Systematic Preoperative Coronary Angiography and Stenting Improves Postoperative Results of Carotid Endarterectomy in Patients with Asymptomatic Coronary Artery Disease: A Randomised Controlled Trial

Abstract

Objective: To evaluate the usefulness of systematic coronary angiography followed, if needed, by coronary artery angioplasty (percutaneous coronary intervention (PCI)) on the incidence of cardiac ischaemic events after carotid endarterectomy (CEA) in patients without evidence of coronary artery disease (CAD).Materials and methods: From January 2005 to December 2008, 426 patients, candidates for CEA, with no history of CAD and with normal cardiac ultrasound and electrocardiography (ECG), were randomised into two groups. In group A (n ϭ 216) all the patients had coronary angiography performed before CEA. In group B, all the patients had CEA without previous coronary angiography. In group A, 66 patients presenting significant coronary artery lesions at angiography received PCI before CEA. They subsequently underwent surgery under aspirin (100 mg day Ϫ1 ) and clopidogrel (75 mg day Ϫ1 ). CEA was performed within a median delay of 4 days after PCI (range: 1-8 days).Risk factors, indications for CEA and surgical techniques were comparable in both groups (p Ͼ 0.05). The primary combined endpoint of the study was the incidence of postoperative myocardial ischaemic events combined with the incidence of complications of coronary angiography. Secondary endpoints were death and stroke rates after CEA and incidence of cervical haematoma.Results: Postoperative mortality was 0% in group A and 0.9% in group B (p ϭ 0.24). One postoperative stroke (0.5%) occurred in group A, and two (0.9%) in group B (p ϭ 0.62). No postoperative myocardial event was observed in group A, whereas nine ischaemic events were observed in group B, including one fatal myocardial infarction (p ϭ 0.01). Binary logistic regression analysis demonstrated that preoperative coronary angiography was the only independent variable that predicted the occurrence of postoperative coronary ischaemia after CEA. The odds ratio for coronary angiography (group A) indicated that when holding all other variables constant, a patient having preoperative coronary angiography before carotid surgery was 4 times less likely to have a cardiac ischaemic event after carotid surgery. No complications related to coronary angiography were observed and no cervical haematomas occurred in patients undergoing surgery under aspirin and clopidogrel in this study.Conclusions: Systematic preoperative coronary angiography, possibly followed by PCI, significantly reduces the incidence of postoperative myocardial events after CEA in patients without clinical evidence of CAD.

Early and Long-Term Outcomes After Combined Percutaneous Revascularization in Patients With Carotid and Coronary Artery Stenoses

“…Indeed, evidence in support of coronary revascularization in patients needing carotid interventions is becoming more consistent (25), although it remains to be proved in large randomized clinical trials. 3) The shorter hospital stay might translate into a reduction in costs compared with the costs of hybrid or surgical strategies.…”

Long-term Results of a Randomized Controlled Trial Analyzing the Role of Systematic Pre-operative Coronary Angiography before Elective Carotid Endarterectomy in Patients with Asymptomatic Coronary Artery Disease

“…18 As previously reported, 17 patients referred for CEA were enrolled in the study if they had no evidence of CAD, defined as the absence of any clinical sign or history of ischaemic cardiac disease, no electrical signs of cardiac ischemia at rest and a left ventricular ejection fraction > 50% on transthoracic echocardiogram. In order to measure functional capacity (METSmetabolic equivalent), the cardiologists included a questionnaire on physical activity following the International Physical Activity Questionnaire (IPQ), the Physical Activity Scale for the Elderly (PASE), and the Metabolic Equivalent Task Scale (METS) with careful investigation of any clinical metabolic impairment before randomization.…”

“…14e16 In a previous data analysis, it was demonstrated that systematic pre-operative angiography, followed by selective coronary revascularization, significantly reduced the incidence of post-operative MI after carotid endarterectomy (CEA) in patients without clinical evidence of CAD. 17 We are reporting in the present study, the long-term follow up of this trial to assess whether the systematic use of preoperative coronary angiography followed by selective coronary artery revascularization significantly reduces occurrence of late MI and improves survival in patients without a previous history of CAD at the time of carotid surgery.…”

Prevalence and Predictors of Concomitant Carotid and Coronary Artery Atherosclerotic Disease

“…Conversely, the presence of CAD increases the risk of peripheral vascular surgery including carotid endarterectomy (19). Notwithstanding, the role of pre-emptive interventions on asymptomatic carotid or coronary lesions prior to coronary or carotid revascularization, respectively, is controversial (18,20), and guideline recommendations regarding screening for asymptomatic CAS in patients with CAD are unsettled (21,22). Our data indicate that although at least some degree of atherosclerotic carotid disease is frequently detected among patients with extensive CAD (i.e., 3VD and/or LMD), the prevalence of CAS potentially mandating intervention is lower than previously reported (i.e., in the range of 7% to 11% in the highest-risk anatomic subsets of CAD).…”