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Outcomes good with carotid stenting before cardiac surgery

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – In patients with concomitant cardiac disease requiring surgery and symptomatic carotid artery disease, carotid artery stenting before surgery yields favorable outcomes, a Dutch team reports in the November issue of JACC: Cardiovascular Interventions.

“In such a high-risk population, this strategy might offer a valuable alternative to the combined surgical approach,” the authors comment.

Dr. Jan Van der Heyden and colleagues at St-Antonius Hospital, Nieuwegein, explain that the risk of periprocedural stroke during cardiac surgery among patients with carotid artery disease is four times higher when the patients have a history of TIA or stroke compared to those without neurologic symptoms.

In symptomatic cases, they continue, prophylactic carotid endarterectomy before heart surgery has been offered but recent data suggest that carotid artery stenting may also be effective in reducing risk.

In the current study, the team reports their experience with carotid artery stenting (CAS) performed an average of 28 days before cardiac surgery in 57 patients with symptomatic carotid artery disease. Most of the patients (52) underwent coronary artery bypass graft (CABG) surgery, three had valve surgery combined with CABG, and two had reconstructive surgery of the ascending aorta.

Following carotid stenting and before cardiac surgery there were four minor strokes (7.0%) and one MI (1.5%). During and up to 30 days after cardiac surgery there was one major stroke and one death. Overall, the combined outcome of death, stroke or MI occurred in 7 patients (12.3%), the authors report.

During 5 years follow-up, the survival rate was 63.7%, with a significantly higher rate of all-cause deaths among patients 75 years of age and older, Dr. Van der Heyden and colleagues report.

“The periprocedural complication rate and long-term results of the CAS-CABG strategy in this high-risk population support the reliability of this approach,” they conclude. However, a large trial comparing CAS to carotid endarterectomy (CEA) before cardiac surgery “is clearly warranted,” they add.

In an editorial, Dr. William Anthony Gray of Columbia University, New York, points out the difficulty of comparing these results with historical data on pre-surgery CEA. Still, based on the present findings, he writes, “We can conclude that a well-performed CAS by experienced operators is likely to be at least on par with CEA as a staged pre-treatment strategy and likely better than nothing at all, for managing symptomatic patients with carotid disease undergoing cardiac surgery.”

Reference:

Carotid Artery Stenting and Cardiac Surgery in Symptomatic Patients

Carotid Artery Stenting Before Cardiac Surgery: A Promising Path Down a Muddy Road?