Treatment strategies in severe symptomatic carotid and coronary artery disease

Abstract

Coexistent carotid artery stenosis (CS) and multivessel coronary artery disease (CAD) is not infrequent. One in 5 patients with multivessel CAD has a severe CS, and CAD incidence reaches 80% in those referred for carotid revascularization. We reviewed treatment strategies for concomitant severe CS and CAD. We performed a literature search (MEDLINE) with terms including carotid artery stenting (CAS), coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), stroke, and myocardial infarction (MI). The main therapeutic option for CS-CAD has been (simultaneous or staged) CEA-CABG. This, however, is associated with a high risk of MI (in those with CEA prior to CABG) or stroke (CABG prior to CEA), and the cumulative major adverse event rate (MAE - death, stroke or MI) reaches 10-12%. With increasing adoption of CAS, a sequential strategy of CAS followed by CABG has emerged. Registries (usually single-centre) indicate an MAE rate of ≈7% for CAS followed by CABG (frequently after >30 days, due to double antiplatelet therapy). Recently, 1-stage CAS-CABG has been introduced. This involves different antiplatelet regimens and, in some centers, preferred off-pump CABG, with a cumulative MAE of 1.4-4.5%. No randomized trial comparing different treatment strategies in CS-CAD has been conducted, and thus far reported series are prone to selection/reporting bias. In addition to the established surgical treatment (CEA-CABG, sequential/simultaneous), hybrid revascularization (CAS-CABG) is emerging as a viable therapeutic option. Larger, preferably multi-centre, studies are required before this can become widely applied.

Figure 1

An example of the patient with critical RICA stenosis before and after successful CAS procedure in a patient after left hemisphere stroke (occluded LICA) accepted for staged CAS – CABG strategy.

Figure 2

Coronary angiogram of the same patient (CCS class II angina), a critical stenosis of the left main coronary artery (LMCA) and occlusion of the right coronary artery (RCA).

Figure 3

An example of a coronary unstable patient with multivessel coronary artery disease and recurrent TIAs. An electrocardiogram performed during CAS. CAS was immedaitelly followed by CABG.

Figure 4

Coronary angiogram of the same patient: a critical stenosis of proximal left anterior descending artery (LAD) and stenosis of second marginal branch (Mg). RCA was without significant stenosis after PCI performed 7 years before.

Figure 5

(A) Subtotal LICA stenosis of the same coronary unstable patient (recent amaurosis fugax of the left eye), (B) CAS performed with usage of proximal NPD (flow reversal), (C) final result after stent implantation.

Figure 6

The patient was operated off pump, a total arterial revascularization (TAMR) was performed: LIMA-LAD, Radial Artery (RA): Y-anastomosis.