Current Cardiology Reports

, Volume 14, Issue 2, pp 125–134 | Cite as

Management of Combined Severe Carotid and Coronary Artery Disease

  • Marco Roffi
  • Flavio Ribichini
  • Fausto Castriota
  • Alberto Cremonesi
Peripheral Vascular Disease (M Shishehbor, Section Editor)

Abstract

Patients with severe carotid and coronary disease—especially if they require coronary artery bypass grafting (CABG)—are at high risk of cardiac events and stroke. Carotid revascularization should be considered for patients with symptomatic carotid disease and bilateral severe asymptomatic carotid stenosis. In patients with unilateral asymptomatic carotid stenosis, decision to proceed to revascularization should be based more on a perspective of long-term stroke prevention than of perioperative stroke reduction. Compared with endarterectomy, carotid artery stenting is associated with a lower incidence of periprocedural myocardial infarction, an event linked to long-term mortality. This observation may be particularly relevant for patients with advanced coronary artery disease such as those undergoing CABG. Irrespective of the carotid revascularization strategy, a broad disease management approach based on lifestyle modification and pharmacologic cardiovascular prevention is more likely to affect both the quality and duration of life than revascularization itself.

Keywords

Carotid artery disease Coronary artery disease Coronary artery bypass grafting Carotid endarterectomy Carotid artery stenting Perioperative stroke Stroke prevention Perioperative myocardial infarction Multilevel arterial disease 

