Relationship Between the Degree of Carotid Stenosis and the Risk of Stroke in Patients Undergoing Cardiac Surgery

A novel open-vascular single-branched stent graft in total arch repair of type a aortic dissection one-year results of a prospective multicenter randomized controlled study

BACKGROUND

Acute type A aortic dissection (TAAD) is a life-threatening condition requiring timely surgery. Modifications in TAAD arch reconstruction are needed to improve surgical manipulation and reduce complications. This study evaluates a novel single-branched stent graft for arch reconstruction.

METHODS AND RESULTS

We randomly enrolled 156 patients with acute Type A Aortic Dissection (TAAD) from 8 Chinese hospitals to receive either the Fontus branched stent graft (75 patients) or the Cronus straight stent graft (81 patients) for frozen elephant trunk (FET) surgery. In the analysis of the primary endpoint, 30-day mortality was 10.7 % (8/75) in the Fontus group and 11.1 % (9/81) in the Cronus group, with a mortality difference of 0.44 % (95 % CI, -9.34 % to 10.22 %; non-inferiority threshold -14 %). At 12 months, all-cause mortality was 16.0 % in the Fontus group compared to 13.6 % in the Cronus group (p = 0.670). The rates of false lumen (FL) obliteration and freedom from secondary interventions for target lesions were 90.5 % and 98.4 % in the Fontus group, and 92.7 % and 98.6 % in the Cronus group. Instrumental adverse events occurred in 5 patients in the Fontus group, while no such events occurred in the Cronus group (p = 0.024). At 1 month, dissection-associated mortality was 10.7 % (8/75) in the Fontus group and 11.1 % (9/81) in the Cronus group.

CONCLUSIONS

This first randomized clinical study on FET repair for acute TAAD shows that the Fontus single-branched stent graft is safe, effective and non-inferior to the conventional straight stent graft in 1-year survival and adverse event rates.

Benefits of prophylactic carotid revascularization in patients with asymptomatic carotid artery stenosis undergoing coronary artery bypass surgery: A narrative review

Patients undergoing coronary artery bypass grafting (CABG) are at increased risk of perioperative stroke. Carotid atherosclerosis has been identified as an independent risk factor for stroke during and in the early postoperative period of cardiac surgery. However, the pathogenesis of peri-CABG stroke is multifactorial and frequently involves other noncarotid causes, such as cardiac emboli and aortic atheroma. Therefore, routine population-wide screening of carotid stenosis is not recommended, but target screening of patients at high risk of carotid-related perioperative stroke can have benefits. Carotid duplex sonography is recommended as an initial screening tool. Elimination of carotid stenosis before cardiac surgery is indicated in patients in whom carotid atherosclerosis is suspected to be the primary contributor to perioperative stroke. In patients with advanced carotid atherosclerosis, an individualized revascularization approach, including simultaneous or staged procedures, is advocated. The prevailing consensus is that synchronous surgery is safer than staged procedures. Carotid artery stenting represents a less invasive alternative, but its role in high-risk patients requires further investigation. In conclusion, the risk of perioperative stroke in patients undergoing CABG involves different factors, and carotid artery stenosis is involved in its pathogenesis only in some patients. Therefore, individualized approaches and careful consideration of patient risk factors are essential in determining the need for carotid screening and revascularization before CABG.

Clinical and Carotid Plaque Features in Symptomatic and Asymptomatic Ischemic Stroke

Aims/Background Ischemic stroke (IS), a cerebrovascular condition, is commonly detected by evaluating carotid intima-media (CIA) stenosis. Symptomatic CIA stenosis carries a high risk (up to 32%) of another ischemic event within 12 weeks, while asymptomatic CIA stenosis has an annual risk ranging from 1% to 2%. Therefore, this study aims to explore the diagnostic value of clinical features and carotid plaque characteristics in both symptomatic and asymptomatic IS. Methods This study enrolled 543 consecutive patients with internal carotid artery stenosis confirmed by carotid ultrasonography. Participants were categorized into the symptomatic group (n = 356) and the asymptomatic group (n = 187) by clinical symptoms and computed tomography (CT)/magnetic resonance imaging (MRI) of the brain. Demographic data, clinical features, and ultrasonographic characteristics of the carotid plaque were collected, and logistics regression analysis was carried out to explore the predictive risk factors of IS. Results According to the differences in clinical and carotid plaque characteristics between the two groups, coronary heart disease (CHD), stenosis degree, plaque diameter, plaque length, plaque vulnerability, and plaque echo type were included. The results of the multivariate logistics regression analysis showed that plaque vulnerability, CHD, and plaque hypoechogenicity were independent predictors of symptomatic stroke. The clinical-ultrasonographic prediction model showed an area under the curve (AUC) of 0.85 [95% confidence interval (CI): 0.82-0.88], a sensitivity of 0.74 (95% CI: 0.69-0.78), and a specificity of 0.81 (95% CI: 0.76-0.87), with a good performance in the model prediction. Conclusion Plaque vulnerability, CHD, and plaque hypoechogenicity are meaningful predictors of symptomatic ischemic stroke and deserve attention in the future.

