Short-term outcomes after carotid artery stenting followed by open heart surgery were comparable with those after carotid endarterectomy and open heart surgery performed at the same time, in a retrospective study that compared three approaches with treating patients who had both severe carotid artery disease and coronary artery disease.
However, after 1 year, staged carotid artery stenting and open heart surgery (CAS-OHS) "appears to be a better choice," with a significantly lower risk in the primary composite endpoint of death, stroke, or myocardial infarction, reported Dr. Mehdi H. Shishehbor and his coauthors (J. Am. Coll. Cardiol. 2013 [doi:10.1016/j.jacc.2013.03.094]).
Dr. Mehdi Shishehbor
The primary composite endpoint after undergoing CAS-OHS or combined carotid endarterectomy and OHS (CEA-OHS) were similar in both groups.
The third approach studied was carotid endarterectomy (CEA) followed by open heart surgery (staged CEA-OHS), which had the least favorable outcomes of all three approaches, with a "substantial risk of interstage MI," they reported. This approach, therefore, "should be avoided if possible," they concluded in the studywhich was published online on July 31, in the Journal of the American College of Cardiology Cardiovascular Interventions. Dr. Shishehbor is director of endovascular services in the Miller Family Heart and Vascular Institute at the Cleveland Clinic.
The study evaluated outcomes among 350 patients with severe carotid artery stenosis and were candidates for OHS, who underwent carotid revascularization within 90 days of having open heart surgery, at the Cleveland Clinic from 1997 to 2009: 45 had staged CEA-OHS, 195 had combined CEA-OHS, and 110 has staged CAS-OHS. Most of the open heart surgeries were coronary artery bypass grafting procedures.
Based on their analyses, they determined that in the short term, the composite endpoint was similar between those in the staged CAS-OHS group and those in the combined CEA-OHS group – although those in the CAS-OHS group had more MIs, most of which were between the procedures, and those in the combined CEA-OHS group has more perioperative strokes.
Of all three approaches, short-term outcomes were worse in the staged CEA-OHS group, because of the significantly higher risk of interstage MIs.
After 1 year, those in the staged CAS-OHS group had a significantly lower risk of the composite outcomes, compared with the other two groups: a 65% lower risk, compared with those in the combined CEA-OHS group; and a 67% lower risk, compared with those in the staged CAS-OHS group. The risk in the composite outcomes after 1 year in the two CEA groups was similar. Mortality after 1 year was similar in the three groups.
"In choosing between staged CAS-OHS and combined CEA-OHS, the increased risk of interstage MI with the former and perioperative stroke with the latter are important considerations despite similar risks for the early composite endpoint," the authors noted.
"Our study shows that carotid stenting followed by open heart surgery should be the first line strategy for treating patients with severe carotid and coronary disease, if the three- to four-week wait between procedures is clinically acceptable," Dr. Shishehbor said in a statement issued by the Cleveland Clinic. Although there has never been a randomized trial to determine what the best approach is for the types of patients in the study, "the evidence in this study may be enough to change practice," he added.
In fact, as a result of the study findings, changes are being made to the way patients with severe carotid and coronary artery disease are being managed at the Cleveland Clinic, and "we are collaborating across disciplines to identify the lowest risk treatment option for each patient," he added.
In the United States, currently, only 3% of patients with severe carotid and coronary artery disease are treated with staged carotid stenting followed by open heart surgery – compared with 31% of the patients in this study, the statement points out.