trial. Circulation 126:3054–3061

    Article  PubMed  PubMed Central  Google Scholar 

  39. International Carotid Study Investigators et al (2010) Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study). An interim analysis of a randoimized controlled trial. Lancet 375:985–997

    Article  Google Scholar 

  40. Luebke T, Brunkwall J (2016) Carotid artery stenting versus carotid endarterectomy: updated meta-analysis, metaregression and trial sequential analysis of short-term and intermediate-to long-term outcomes of randomized trials. J Cardiovasc Surg 57:519–539

    Google Scholar 

  41. Halliday A, Mansfield A, Marro J et al (2004) Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controled trial. Lancet 363:1491–1502

    Article  PubMed  CAS  Google Scholar 

  42. Halliday A, Harrison M, Hayter E et al (2010) 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet 376:1074–1084

    Article  PubMed  PubMed Central  Google Scholar 

  43. Hertzer NR, Beven EG, O’Hara PJ, Krjewski LP (1989) Surgical staging for simultaneous coronary and carotid disease: a study including prospective randomisation. J Vasc Surg 9:455–463

    Article  PubMed  CAS  Google Scholar 

  44. Knipp S, Scherag A, Beyersdorf F et al (2012) Randomized comparison of synchronous CABG and carotid endarterectomy vs. isolated CABG in patients with asymptomatic carotid stenosis: the CABACS trial. Int J Stroke 7:354–360

    Article  PubMed  CAS  Google Scholar 

  45. Hertzer NR, O’Hara PJ, Mascha EJ, Krajewski LP, Sullivan TM, Beven EG (1997) Early outcome assessment for 2228 consecutive carotid endarterectomy procedures: the cleveland clinic experience from 1989 to 1995. J Vasc Surg 26:1–10

    Article  PubMed  CAS  Google Scholar 

  46. Versaci F, Del Giudice C, Scafuri A et al (2007) Sequential hybrid carotid coronary artery revascularization: immediate and mid-term results. Ann Thorac Surg 84:1508–1513

    Article  PubMed  Google Scholar 

  47. Versaci F, Reimers B, Del Giudice C et al (2009) Simultaneous hybrid revascularization by carotid stenting and coronary artery bypass grafting. The SHARP study. J Am Coll Cardiol Intv 2:393–401

    Article  Google Scholar 

  48. Randall MS, McKevitt FM, Cleveland TJ, Gaines PA, Venables GS (2006) Is there any benefit from staged carotid and coronary revascularization using carotid stents? A single-center experience highlights the need for a randomized controlled trial. Stroke 37:435–439

    Article  PubMed  Google Scholar 

  49. Van der Heyden J, Suttorp MJ, Bal ET et al (2008) Will carotid angioplasty become the preferred alternative to staged or synchronous carotid endarterectomy in patients undergoing cardiac surgery? Eur J Vasc Endovasc Surg 36:379–384

    Article  PubMed  CAS  Google Scholar 

  50. Chiariello L, Nardi P, Pellegrino A et al (2015) Simultaneous carotid artery stenting and heart surgery: expanded experience of hybrid surgical procedures. Ann Thorac Surg 99:1291–1297

    Article  PubMed  Google Scholar 

  51. Minami K, Fukahara K, Boethig D, Bairaktaris A, Fritzsche D, Koerfer R (2000) Long-term results of simultaneous carotid endarterectomy and myocardial revascularization with cardiopulmonary bypass used for both procedures. J Thorac Cardiovasc Surg 119:764–773

    Article  PubMed  CAS  Google Scholar 

  52. Bonacchi M, Prifti E, Frati G et al (2002) Concomitant carotid endarterectomy and coronary bypass surgery: should cardiopulmonary bypass be used for the carotid procedure? J Card Surg 17:51–59

    Article  PubMed  CAS  Google Scholar 

  53. Naylor AR, Cuffe RL, Rothwell PM, Bell PR (2003a) A systematic review of outcomes following staged and synchronous carotid endarterectomy and coronary artery bypass. Eur J Vasc Endovasc Surg 25:380–389

    Article  PubMed  CAS  Google Scholar 

  54. Roffi M (2007) Management of patients with concomittant severe coronary and carotid artery disease: Is there a perfect solution. Circulation 116:2002–2004

    Article  PubMed  Google Scholar 

  55. Gopaldas RR, Chu D, Dao TK et al (2011) Staged versus synchronous carotid endarterectomy and coronary artery bypass grafting: analysis of 10-year nationwide outcomes. Ann Thorac Surg 91:1323–1329

    Article  PubMed  Google Scholar 

  56. Timaran CH, Rosero EB, Smith ST et al (2008) Trends and ouitcomes of concurent carotid revascularization and coronary bypass. J Vasc Surg 48:355–361

    Article  PubMed  Google Scholar 

  57. Beauford RB, Saunders CR, Goldstein DJ (2003) Off pump concomitant coronary revascularization and carotid endarterectomy. J Cardiovasc Surg (Torino) 44:407–415