The correlation between severe asymptomatic carotid artery stenosis and severe multi-organ dysfunction after off-pump coronary artery bypass grafting

Background

The current research aimed to demonstrate the independent association between preoperative severe asymptomatic carotid artery stenosis (ACAS) and severe multi-organ dysfunction after off-pump coronary artery bypass grafting (OPCAB), which may further indicate the relationship between severe ACAS and adverse 30-day postoperative outcomes of patients undergoing OPCAB.

Methods

This was a single-center, retrospective observational study including patients without a history of stroke or Transient Ischemic Attacks (TIA) (asymptomatic), who underwent for an isolated OPCAB in the center for operative treatment of coronary artery disease of Beijing Anzhen Hospital from January 2020 to December 2021. All enrolled patients underwent carotid artery ultrasound prior to OPCAB. The information was extracted independently by two authors of the study from the medical records. Both univariate and multivariate analyses were conducted.

Results

A total of 562 patients met the inclusion criteria for the current study. 63 (11.2%) suffered from severe ACAS. The Sequential Organ Failure Assessment (SOFA) maximum in the severe ACAS group was significantly higher than that in the non-severe ACAS group (9.76 ± 3.03 vs. 7.75 ± 2.96, p < 0.0001), and a higher proportion of patients in the severe ACAS group exhibited severe multi-organ dysfunction (44.4% vs. 14.0%, p < 0.0001). In addition, severe ACAS was related to an increased rate of 30-day postoperative major adverse cardiovascular and cerebral events (MACCEs), including a 30-day postoperative stroke. Severe ACAS was associated with an elevated risk of delirium, and acute kidney injury (AKI). The results of the multivariate analysis demonstrated that severe ACAS may be independently associated with severe multi-organ dysfunction (OR, 7.37, 95% CI 4.80-14.30, p < 0.0001) after OPCAB. Also, severe ACAS may be independently associated with 30-day postoperative stroke (OR, 2.83, 95% CI 1.03-7.75, p = 0,043).

Conclusions

Severe ACAS was independently associated with severe multi-organ dysfunction after OPCAB, which may be associated further with an increased rate of 30-day postoperative mortality and complications. This study highlights: (1) the importance of personalized assessment for potential advantages and disadvantages in prognosis of severe ACAS patients undergoing OPCAB with carotid endarterectomy; (2) the role of multi-organ parameters, especially cardio-cerebral factors, should be emphasized during the process of severe ACAS management.

A meta-analysis supporting the superiority of staged carotid artery stenting and coronary artery bypass grafting in patients with concurrent severe coronary and carotid artery stenosis

BACKGROUND

This study sought to ascertain whether a staged approach involving carotid artery stenting (CAS) and coronary artery bypass grafting (CABG) holds superiority over the synchronous (Syn) strategy of CAS or carotid endarterectomy (CEA) and CABG in patients necessitating combined revascularization for concurrent carotid and coronary artery disease.

METHOD

Studies were identified through 3 databases: PubMed, EMBASE, and the Cochrane Library. Statistical significance was defined as a P value of less than .05 for all analyses, conducted using STATA version 12.0.

RESULTS

In the comparison between staged versus Syn CAS and CABG for patients with concomitant severe coronary and carotid stenosis, 4 studies were analyzed. The staged procedure was associated with a lower rate of 30-day stroke (OR = 8.329, 95% CI = 1.017-69.229, P = .048) compared to Syn CAS and CABG. In the comparison between staged CAS and CABG versus Syn CEA and CABG for patients with concomitant severe coronary and carotid stenosis, 5 studies were examined. The staged CAS and CABG procedure was associated with a lower rate of mortality (OR = 2.046, 95% CI = 1.304-3.210, P = .002) compared to Syn CEA and CABG.

