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Management of Patients with Concomitant Coronary and Carotid Artery Disease

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Ischemic Heart Disease

Abstract

The relationship between coronary and carotid artery disease is well recognized as one of the underlying pathophysiological mechanisms of atherosclerosis, but the risk of stroke associated with carotid artery disease in patients undergoing coronary artery bypass grafting remains a matter of debate. In this respect, ischemic/embolic stroke after bypass surgery may be multifactorial in origin: intraoperative surgical manipulation of the vascular bed, perioperative arrhythmias, hemodynamic instability, and, partially, status of the carotid vessels. Consequently, also the treatment of concomitant carotid artery disease (i.e., before, during, or after coronary artery bypass grafting, or carotid endarterectomy vs. stenting) remains a controversial issue. Current guidelines do not provide clear indications but only suggest to adopt a multidisciplinary approach for shared decision-making, with the involvement of a neurologist. However, current guidelines on this topic are mostly based on data derived from publications of early 2000s.

This chapter aims at providing practical suggestions for the selection of the best treatment option for patients with carotid artery stenosis undergoing coronary artery bypass grafting by updating current guidelines to the latest scientific evidence with potential speculations on future perspectives for this patient population.

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References

  1. Masabni K, Raza S, Blackstone EH, Gornik HL, Sabik JF 3rd. Does preoperative carotid stenosis screening reduce perioperative stroke in patients undergoing coronary artery bypass grafting? J Thorac Cardiovasc Surg. 2015;149:1253–60.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Lee R, Matsutani N, Polimenakos AC, Levers LC, Lee M, Johnson RG. Preoperative noncontrast chest computed tomography identifies potential aortic emboli. Ann Thorac Surg. 2007;84:38–41.

    Article  PubMed  Google Scholar 

  3. Biancari F, Santini F, Tauriainen T, Bancone C, Ruggieri VG, Perrotti A, Gherli R, Demal T, Dalén M, Santarpino G, Rubino AS, Nardella S, Nicolini F, Zanobini M, De Feo M, Onorati F, Mariscalco G, Gatti G. Epiaortic ultrasound to prevent stroke in coronary artery bypass grafting. Ann Thorac Surg. 2020;109:294–301.

    Article  PubMed  Google Scholar 

  4. 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;41:607–24.

    Article  CAS  PubMed  Google Scholar 

  5. Naylor AR. Does the risk of post-CABG stroke merit staged or synchronous reconstruction in patients with symptomatic or asymptomatic carotid disease? J Cardiovasc Surg. 2009;50:71–81.

    CAS  Google Scholar 

  6. Lin JC, Kabbani LS, Peterson EL, Masabni K, Morgan JA, Brooks S, Wertella KP, Paone G. Clinical utility of carotid duplex ultrasound prior to cardiac surgery. J Vasc Surg. 2016;63:710–4.

    Article  PubMed  Google Scholar 

  7. Aboyans V, Ricco JB, Bartelink MEL, Bjorck M, Brodmann M, Cohnert T, Collet JP, Czerny M, De Carlo M, Debus S, Espinola-Klein C, Kahan T, Kownator S, Mazzolai L, Naylor AR, Roffi M, Rother J, Sprynger M, Tendera M, Tepe G, Venermo M, Vlachopoulos C, Desormais I, ESC Scientific Document Group. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Endorsed by: The European Stroke Organization (ESO). The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of ESC/EACTS Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018;39:763–816.

    Article  PubMed  Google Scholar 

  8. 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;23:283–94.

    Article  CAS  PubMed  Google Scholar 

  9. Schoof J, Lubahn W, Baeumer M, Kross R, Wallesch CW, Kozian A, Huth C, Goertler M. 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. 2007;134:690–6.

    Article  PubMed  Google Scholar 

  10. Stamou SC, Hill PC, Dangas G, Pfister AJ, Boyce SW, Dullum MK, Bafi AS, Corso PJ. Stroke after coronary artery bypass: incidence, predictors, and clinical outcome. Stroke. 2001;32:1508–13.

    Article  CAS  PubMed  Google Scholar 

  11. Naylor AR. Delay may reduce procedural risk, but at what price to the patient? Eur J Vasc Endovasc Surg. 2008;35:383–91.