    CAS  Google Scholar 

  58. Mishra Y, Wasir H, Kohli V et al (2004) Concomitant carotid endarterectomy and coronary bypass surgery: outcome of on-pump and off-pump techniques. Ann Thorac Surg 78:2037–2043

    Article  PubMed  Google Scholar 

  59. Fareed K, Rothwell PM, Mehta Z, Naylor AR (2009) Synchronous carotid endarterectomy and off-pump coronary artery bypass: an updated systematic review of early outcomes. Eur J Vasc Endovasc Surg 37:375–378

    Article  PubMed  CAS  Google Scholar 

  60. Weimar C, Bilbilis K, Rekowski J et al (2017) Safety of simultaneous coronary artery bypass grafting and carotid endarterectomy versus isolated coronary artery bypass grafting: a randomized clinical trial. Stroke 48:2769–2775

    Article  PubMed  PubMed Central  Google Scholar 

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Author information

Authors and Affiliations

  1. Klinik für Thorax- und Kardiovaskuläre Chirurgie, Westdeutsches Herz- und Gefäßzentrum, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45127, Essen, Deutschland

    S. C. Knipp & H. Jakob

  2. Universitätsklinik für Neurologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland

    C. Weimar

Authors
  1. S. C. Knipp
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  2. H. Jakob
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  3. C. Weimar
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Correspondence to S. C. Knipp.

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Interessenkonflikt

S. C. Knipp, H. Jakob und C. Weimar geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Additional information

Redaktion

H. Niehaus, Göttingen

A. J. Rastan, Rotenburg a. d. Fulda

CME-Fragebogen

CME-Fragebogen

Wie ist nach NASCET der Stenosegrad von Karotisstenosen definiert?

Restlumen/stenosiertes Gefäßlumen

Restlumen/distales (nichtstenosiertes) Gefäßlumen

Stenosiertes Gefäßlumen/ursprüngliches Gefäßlumen in Höhe der Stenose

Stenosiertes Gefäßlumen/distales (nichtstenosiertes) Gefäßlumen

Ursprüngliches Gefäßlumen in Höhe der Stenose/distales (nichtstenosiertes) Gefäßlumen

Ab welchem Stenosegrad (NASCET) spricht man von einer hochgradigen Karotisstenose?

50 %

60 %

70 %

80 %

90 %

Wie hoch ist die Prävalenz der hochgradigen Karotisstenose in der Allgemeinbevölkerung?

1,0 %

1,7 %

2,5 %

3,9 %

5,0 %

Wie hoch ist die Prävalenz von hochgradigen Karotisstenosen bei herzchirurgischen Patienten?

1,0 %

1,7 %

2,5 %

3,9 %

5,0 %

Welches Verfahren ist nach aktuellen Leitlinien die Methode der ersten Wahl zur Detektion einer Karotisstenose?

CT-Angiographie

Digitale Subtraktionsangiographie

MR-Angiographie

Doppler‑/Duplexsonographie

Auskultation

Welche Strategie wird weltweit am häufigsten bei operationswürdiger KHK mit bekannter koexistierender hochgradiger Karotisstenose angewandt?

Sequenzielle Karotisendarteriektomie (CEA) und On-pump-CABG („staged CEA + CABG“)

Synchrone CEA + On-pump-CABG („synchronous CEA + CABG“)

Stentgestützte Karotisangioplastie (CAS) + CABG am selben Tag („Same-day“-Hybridrevaskularisation)

Sequenzielle CEA + Off-pump-CABG („staged CEA + off-pump CABG“)

Umgekehrt-sequenzielle CABG und CEA („reverse staged CABG + CEA“)

Welches Verfahren zu Koronar- und Karotisrevaskularisation geht mit der höchsten Dreißigtagemortalität einher?

Sequenzielle CEA + CABG

Synchrone CEA + On-pump-CABG

Umgekehrt-sequenzielle CABG + CEA

Synchrone CEA + Off-pump-CABG

Sequenzielle CAS + CABG

In welcher randomisierten Studie wurde die synchrone CEA + CABG mit der isolierten CABG verglichen?

CABACS

TACIT

CREST

NASCET

ACST

Wie hoch war nach den Ergebnissen der ACST-Studie der Vorteil der operierten Patienten im Vergleich zu den konservativ behandelten Patienten nach 10 Jahren, ausgedrückt als absolute Risikoreduktion (ARR)?

14,2 %

4,6 %

7,3 %

2,8 %

9,7 %

Bei welchem Befund besteht eine gesicherte Indikation zur Intervention einer Karotisstenose?

Asymptomatische subtotale Karotisstenose

Symptomatische Karotisstenose

Symptomatischer Karotisverschluss

Hochgradige asymptomatische bilaterale Karotisstenose

Mittelgradige asymptomatische Karotisstenose bei kontralateralem Verschluss

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Knipp, S.C., Jakob, H. & Weimar, C. Extrakranielle Karotisstenose beim herzchirurgischen Patienten. Z Herz- Thorax- Gefäßchir 32, 271–285 (2018). https://doi.org/10.1007/s00398-018-0250-x

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