One-day, sequential carotid artery stenting followed by cardiac surgery in patients with severe carotid and cardiac disease

Abstract

Optimal management of patients with internal carotid artery (ICA) stenosis concurrent with severe cardiac disease remains undefined. The aim of this study is to evaluate the safety and feasibility of the one-day, sequential approach by carotid artery stenting (CAS) immediately followed by cardiac surgery. The study included 70 consecutive patients with symptomatic > 50% or ⩾ 80% asymptomatic ICA stenosis coexisting with severe coronary/valve disease, who underwent one-day, sequential CAS + cardiac surgery. The majority of patients (85.7%) had CSS class III or IV angina and 10% had non-ST elevation myocardial infarction. The EuroSCORE II risk was 2.4% (IQR 1.69–3.19%). All CAS procedures were performed according to the ‘tailored’ algorithm with a substantial use of proximal neuroprotection devices of 44.3%. Closed-cell (75.7%) and mesh-covered (18.6%) stents were implanted in most cases. The majority of patients underwent isolated coronary artery bypass grafting (88.6%) or isolated valve replacement (7.1%). No major adverse cardiac and cerebrovascular events (MACCE) occurred at the CAS stage. There were three (4.3%) perioperative MACCE: one myocardial infarction and two deaths. All MACCE were related to cardiac surgery and were due to the high surgical risk profile of the patients. Up to 30 days, no further MACCE were observed. No perioperative or 30-day neurological complications occurred. In this patient series, one-day, sequential CAS and cardiac surgery was relatively safe and did not result in neurological complications. Thus, a strategy of preoperative CAS could be considered for patients with severe or symptomatic ICA stenosis who require urgent cardiac surgery.

Carotid Artery Stenting before CABG: A Better Alternative to Treat Concomitant Coronary and Carotid Artery Disease

“…In addition, a number of studies have shown that phased CAS and CABG procedures may be effective and risk-free (26,27). Individuals who have significant atherosclerotic disease and who come in an unstable state and need an urgent OHS may benefit from a less intrusive therapy, such as CAS, to address carotid artery stenosis, which may enhance the risk of stroke for OHS patients (28).…”

Misclassification of carotid stenosis severity with area stenosis-based evaluation by computed tomography angiography: impact on erroneous indication to revascularization or patient (lesion) migration to a higher guideline recommendation class as per ESC/ESVS/ESO/SVS and CMS-FDA thresholds

“…This was a prospective study in consecutive patients referred for potential carotid revascularization to a tertiary vascular centre performing high-volume carotid revas-cularization by means of CEA, CAS, and TCAR in patients with indications established by the multispecialty Neuro-Vascular Team and a final decision on the treatment modality incorporating the patient's informed opinion [29][30][31][32][33][34][35][36][37][38]. Referral stenosis severity had to be at least "50%" according to the modality and measurement method used by the referring centre.…”

Clinical Outcomes of Extracranial Carotid Artery-Related Stroke Eligible for Mechanical Reperfusion on Top of Per-Guidelines Thrombolytic Therapy: Analysis from a 6-Month Consecutive Patient Sample in 2 Centers

“…Prospective data collection involved all consecutive patients with AIS receiving cerebral and vascular imaging in 2 collaborating centers with acute stroke neurology. Study Center 1 is a high-volume major tertiary 24/7 cardiovascular center with carotid artery stenting (CAS) expertise with a case load of 350-400 CAS procedures per year [26][27][28] and MT service under World Federation for Stroke Treatment (WIST) certification and supervision (Level-2 stroke center -Thrombectomy-Capable Stroke Center, TCSC) [24,29]. In addition, vascular surgery treatments (including carotid endarterectomy of »200 cases per year) are performed [26][27][28].…”

“…Study Center 1 is a high-volume major tertiary 24/7 cardiovascular center with carotid artery stenting (CAS) expertise with a case load of 350-400 CAS procedures per year [26][27][28] and MT service under World Federation for Stroke Treatment (WIST) certification and supervision (Level-2 stroke center -Thrombectomy-Capable Stroke Center, TCSC) [24,29]. In addition, vascular surgery treatments (including carotid endarterectomy of »200 cases per year) are performed [26][27][28]. A multispecialty local Stroke Endovascular Mechanical Reperfusion Team with interventional cardiology and angiology, stroke neurology, radiology, and anesthesia is operational within the Level-2 WIST stroke center framework [24,29].…”