Notes

Disclosure

Conflicts of interest: M. Roffi: none; F. Ribichini: none; F. Castriota: has received grant support from Medtronic and Boston Scientific; has received a consulting fee or honorarium from Medtronic and Boston Scientific; and has received travel/accommodations expenses covered or reimbursed from Medtronic and Boston Scientific; A. Cremonesi: has received grant support from Medtronic and Boston Scientific; has received a consulting fee or honorarium from Medtronic and Boston Scientific; and has received travel/accommodations expenses covered or reimbursed from Medtronic and Boston Scientific.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Alberts MJ, Bhatt DL, Mas JL, et al. Three-year follow-up and event rates in the international REduction of Atherothrombosis for Continued Health Registry. Eur Heart J. 2009;30(19):2318–26.PubMedCrossRefGoogle Scholar
  2. 2.
    Steg PG, Bhatt DL, Wilson PW, et al. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA. 2007;297(11):1197–206.PubMedCrossRefGoogle Scholar
  3. 3.
    Venkatachalam S, Gray BH, Mukherjee D, Shishehbor MH. Contemporary management of concomitant carotid and coronary artery disease. Heart. 2011;97(3):175–80.PubMedCrossRefGoogle Scholar
  4. 4.
    Naylor AR, Mehta Z, Rothwell PM, Bell PR. Carotid artery disease and stroke during coronary artery bypass: a critical review of the literature. Eur J Vasc Endovasc Surg. 2002;23(4):283–94.PubMedCrossRefGoogle Scholar
  5. 5.
    de Weerd M, Greving JP, Hedblad B, et al. Prevalence of asymptomatic carotid artery stenosis in the general population: an individual participant data meta-analysis. Stroke. 2010;41(6):1294–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Kurvers HA, van der Graaf Y, Blankensteijn JD, Visseren FL, Eikelboom BC. Screening for asymptomatic internal carotid artery stenosis and aneurysm of the abdominal aorta: comparing the yield between patients with manifest atherosclerosis and patients with risk factors for atherosclerosis only. J Vasc Surg. 2003;37(6):1226–33.PubMedCrossRefGoogle Scholar
  7. 7.
    Aboyans V, Lacroix P. Indications for carotid screening in patients with coronary artery disease. Presse Med. 2009;38(6):977–86.PubMedCrossRefGoogle Scholar
  8. 8.
    Berens ES, Kouchoukos NT, Murphy SF, Wareing TH. Preoperative carotid artery screening in elderly patients undergoing cardiac surgery. J Vasc Surg. 1992;15(2):313–21. discussion 322–313.PubMedCrossRefGoogle Scholar
  9. 9.
    Qureshi AI, Janardhan V, Bennett SE, Luft AR, Hopkins LN, Guterman LR. Who should be screened for asymptomatic carotid artery stenosis? Experience from the Western New York Stroke Screening Program. J Neuroimaging. 2001;11(2):105–11.PubMedCrossRefGoogle Scholar
  10. 10.
    Hillis LD, Smith PK, Anderson JL, et al. ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011; in print.Google Scholar
  11. 11.
    • Tendera M, Aboyans V, Bartelink ML, et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries * The Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2851–6. For the first time, the European Guidelines on the diagnosis and treatment of peripheral artery diseases include the management of patients with multilevel arterial disease, and specifically those with carotid and coronary disease. PubMedCrossRefGoogle Scholar
  12. 12.
    Likosky DS, Caplan LR, Weintraub RM, et al. Intraoperative and postoperative variables associated with strokes following cardiac surgery. Heart Surg Forum. 2004;7(4):E271–6.PubMedCrossRefGoogle Scholar
  13. 13.
    Likosky DS, Marrin CA, Caplan LR, et al. Determination of etiologic mechanisms of strokes secondary to coronary artery bypass graft surgery. Stroke; J Cereb Circ. 2003;34(12):2830–4.CrossRefGoogle Scholar
  14. 14.
    Bucerius J, Gummert JF, Borger MA, et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg. 2003;75(2):472–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Stamou SC, Hill PC, Dangas G, et al. Stroke after coronary artery bypass: incidence, predictors, and clinical outcome. Stroke; J Cereb Circ. 2001;32(7):1508–13.CrossRefGoogle Scholar
  16. 16.
    Tarakji KG, Sabik 3rd JF, Bhudia SK, Batizy LH, Blackstone EH. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA. 2011;305(4):381–90.PubMedCrossRefGoogle Scholar
  17. 17.