CONCLUSION

The Syn CAS and CABG was linked to a higher risk of peri-operative stroke compared to staged CAS and CABG. Additionally, patients undergoing staged CAS and CABG exhibited a significantly decreased risk of 30-day mortality compared to Syn CEA and CABG. Future randomized trials or prospective cohorts are essential to confirm and validate these findings.

The role of carotid artery stenosis in predicting stroke after coronary artery bypass grafting in a Chinese cohort study

Current guidelines give priority to surgical treatment of carotid artery stenosis (CAS) before coronary artery bypass grafting (CABG), especially in symptomatic patients. Carotid artery stenting is an alternative treatment for narrowing of the carotid arteries. This study sought to demonstrate the role of severe CAS in predicting stroke after CABG and assess the efficacy of carotid artery stenting in preventing postoperative stroke in a Chinese cohort. From 2015 to 2021, 1799 consecutive patients undergoing isolated CABG surgery were retrospectively recruited in a Chinese cohort. The predictive value of severe CAS in postoperative stroke and carotid stenting in preventing postoperative stroke was statistically analyzed. The incidence of postoperative stroke was 1.67%. The incidence of CAS with stenosis ≥ 50% and ≥ 70% was 19.2% and 6.9%. After propensity matching, the incidence of stroke was 8.0% in the severe CAS group and 0% in the non-severe CAS group. We successfully established an optimal predictive nomogram for predicting severe CAS in patients undergoing CABG. Carotid artery stenting was found ineffective in preventing postoperative stroke. The present study provides the incidence of CAS and postoperative stroke in a Chinese cohort, identifies severe CAS as an independent risk factor for postoperative stroke after CABG, constructs a nomogram predicting the incidence of severe CAS, and evaluates the effectiveness of carotid artery stenting in preventing postoperative stroke after CABG.

Endovascular carotid revascularization under open-chest extracorporeal circulation combined with cardiac surgery in unstable patients at increased risk of carotid-related stroke: SIMultaneous urgent cardiac surgery and MicroNet-covered stent carotid revascularization in extreme-risk patients-SIMGUARD Study

BACKGROUND

In patients at urgent need for cardiac surgery coexisting with increased-stroke-risk carotid stenosis, any staged intervention increases the risk of complications from the primarily unaddressed pathology. In this challenging cohort, we assessed safety and feasibility of endovascular carotid revascularization under open-chest extracorporeal circulation (ECC) combined with cardiac surgery (hybrid-room true simultaneous treatment).

METHODS

Per-protocol (PP), after general anesthesia induction, chest-opening and ECC stand-by installation, carotid stenting (CAS) was performed (femoral/radial or direct carotid access) with ad-hoc/on-hand switch to ECC cardiac surgery.

RESULTS

Over 78 months, 60 patients (70.7±6.9years, 85% male, all American Society of Anesthesiology grade IV) were enrolled. All were at increased carotid-related stroke risk (ipsilateral recent stroke/transient ischemick attack, asymptomatic cerebral infarct, increased-risk lesion morphology, bilateral severe stenosis). Majority of study procedures involved CAS+coronary bypass surgery or CAS+valve replacement±coronary bypass. 45 (75%) patients were PP- and 15 (25%) not-PP (NPP-) managed (context therapy). CAS was 100% neuroprotected (transient flow reversal-64.4%, filters-35.6%) and employed micronet-covered plaque-sequestrating stents with routine post-dilatation optimization/embedding. 4 deaths (6.7%) and 7 strokes (11.7%) occurred by 30-days. Despite CAS+surgery performed on aspirin and unfractionated heparin-only (delayed clopidogrel-loading), no thrombosis occurred in the stented arteries, and 30-days stent patency was 100%. NPP-management significantly increased the risk of death/ipsilateral stroke (OR 38.5; P<0.001) and death/any stroke (OR 12.3; P=0.002) by 30-days.

CONCLUSIONS

In cardiac unstable patients at increased carotid-related stroke risk who require urgent cardiac surgery, simultaneous cardiac surgery and CAS with micronet-covered stent lesion sequestration is feasible and safe and shows efficacy in minimizing stroke risk. Larger-scale, multicentric evaluation is warranted. (SIMGUARD NCT04973579).