CEA or CAS followed by CABG - summitMD.com

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CEA or CAS followed by CABG - summitMD.com

Carotid Artery Stenting

Can carotid stenting before CABG

reduce perioperative stroke?

Seong-Wook Park, MD, PhD, FACC

Asan Medical Center,

University of Ulsan College of Medicine, Seoul, Korea

University of Ulsan College of Medicine

Asan Medical Center


Carotid Stenosis in Patients

Undergoing CABG

• The reported incidence of carotid disease in

patients undergoing CABG has varied from 2

to 22%, average of 8%.

• This wide variation in the reported incidence is

related to the population based studies.

Bull DA, Cardiovasc Surg 1993;1:182

Ivey TD, J Thorac Cardiovasc Surg 1984;87:183

University of Ulsan College of Medicine

Schwartz LB, J Vasc Surg 1995;21:146

Loop FD, Ann Thorc Surg 1988;45:591

Asan Medical Center


Risk Factors for Post-CABG Stroke

• Aortic arch disease

• Prolonged cardiopulmonary bypass

• Carotid artery disease

• Diabetes

• Smoking

• Pulmonary disease

• Ventricular thrombus

• Left main disease

Durand DJ, Ann Thorc Surg 2004;78:159

University of Ulsan College of Medicine

Asan Medical Center


Risk of Stroke During CABG

Effect of Time

2

1.75

1.5

1.25

1

0.75

0.5

0.25

0

1.5

CVA/CABG

(666/45486)

1970-1985

(18 studies)

1.8

CVA/CABG

(2593/144963)

1986-2000

(41 studies)

Naylor AR, Eur J Vasc Endovasc Surg 2002;23:283-294

University of Ulsan College of Medicine

Asan Medical Center


Risk of Stroke During CABG

Effect of Age

%

10

8

9

6

4

2.5

2

0

0.5


Risk of Stroke During CABG

Neurological Status

%

10

Odds Ratio, 3.6 p


Perioperative stroke after CABG

%

20

18

16

14

12

10

8

6

4

2

0

19

10

2

< 50% 50-80% ≥ 80%

Diameter stenosis

Naylor AR, Eur J Vasc Endovasc Surg 2002;23:283-294

University of Ulsan College of Medicine

Asan Medical Center


Risk of Stroke During CABG

No carotid disease

Unilateral 50-99%

Bilateral 50-99%

Unilateral Occlusion

0 2 4 6 8 10 12

Perioperative Mortality

Naylor AR, Eur J Vasc Endovasc Surg 2002;23:283-294

University of Ulsan College of Medicine

Asan Medical Center


Great Debates

Carotid Endarterectomy vs. Conservative

Treatment in Asymptomatic Carotid Artery

Disease Before CABG

University of Ulsan College of Medicine

Asan Medical Center


How do we treat

carotid artery disease?

Various Treatment Modalities

University of Ulsan College of Medicine

Asan Medical Center


Operative Mortality According to

Treatment Modalities

Meta-analysis of 97 Studies (8972 patients)

%

6

4.6

4

3.9

2

2

0

Synchronous

CEA+CABG

Staged

CEACABG

Staged

CABGCEA

Naylor AR, Eur J Vasc Endovasc Surg 2003;25:380-389

University of Ulsan College of Medicine

Asan Medical Center


Any Stroke According to

Treatment Modalities

Meta-analysis of 97 Studies (8972 patients)

%

8

6

6.3

4.6

4

2.7

2

0

Synchronous

CEA+CABG

Staged

CEACABG

Staged

CABGCEA

Naylor AR, Eur J Vasc Endovasc Surg 2003;25:380-389

University of Ulsan College of Medicine

Asan Medical Center


AMI According to Treatment

Modalities

Meta-analysis of 97 Studies (8972 patients)

%

8

6

6.5

4

3.6

2

0.9

0

Synchronous

CEA+CABG

Staged

CEACABG

Staged

CABGCEA

Naylor AR, Eur J Vasc Endovasc Surg 2003;25:380-389

University of Ulsan College of Medicine

Asan Medical Center


Current (2004) ACC/AHA Guideline

CEA is probably recommended before CABG or

concomitant to CABG in patients with a

symptomatic or asymptomatic patients with

unilateral or bilateral internal carotid stenosis of

80% or more.

• Class IIa, level of evidence C

Eagle K et al, Circulation 2004;110:1168-1176

University of Ulsan College of Medicine

Asan Medical Center


Comparison CAS vs. CEA in Open Heart

Surgery with CABG (N=167)

30 Days Adverse Events

%

25

20

P=0.02

CAS+CABG

18.9

CEA+CABG

21.6

15

10

5

3.3

12.6

1.8

9

7.2

5.4 5.4

7.1

12.6

10.7

0

MI CVA MI/CVA Death Death/ Death

CVA /MI/CVA

Ziada KM et al, Am J Cardiol 2005;96:519-523

University of Ulsan College of Medicine

Asan Medical Center


Staged CAS Followed by CABG in

Asymptomatic Severe Carotid Stenosis

Patients (N=356)