    • Naylor AR, Bown MJ. Stroke after cardiac surgery and its association with asymptomatic carotid disease: an updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2011;41(5):607–24. This is a comprehensive review on stroke among patients undergoing CABG, especially those with carotid disease. PubMedCrossRefGoogle Scholar
  18. 18.
    Selim M. Perioperative stroke. N Engl J Med. 2007;356(7):706–13.PubMedCrossRefGoogle Scholar
  19. 19.
    Kronzon I, Tunick PA. Aortic atherosclerotic disease and stroke. Circulation. 2006;114(1):63–75.PubMedCrossRefGoogle Scholar
  20. 20.
    Borger MA. Preventing stroke during coronary bypass: are we focusing on the wrong culprit? J Card Surg. 2005;20(1):58–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Roach GW, Kanchuger M, Mangano CM, et al. 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. 1996;335(25):1857–63.PubMedCrossRefGoogle Scholar
  22. 22.
    Kurra V, Lieber ML, Sola S, et al. Extent of thoracic aortic atheroma burden and long-term mortality after cardiothoracic surgery: a computed tomography study. JACC Cardiovasc Imaging. 2010;3(10):1020–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Dubinsky RM, Lai SM. Mortality from combined carotid endarterectomy and coronary artery bypass surgery in the US. Neurology. 2007;68(3):195–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Timaran CH, Rosero EB, Smith ST, et al. Trends and outcomes of concurrent carotid revascularization and coronary bypass. J Vasc Surg. 2008;48(2):355–60. discussion 360–351.PubMedCrossRefGoogle Scholar
  25. 25.
    • Venkatachalam S, Gray BH, Shishehbor MH. Open and endovascular management of concomitant severe carotid and coronary artery disease: tabular review of the literature. Ann Vasc Surg 2011; in print. This is an extensive review with a tabular summary of outcome data of patients with carotid and coronary disease. Google Scholar
  26. 26.
    Roffi M, Mukherjee D, Clair DG. Carotid artery stenting vs. endarterectomy. Eur Heart J. 2009;30(22):2693–704.PubMedCrossRefGoogle Scholar
  27. 27.
    Economopoulos KP, Sergentanis TN, Tsivgoulis G, Mariolis AD, Stefanadis C. Carotid artery stenting versus carotid endarterectomy: a comprehensive meta-analysis of short-term and long-term outcomes. Stroke; J Cereb Circ. 2011;42(3):687–92.CrossRefGoogle Scholar
  28. 28.
    Roffi M, Sievert H, Gray WA, et al. Carotid artery stenting versus surgery: adequate comparisons? Lancet Neurol. 2010;9(4):339–41. author reply 341–332.PubMedCrossRefGoogle Scholar
  29. 29.
    Van der Heyden J, Suttorp MJ, Bal ET, et al. Staged carotid angioplasty and stenting followed by cardiac surgery in patients with severe asymptomatic carotid artery stenosis: early and long-term results. Circulation. 2007;116(18):2036–42.PubMedCrossRefGoogle Scholar
  30. 30.
    Roffi M. Management of patients with concomitant severe coronary and carotid artery disease: is there a perfect solution? Circulation. 2007;116(18):2002–4.PubMedCrossRefGoogle Scholar
  31. 31.
    Velissaris I, Kiskinis D, Anastasiadis K. Synchronous carotid artery stenting and open heart surgery. J Vasc Surg. 2011;53(5):1237–41.PubMedCrossRefGoogle Scholar
  32. 32.
    Versaci F, Reimers B, Del Giudice C, et al. Simultaneous hybrid revascularization by carotid stenting and coronary artery bypass grafting: the SHARP study. JACC Cardiovasc Interv. 2009;2(5):393–401.PubMedCrossRefGoogle Scholar
  33. 33.
    Blackshear JL, Cutlip DE, Roubin GS, et al. Myocardial infarction after carotid stenting and endarterectomy: results from the carotid revascularization endarterectomy versus stenting trial. Circulation. 2011;123(22):2571–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Landesberg G, Shatz V, Akopnik I, et al. Association of cardiac troponin, CK-MB, and postoperative myocardial ischemia with long-term survival after major vascular surgery. J Am Coll Cardiol. 2003;42(9):1547–54.PubMedCrossRefGoogle Scholar
  35. 35.
    Kertai MD, Boersma E, Klein J, Van Urk H, Bax JJ, Poldermans D. Long-term prognostic value of asymptomatic cardiac troponin T elevations in patients after major vascular surgery. Eur J Vasc Endovasc Surg. 2004;28(1):59–66.PubMedCrossRefGoogle Scholar
  36. 36.
    • Brott TG, Halperin JL, Abbara S, et al. ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation 2011;124(4):e54–130. This is the latest American guidelines on the management of patients with carotid disease. PubMedCrossRefGoogle Scholar
  37. 37.
