Prevalence, risk factors, and clinical effect of coronary artery disease in patients with asymptomatic bilateral carotid stenosis

Outcomes of Carotid Artery Stenting and Endarterectomy in Patients with Prior Contralateral Carotid Revascularization

BACKGROUND

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are available treatment options for stroke prevention in individuals with severe carotid stenosis. This study aims to compare the early postoperative outcomes in patients who underwent CEA or CAS after prior contralateral carotid revascularization.

METHODS

We conducted a retrospective review of the Society of Vascular Surgery Vascular Quality Initiative database, identifying patients who had prior carotid artery revascularization followed by a contralateral CEA or CAS between 2017 and 2023. Based on the sequence of the procedures performed, patients were categorized into 4 groups: 1) patients who had a prior unilateral CEA followed by a contralateral CEA; 2) patients who had a prior unilateral CAS followed by a contralateral CEA; 3) patients had a prior unilateral CAS followed by a contralateral CAS; and 4) patients had a prior unilateral CEA followed by a contralateral CAS. Univariate analysis (Pearson χ2, Wilcoxon rank sum test) and multivariate logistic regression were employed to assess length of stay, rates of in-hospital stroke, myocardial infarction, new-onset arrhythmia, and 30-day mortality.

RESULTS

A total of 20,761 patients with a history of prior unilateral carotid revascularization procedures were identified, of which 12,788 underwent contralateral CEA and another 7,973 underwent contralateral CAS. Compared to the prior unilateral CAS followed by a contralateral CAS group, patients who underwent CEA followed by contralateral CAS (prior unilateral CEA followed by a contralateral CAS group) were associated with higher rates of postoperative in-hospital stroke (1.8% vs. 1%, P = 0.003), new-onset arrhythmia (2% vs. 1.2%, P = 0.006), and 30-day mortality (1.3% vs. 0.8%, P = 0.04). On multivariate analysis, preoperative use of statins and beta-blockers was associated with lower odds of in-hospital stroke (odds ratio [OR] 0.42; 95% confidence interval 0.29-0.69; P = 0.0002) and new-onset arrhythmia (OR 0.62; 95% confidence interval 0.49-0.9; P = 0.01), respectively, after CAS. There were no significant differences in outcomes for prior unilateral CEA followed by a contralateral CEA and prior unilateral CEA followed by a contralateral CAS groups.

CONCLUSIONS

Patients with prior CEA undergoing contralateral CAS had higher rates of in-hospital stroke, new-onset arrhythmia, and 30-day mortality. Beta-blockers may reduce postoperative arrhythmia rates in these patients, and established regimens should not be discontinued in the perioperative period; however, further prospective studies are needed to confirm this finding. Optimized medical treatment and appropriate imaging follow-up remain crucial for improvement outcomes.

A Prosthetic Conduit can be Used Safely for TransCarotid Artery Revascularization Under Local Anesthesia in High-Risk Patients

Surgical management of carotid stenosis has evolved from open carotid endarterectomy (CEA) to include multiple alternative procedures including transfemoral carotid artery stenting (tfCAS) and transcarotid artery stenting. In recent years, Transcarotid Artery Revascularization (TCAR) has emerged as a third option, combining open cut down to the common carotid artery (CCA) with endovascular stenting and neuroprotection via reversal of cerebral blood flow. In this case series, a modified TCAR procedure using a prosthetic conduit was successfully performed exclusively under local anesthesia in a total of 10 patients with carotid artery stenosis, high cardiac risk, and anatomical contraindications to a traditional TCAR.

Simultaneous Carotid Artery Stenting and Coronary Artery Bypass Grafting in Urgent Patients: A Single Center Experience

Background: Coexisting coronary artery disease and critical carotid stenosis present challenges in revascularization, particularly in urgent cases requiring surgery. Combining carotid artery stenting (CAS) with coronary artery bypass grafting (CABG) has gained popularity. Methods: This study analyzed 36 patients who underwent simultaneous CAS and CABG from 2014 to 2024. CAS was performed first, with the patient awake for real-time neurocognitive assessment. A clopidogrel loading dose was administered three hours post-surgery. From postoperative day 1, dual antiplatelet therapy was initiated. Results: The median age was 72 years (64-77) and 22.2% were females. The median EuroSCORE II was 2.80 (2.06-3.58). Nine patients (25%) underwent associated procedures. The median cardiopulmonary bypass and cross-clamp times were 66 (54-89) and 51 (41-72) minutes. We observed no in-hospital mortality and no postoperative stroke. The median postoperative bleeding in 24 h was 500 mL and only one (2.8%) patient needed resternotomy for bleeding. The median ventilation time was 9 h (6-12). The median intensive care unit and postoperative length of stay were 2 (2-4) days and 8 (7-11) days, respectively. The median follow-up time was 6 years. Survival at 1, 5, and 10 years was 93.7%, 81.5%, and 60.2%, respectively, while freedom from PTCA/PCI at 1, 5, and 10 years was 100%, 96.7%, and 87.5%, respectively. Conclusions: Simultaneous CAS and CABG is a safe and effective procedure with low in-hospital mortality and morbidity. Our protocol carries a low risk of perioperative stroke. Antiplatelet therapy administration on the day of surgery does not increase the risk of postoperative bleeding.

A Routine Coronary Angiography before Carotid Endarterectomy as an Example of Interdisciplinary Work: The Immediate Results of the Surgery

The aim: to evaluate the incidence of obstructive lesions of the coronary arteries during routine coronary angiography (CAG) before carotid endarterectomy (CEA) and the incidence of perioperative complications. Materials and Methods: We examined a continuous sample of 498 patients before CEA who underwent an invasive evaluation of the coronary bed during CAG. Depending on the hemodynamic significance of coronary artery lesions, the patients were divided into three groups: group I-obstructive coronary artery disease (≥70%) (n = 309, 62.0%); group II-non-obstructive lesions of the coronary arteries (<70%) (n = 118, 23.7%); group III-intact coronary arteries (n = 71, 14.3%). The groups were compared with each other according to the data of the preoperative examination (clinical and anamnestic parameters, laboratory data and results of echocardiography), as well as according to the immediate results of the operation. In the hospital period, adverse cardiovascular events were assessed: death, myocardial infarction (MI), stroke, arrhythmias, atrial fibrillation or flutter (AF/AFL) and combined endpoint. Results: The groups differed significantly in the presence of symptoms of angina pectoris, myocardial infarction and myocardial revascularization procedures in their medical history and in the presence of chronic ischemia of the lower extremities. However, in the group of intact coronary arteries, the symptoms of angina were in 14.1% of patients, and a history of myocardial infarction was in 12.7%. Myocardial revascularization before CEA or simultaneously with it was performed in 43.0% of patients. As a result, it was possible to reduce the number of perioperative cardiac complications (mortality 0.7%, perioperative myocardial infarction 1.96%). Conclusions: The high incidence of obstructive lesions in the coronary arteries in our patients and the minimum number of perioperative complications favor routine CAG before CEA.