Prognostic Impact of Asymptomatic Carotid Artery Stenosis in Patients Undergoing Coronary Artery Bypass Grafting

Santarpino, Giuseppe; Nicolini, Francesco; Feo, Marisa De; Dalén, Magnus; Fischlein, Theodor; Perrotti, Andréa; Reichart, Daniel; Gatti, Giuseppe; Franzese, Ilaria; Faggian, Giuseppe; Bancone, Ciro; Chocron, Sidney; Khodabandeh, Sorosh; Rubino, A; Maselli, Daniele; Nardella, Saverio; Gherli, Riccardo; Salsano, Antonio; Zanobini, Marco; Saccocci, Matteo; Bounader, Karl; Rosato, Stefano; Tauriainen, Tuomas; Mariscalco, Giovanni; Airaksinen, Juhani; Ruggieri, Vito Giovanni; Biancari, Fausto

doi:10.1016/j.ejvs.2018.07.042

Cited by 24 publications

(14 citation statements)

References 16 publications

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“…If ICA stenosis is left untreated, the risk of perioperative stroke in asymptomatic patients grows with stenosis severity and is highest among those with subtotal or bilateral stenosis. 2,3,32 The benefit of 'prophylactic' ICA revascularization preceding cardiac surgery in asymptomatic patients is still not well proven, and according to the current guidelines it might be considered in selected cases only. 15 Owing to some experts' opinions, however, it is reasonable to perform carotid revascularization in asymptomatic ICA stenosis ⩾ 80%, not only for perioperative stroke prevention, but also for long-term prognosis, and experienced centres should prefer CAS staged with CABG because of the lower MI rate.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2019

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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.

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Section: Discussionmentioning

confidence: 99%

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

et al. 2019

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“…Advanced age, prior cerebrovascular disease/stroke, severity of carotid artery stenosis and peripheral vascular disease, presence of contralateral carotid occlusion and porcelain ascending aorta, postoperative IABP or ECMO supporting, unstable angina, urgency of the procedure, prolonged cardiopulmonary bypass time and postoperative atrial fibrillations were reported as the most consistent independent predictors of perioperative stroke after CABG (7,41,42) . Gender, diabetes mellitus, hypertension, prior myocardial infarction, chronic renal failure and congestive heart failure showed contradictive results (7) .…”

Section: What Are the Predictors Associated With Stroke After Cabg?mentioning

confidence: 96%

“…Also, patients who described a history of stroke were significantly more likely (OR=3.6) to have further stroke than those who were asymptomatic (4) . Santarpino et al (7) reported that among 649 patients with asymptomatic carotid artery stenosis >50% undergoing isolated CABG, the incidence of postoperative stroke was 1.5% and the risk of stroke were significant only in patients with a stenosis ³90% (OR=12, CI=1.4-33.3). They concluded as asymptomatic, severe carotid artery stenosis has a low prevalence and when left untreated is associated with a relatively low risk of postoperative stroke.…”

Section: Does Untreated Asymptomatic Carotid Stenosis Was Associated mentioning

confidence: 99%

“…Patients with severe carotid artery stenosis undergoing coronary artery bypass graft (CABG) face a higher risk of stroke than patients without carotid disease but most strokes are unrelated to carotid disease (4,5) . Although several strategies have been developed for minimize to peri-operative stroke such as avoiding the manipulation of ascending aorta, prompt treatment of arrhythmias and low cardiac output, minimizing aortic cannulation or using offpump bypass techniques, optimal regulation of metabolic state and cerebral perfusion, the prevalence of stroke in cardiac surgery patients with no evidence of significant carotid artery stenosis was found 1.8% (6,7) . The indication to treatment of patients with carotid disease should consider neurological symptomatology, degree of carotid stenosis, medical comorbidities, vascular and local anatomical features and carotid plaque morphology.…”

Section: Introductionmentioning

confidence: 99%

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How Can We Treat Asymptomatic Carotid Disease in Patients with a Planned CABG?

Kutay¹

2019

ejcm

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Carotid artery intervention to the neurological asymptomatic patients is one of the most controversial issues of vascular surgery throughout the last decades. The decision about how to manage asymptomatic carotid disease in the setting of planned coronary artery bypass graft (CABG) becomes more complex due to surgical treatment of either pathology may be complicated by multiple factors. Current guidelines do not support routine screening for carotid artery stenosis before CABG because of given the low prevalence of stroke after CABG. Optimal surgical intervention and timing for patients having concomitant severe carotid and coronary artery stenosis remains uncertain. In this brief review, we analyze the incidence of significant carotid stenosis in patients undergoing CABG, association of untreated asymptomatic carotid stenosis on postoperative stroke, effects of carotid endarterectomy (CEA) on postoperative incidence of stroke, determination of surgical options and technical variations for CEA, scanning methods for identifying the vulnerable carotid plaque and revealing risk factors and predictors associated with stroke after CABG. Synchronous or staged CEA still remain valuable options in order to diminish postoperative risk of stroke for neurologically asymptomatic patients undergoing to CABG who have bilateral significant carotid artery stenosis or contralateral occlusion.

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“…Mehta et al demonstrated that both asymptomatic unilateral and bilateral carotid stenoses were independent risk factors for in-hospital stroke after CABG 11 . However, other investigations have suggested that routine preoperative screening for asymptomatic carotid artery disease in CABG patients does not translate into reduced perioperative stroke risk and is likely not justified 12,13 . Some institutions continue to perform routine carotid artery ultrasound screening prior to CABG in order to identify significant carotid arterial disease that may require revascularization before or during CABG with the assumption that carotid disease is causally related to perioperative stroke and that prophylactic carotid revascularization may decrease the risk for post-CABG neurologic events.…”

Section: Coexisting Coronary and Carotid Artery Diseasementioning

confidence: 99%