    Spence JD. Is there a role for revascularisation in asymptomatic carotid stenosis? No. BMJ. 2010;341:c4900.PubMedCrossRefGoogle Scholar
  38. 38.
    Roffi M. Is there a role for revascularisation in asymptomatic carotid stenosis? Yes. BMJ. 2010;341:c4898.PubMedCrossRefGoogle Scholar
  39. 39.
    Aichner FT, Topakian R, Alberts MJ, et al. High cardiovascular event rates in patients with asymptomatic carotid stenosis: the REACH Registry. Eur J Neurol. 2009;16(8):902–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Kakkos SK, Sabetai M, Tegos T, et al. Silent embolic infarcts on computed tomography brain scans and risk of ipsilateral hemispheric events in patients with asymptomatic internal carotid artery stenosis. J Vasc Surg. 2009;49(4):902–9.PubMedCrossRefGoogle Scholar
  41. 41.
    Markus HS, King A, Shipley M, et al. Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observational study. Lancet Neurol 9(7):663-71.Google Scholar
  42. 42.
    Inzitari D, Eliasziw M, Gates P, et al. The causes and risk of stroke in patients with asymptomatic internal-carotid-artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators [see comments]. N Engl J Med. 2000;342(23):1693–700.PubMedCrossRefGoogle Scholar
  43. 43.
    Gurm HS, Yadav JS, Fayad P, et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med. 2008;358(15):1572–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Eckstein HH, Ringleb P, Allenberg JR, et al. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Lancet Neurol. 2008;7(10):893–902.PubMedCrossRefGoogle Scholar
  45. 45.
    Mas JL, Trinquart L, Leys D, et al. Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial. Lancet Neurol. 2008;7(10):885–92.PubMedCrossRefGoogle Scholar
  46. 46.
    Brott TG, Hobson 2nd RW, Howard G, Roubin GS, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11–23.PubMedCrossRefGoogle Scholar
  47. 47.
    Naylor AR, Mehta Z, Rothwell PM. A systematic review and meta-analysis of 30-day outcomes following staged carotid artery stenting and coronary bypass. Eur J Vasc Endovasc Surg. 2009;37(4):379–87.PubMedCrossRefGoogle Scholar
  48. 48.
    Maatz W, Kohler J, Botsios S, John V, Walterbusch G. Risk of stroke for carotid endarterectomy patients with contralateral carotid occlusion. Ann Vasc Surg. 2008;22(1):45–51.PubMedCrossRefGoogle Scholar
  49. 49.
    Mehta RH, Zahn R, Hochadel M, et al. Effectiveness and safety of carotid artery stenting for significant carotid stenosis in patients with contralateral occlusion (from the German ALKK-CAS Registry experience). Am J Cardiol. 2009;104(5):725–31.PubMedCrossRefGoogle Scholar
  50. 50.
    Feng ZZ, Shi J, Zhao XW, Xu ZF. Meta-analysis of on-pump and off-pump coronary arterial revascularization. Ann Thorac Surg. 2009;87(3):757–65.PubMedCrossRefGoogle Scholar
  51. 51.
    Shroyer AL, Grover FL, Hattler B, et al. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med. 2009;361(19):1827–37.PubMedCrossRefGoogle Scholar
  52. 52.
    Sharony R, Bizekis CS, Kanchuger M, et al. Off-pump coronary artery bypass grafting reduces mortality and stroke in patients with atheromatous aortas: a case control study. Circulation. 2003;108 Suppl 1:II15–20.PubMedGoogle Scholar
  53. 53.
    Tomai F, Pesarini G, Castriota F, et al. Early and long-term outcomes after combined percutaneous revascularization in patients with carotid and coronary artery stenoses. JACC Cardiovasc Interv. 2011;4(5):560–8.PubMedCrossRefGoogle Scholar
  54. 54.
    Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360(10):961–72.PubMedCrossRefGoogle Scholar
  55. 55.
    Kapur A, Hall RJ, Malik IS, et al. Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients. 1-year results of the CARDia (Coronary Artery Revascularization in Diabetes) trial. J Am Coll Cardiol. 2010;55(5):432–40.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Marco Roffi
    • 1
  • Flavio Ribichini
    • 2
    • 4
  • Fausto Castriota
    • 3
    • 5
  • Alberto Cremonesi
    • 3
    • 5
  1. 1.Interventional Cardiology Unit, Division of CardiologyUniversity HospitalGeneva 14Switzerland
  2. 2.Department of Medicine, Catheterisation LaboratoriesUniversity of VeronaVeronaItaly
  3. 3.GVM Care and Research, Interventional Cardio-Angiology UnitCotignolaItaly
  4. 4.Cardiovascular Interventional UnitVeronaItaly
  5. 5.Maria Cecilia Hospital—GVM Care and Research CotignolaCotignolaItaly

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