    Article  CAS  PubMed  Google Scholar 

  12. Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E, Straka Z, Piegas LS, Akar AR, Jain AR, Noiseux N, Padmanabhan C, Bahamondes JC, Novick RJ, Vaijyanath P, Reddy S, Tao L, Olavegogeascoechea PA, Airan B, Sulling TA, Whitlock RP, Ou Y, Ng J, Chrolavicius S, Yusuf S, Investigators CORONARY. Off-pump or on-pump coronary-artery bypass grafting at 30 days. N Engl J Med. 2012;366:1489–97.

    Article  CAS  PubMed  Google Scholar 

  13. Randall MS, McKevitt F, Cleveland TJ, Gaines PA, Venables GS. 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. 2006;37:435–9.

    Article  PubMed  Google Scholar 

  14. Van der Heyden JSM, Bal ET, Ernst JM, Ackerstaff RG, Schaap J, Kelder JC, Schepens M, Plokker HW. Staged carotid angioplasty and stenting followed by cardiac surgery in patients with severe asymptomatic carotid artery stenosis: early and long-term results. Circulation. 2007;116:2036–342.

    Article  PubMed  Google Scholar 

  15. Shishehbor MH, Venkatachalam S, Sun Z, Rajeswaran J, Kapadia SR, Bajzer C, Gornik HL, Gray BH, Bartholomew JR, Clair DG, Sabik JF 3rd, Blackstone EH. A direct comparison of early and late outcomes with three approaches to carotid revascularization and open heart surgery. J Am Coll Cardiol. 2013;62:1948–56.

    Article  PubMed  Google Scholar 

  16. Durand DJ, Perler BA, Roseborough GS, Grega MA, Borowicz LM Jr, Baumgartner WA, Yuh DD. Mandatory versus selective preoperative carotid screening: a retrospective analysis. Ann Thorac Surg. 2004;78:159–66.

    Article  PubMed  Google Scholar 

  17. Aboyans V, Lacroix P. Indications for carotid screening in patients with coronary artery disease. Presse Med. 2009;38:977–86.

    Article  PubMed  Google Scholar 

  18. Versaci F, Del Giudice C, Scafuri A, Zeitani J, Gandini R, Nardi P, Salvati A, Pampana E, Sebastiano F, Romagnoli A, Simonetti G, Chiariello L. Sequential hybrid carotid and coronary artery revascularization: immediate and mid-term results. Ann Thorac Surg. 2007;84:1508–13.

    Article  PubMed  Google Scholar 

  19. Chiariello LNP, Pellegrino A, Saitto G, Chiariello GA, Russo M, Zeitani J, Versaci F. Simultaneous carotid artery stenting and heart surgery: expanded experience of hybrid surgical procedures. Ann Thorac Surg. 2015;99:1291–7.

    Article  PubMed  Google Scholar 

  20. Illuminati G, Ricco JB, Calio F, Pacile MA, Miraldi F, Frati G, Macrina F, Toscano M. Short-term results of a randomized trial examining timing of carotid endarterectomy in patients with severe asymptomatic unilateral carotid stenosis undergoing coronary artery bypass grafting. J Vasc Surg. 2011;54:993–9.

    Article  PubMed  Google Scholar 

  21. Halliday A, Bax JJ. 2017 ESC Guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS)-Web Addenda. Eur J Vasc Endovasc Surg. 2018;55:1–22.

    Article  Google Scholar 

  22. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso BAP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Juni P, Kastrati A, Koller A, Kristensen SD, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2018;2019(40):87–165.

    Google Scholar 

  23. Naylor AR, Cuffe RL, Rothwell PM, Bell PR. A systematic review of outcomes following staged and synchronous carotid endarterectomy and coronary artery bypass. Eur J Vasc Endovasc Surg. 2003;25:380–9.

    Article  CAS  PubMed  Google Scholar 

  24. Paraskevas KI, Nduwayo S, Saratzis AN, Naylor AR. Carotid stenting prior to coronary bypass surgery: an updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2017;53:309–19.

    Article  CAS  PubMed  Google Scholar 

  25. Tzoumas A, Giannopoulos S, Charisis N, Texakalidis P, Kokkinidis DG, Zisis SN, Machinis T, Koullias GJ. Synchronous versus staged carotid artery stenting and coronary artery bypass graft for patients with concomitant severe coronary and carotid artery stenosis: a systematic review and meta-analysis. Vascular. 2020;28:808–15.

