CAS Plus Cardiac Surgery a Promising Option for Symptomatic Patients

Download this article's Factoid (PDF & PPT for Gold Subscribers)


In symptomatic patients with concurrent carotid and coronary artery disease, carotid artery stenting (CAS) before cardiac surgery may be a viable alternative to a double surgical approach, according to a study published in the November 2011 issue of JACC: Cardiovascular Interventions.

For the prospective, nonrandomized study, Jan Van der Heyden, MD, of St. Antonius Hospital (Nieuwegein, The Netherlands), and colleagues analyzed clinical outcomes of 57 consecutive symptomatic patients scheduled for CAS and cardiac surgery between December 1998 and January 2008. Patients were considered neurologically symptomatic if they had an ipsilateral carotid territory stroke or TIA in the previous 4 months.

All patients were evaluated by impartial neurologists before, during, and after CAS, before and after cardiac surgery, and at 1- and 3-month follow-up.

Encouraging Outcomes

CAS was performed predominantly in the proximal internal carotid artery (n = 52), but also in the distal (n = 3) and proximal (n = 2) common carotid artery. Coronary artery bypass graft (CABG) surgery was performed in 52 patients (91.2%); 3 patients (5%) had valve surgery combined with CABG; and 2 (3.5%) underwent reconstructive surgery of the ascending aorta.

During the periprocedural period for the staged procedures (CAS to 30 days post surgery), the primary endpoint (composite of death, all stroke, and MI) occurred in 12.3% of patients. Specifically, during the period between CAS and surgery (median 28 days), events included 1 MI and 4 minor strokes. One patient who suffered an MI while waiting for cardiac surgery died 3 months after the procedure. In addition, 1 patient suffered a cardiac-related death and 1 had a major stroke (with no ultrasound evidence of restenosis or stent thrombosis) within 30 days of surgery (table 1). Complication rates were similar in male and female patients.

Table 1. Periprocedural Outcomes After Staged CAS and Cardiac Surgery

 

CAS

Cardiac
Surgery

Total
(n = 57)

Death

1.5%

1.5%

All Stroke

7.0%

1.5%

8.8%

     Major Stroke

1.5%

1.5%

     Minor Stroke

7.0%

7.0%

MI

1.5%

1.5%

Death/Major Stroke

3.5%

3.5%

Death/Stroke/MI

8.8%

3.5%

12.3%

 

After 5 years, 18 deaths (31.6%) had occurred—8 cardiac-related (14%) and 2 stroke-related (3.5%)—and no reintervention for carotid restenosis was necessary. There was one late minor stroke and 1 late major stroke, and no MI occurred.

 

The 5-year survival rate was 63.7% (95% CI 51.3-79.1), while the rate of freedom from death, all strokes, or MI was 56.7%. The all-cause mortality, stroke, and MI rates were significantly lower in patients younger than 75 years (P = 0.02).

Filling a Gap in Vascular Care

Given countless studies comparing CAS and carotid endarterectomy (CEA) in patients with isolated carotid disease, Dr. Van der Heyden told TCTMD in an e-mail communication that special emphasis should be placed on analyzing data “in a different perspective” by treating combined disease with CAS. And in fact the study results support the combined use of CAS and cardiac surgery in high-risk patients, he said.

Many cardiologists and neurologists tend to focus on their own territory and ignore the possibility that generalized atherosclerosis may be causing disease in both coronary and carotid arteries, Dr. Van der Heyden suggested. “Therefore, there is a lack of screening for combined artery disease in many centers. Although devastating for the patient and the community, neurological complications during cardiac surgery seem to be of minor interest,” he said, adding that he hopes these results will encourage physicians to screen patients for both vascular conditions.

Dr. Van der Heyden and his team plan to perform additional studies of impaired cerebral circulation in the same patient population. “We believe that more detailed invasive or noninvasive measurements of the cerebral perfusion could help in the detection of patients with increased perioperative risk for cerebral events, not just focusing on artery stenosis,” he said.

Not Superior, But on Par 

In an editorial accompanying the study, William A. Gray, MD, of Columbia University Medical Center (New York, NY), writes that “it is tempting to suggest that CAS might be the preferred treatment in these cases given the previously enumerated problems in comparisons with historical CEA outcomes.” However, without historical data and a comparison to a randomized study, he says, “it is not possible to make any definitive statements about the relative merits of 1 approach over the other.”

“We can conclude that a well-performed CAS by experienced operators is likely to be at least on par with CEA as a staged pretreatment strategy and likely better than nothing at all, for managing symptomatic patients with carotid disease undergoing cardiac surgery,” Dr. Gray states.

Study Details

One third of patients were female and the average age was 70 years. About 20% were smokers and more than one quarter had had a previous MI. The median waiting time between the last neurological event and the CAS procedure was 36 days.

Note: Dr. Gray is a faculty member of the Cardiovascular Research Foundation, which owns and operates TCTMD. 



Sources:
1. Van der Heyden J, Van Neerven D, Sonker U et al. Carotid artery stenting and cardiac surgery in symptomatic patients. J Am Coll Cardiol Intv. 2011;4:1190-1196.

2. Gray WA. Carotid artery stenting before cardiac surgery: A promising path down a muddy road? J Am Coll Cardiol Intv. 2011;4:1197-1199.

 

  • Dr. Gray reports research funding from Abbott Vascular, Silk Road Medical, and WL Gore and consulting fees from Abbott Vascular, Medtronic, Silk Road Medical, and WL Gore.

 

Related Stories:

Disclosures
  • Dr. Van der Heyden reports no relevant conflicts of interest.

Comments