%

8

30 Days after CABG

6.7

6

4.8

4

3.7

3.1

3.7

2

2

0

MI TIA CVA Death Death/ Death

CVA /MI/CVA

Vand der Heyden J et al, Circulation 2007;116:2036-2042

University of Ulsan College of Medicine

Asan Medical Center


Staged CAS followed by CABG in

Asymptomatic Severe Carotid Stenosis

Patients (N=356)

%

35

5-Year Event Rates

30

25

20

24.5

28.6

20.5

15

10

5

2

5.6 6

0

MI TIA CVA Death Death/ CD

CVA /MI/CVA

Vand der Heyden J et al, Circulation 2007;116:2036-2042

University of Ulsan College of Medicine

Asan Medical Center


AMC Experience

University of Ulsan College of Medicine

Asan Medical Center


Carotid Stenting in AMC

AMC

• From 01/2001’ to 11/2007’

• 42 patients (staged bilateral procedure in 2

patients)

• Use of EPD : 39/44 lesions (89%)

Balloon type : 7/39 (16%)

Filter type : 32/39 (73%)

• All severe (≥70% ) ICA stenosis

University of Ulsan College of Medicine

Asan Medical Center


Baseline Characteristics

AMC

Variables N=42

Age, years 67.3±6.6

Sex, men 21 (50%)

Diabetes 21 (50%)

Hypertension 28 (66.7%)

Dyslipidemia 19 (45.2%)

Smoking 28 (66.7%)

Previous myocardial infarction 7 (16.7%)

Previous coronary angioplasty

7 (16.7%)

Previous congestive heart failure

11 (26.2%)

Previous carotid angioplasty

4 (9.5%)

Previous CEA

0

Previous head/neck radiotherapy

0

Previous TIA 0

Previous stroke 7 (16.7%)

Peripheral vascular disease 1 (2.4%)

Chronic lung disease 1 (2.4%)

University of Ulsan College of Medicine

Asan Medical Center


Baseline Characteristics

AMC

Variables

N=42 (44 lesions)

Chronic renal failure 3 (7.1%)

Atrial fibrillation 2 (4.8%)

Acute coronary syndrome 27 (64.3%)

Severe coronary artery disease

2 vessel disease 5 (11.9%)

3 vessel disease 27 (64.3%)

Left main plus 3 vessel disease 10 (23.8%)

Left ventricular ejection fraction (%)

Study Population Classification

Symptomatic high risk

Symptomatic low risk

Asymptomatic high risk

56.5 ± 9.3

7 (15.9%)

0

37 (84.1%)

Asymptomatic low risk 0

Time interval between CAS and CABG 65.5 ± 162.9 days

Dual antiplatelet therapy 42 (100%)

University of Ulsan College of Medicine

Asan Medical Center


Patients (Lesions) 42 (44)

Degree of stenosis

Severe stenosis (>90%) 4 lesions (9.1%)

Severe stenosis (70-90%) 40 lesions (90.9%)

Mild to moderate stenosis 0

Common carotid artery stenosis 2 (4.5%)

Bilateral ICA stenosis 2 patients (4.8%)

Right ICA stenosis

26 lesions (59.1%)

Left ICA stenosis

16 lesions (36.4%)

Success rate

44 lesions (100%)

Protection device

39 lesions (88.6%)

Balloon type

7 lesions (15.9%)

Filter type 32 lesions (72.7%)

Number of used stent

1.02 per lesion

Length of used stent, mm

36.7 ± 7.3

Average stent diameter, mm 6.7 ± 0.6

AMC

Angiographic and Procedural Characteristics

University of Ulsan College of Medicine

Asan Medical Center


In-hospital outcomes

AMC

%

8

7

6

5

4

3

2

1

0

Death/MI/Stroke/TIA

2.4 2.4

0 0 0

1* 1

Death MI TIA Stroke All events

*Stroke: 1 minor, asx high risk with EPD, minor impairment at discharge

University of Ulsan College of Medicine

Asan Medical Center


AMC

From CAS to CABG

No further events

30-day After CABG

No further events

University of Ulsan College of Medicine

Asan Medical Center


Long-term outcomes

AMC

%

5

4

Death/Stroke

Follow-up duration : median 33.1 (24.9-49.8) months

4.8 4.8

3

2

1

2 *

2

0

0 0

Minor stroke Major stroke Death All events

* Only 2 additional deaths (noncardiac death)

University of Ulsan College of Medicine

Asan Medical Center


Conclusions

• There is no strong consensus regarding the prophylactic

carotid revascularization in patients scheduled for CABG.

• Carotid endarterectomy is probably recommended before

CABG or concomitant to CABG in patients with a

symptomatic or asymptomatic patients with unilateral or

bilateral internal carotid stenosis of 80% or more.

• Recent data suggest carotid stenting before CABG may be

another viable treatment option.

University of Ulsan College of Medicine

Asan Medical Center


Conclusions

Future Direction

• The best strategy for managing patients who have

combined coronary & carotid disease will be established

only by prospective, randomized trials.

- CEA or CAS followed by CABG

- CABG alone

- CABG followed by CEA or CAS

• Until then, the optimal treatment strategy should be

determined on a case-by-case basis by a multidisciplinary

team that includes a neurologist, a vascular surgeon, and

an interventionists.

University of Ulsan College of Medicine

Asan Medical Center

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