    Article  PubMed  Google Scholar 

  26. Giannopoulos S, Texakalidis P, Charisis N, Jonnalagadda AK, Chaitidis N, Giannopoulos S, Kaskoutis C, Machinis T, Koullias GJ. Synchronous carotid endarterectomy and coronary artery bypass graft versus staged carotid artery stenting and coronary artery bypass graft for patients with concomitant severe coronary and carotid stenosis: a systematic review and meta-analysis. Ann Vasc Surg. 2020;62:463–473.e4.

    Article  PubMed  Google Scholar 

  27. Santarpino G, Nicolini F, De Feo M, Dalén M, Fischlein T, Perrotti A, Reichart D, Gatti G, Onorati F, Franzese I, Faggian G, Bancone C, Chocron S, Khodabandeh S, Rubino AS, Maselli D, Nardella S, Gherli R, Salsano A, Zanobini M, Saccocci M, Bounader K, Rosato S, Tauriainen T, Mariscalco G, Airaksinen J, Ruggieri VG, Biancari F. Prognostic impact of asymptomatic carotid artery stenosis in patients undergoing coronary artery bypass grafting. Eur J Vasc Endovasc Surg. 2018;56:741–8.

    Article  PubMed  Google Scholar 

  28. Weimar C, Bilbilis K, Rekowski J, Holst T, Beyersdorf F, Breuer M, Dahm M, Diegeler A, Kowalski A, Martens S, Mohr FW, Ondrášek J, Reiter B, Roth P, Seipelt R, Siggelkow M, Steinhoff G, Moritz A, Wilhelmi M, Wimmer-Greinecker G, Diener HC, Jakob H, Ose C, Scherag A, Knipp SC. CABACS Trial Investigators. Safety of simultaneous coronary artery bypass grafting and carotid endarterectomy versus isolated coronary artery bypass grafting: a randomized clinical trial. Stroke. 2017;48:2769–75.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Zhang J, Xu RW, Fan X, Ye Z, Liu P. A systematic review of early results following synchronous or staged carotid artery stenting and coronary artery bypass grafting. Thorac Cardiovasc Surg. 2017;65:302–10.

    Article  PubMed  Google Scholar 

  30. Yang T, Zhang L, Wang X, Dong H, Jiang X, Sun H. Revascularization by carotid artery stenting and off-pump coronary artery bypass. ANZ J Surg. 2016;86:602–7.

    Article  PubMed  Google Scholar 

  31. Sharma V, Deo SV, Park SJ, Joyce LD. Meta-analysis of staged versus combined carotid endarterectomy and coronary artery bypass grafting. Ann Thorac Surg. 2014;97:102–9.

    Article  PubMed  Google Scholar 

  32. Oakes DA, Eichenbaum KD. Perioperative management of combined carotid and coronary artery bypass grafting procedures. Anesthesiol Clin. 2014;32:699–721.

    Article  PubMed  Google Scholar 

  33. Gopaldas RR, Chu D, Dao TK, Huh J, LeMaire SA, Lin P, Coselli JS, Bakaeen FG. Staged versus synchronous carotid endarterectomy and coronary artery bypass grafting: analysis of 10-year nationwide outcomes. Ann Thorac Surg. 2011;91:1323–9.

    Article  PubMed  Google Scholar 

  34. Williams Z, Olivere LA, Gilmore B, Weissler H, Cox MW, Long C, Shortell CK, Schroder J, Southerland KW. Safety and feasibility of simultaneous transcarotid revascularization with flow reversal and coronary artery bypass grafting for concomitant carotid artery stenosis and coronary artery disease. Vasc Endovasc Surg. 2020;54:395–9.

    Article  Google Scholar 

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Correspondence to Giuseppe Santarpino .

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Santarpino, G., Fina, D., Simeone, C., Nicoletti, A., Nasso, G. (2023). Management of Patients with Concomitant Coronary and Carotid Artery Disease. In: Concistrè, G. (eds) Ischemic Heart Disease. Springer, Cham. https://doi.org/10.1007/978-3-031-25879-4_26

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  • DOI: https://doi.org/10.1007/978-3-031-25879-4_26

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