Synchronous versus staged carotid artery stenting and coronary artery bypass graft for patients with concomitant severe coronary and carotid artery stenosis: A systematic review and meta-analysis

Abstract

Background: Coronary artery disease requiring coronary artery bypass graft (CABG) frequently coexists with critical carotid stenosis. The most optimized strategy for treating concomitant carotid and coronary artery disease remains debatable.

Objective: The aim of this meta-analysis was to compare synchronous CAS and CABG versus staged CAS and CABG for patients with concomitant coronary artery disease and carotid artery stenosis in terms of peri-operative (30-day) and long-term clinical outcomes.

Methods: This study was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane database until December 2019. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess heterogeneity.

Results: Four studies comprising 357 patients were included in this meta-analysis. Patients who were treated with the synchronous approach had a statistically significant higher risk for peri-operative stoke (OR: 3.71; 95% CI: 1.00-13.69; I² = 0%) compared tο the staged group. Peri-operative mortality (OR: 4.50; 95% CI: 0.88-23.01; I² = 0%), myocardial infarction (MI) (OR: 1.54; 95% CI: 0.18- 13.09; I² = 0%), postoperative bleeding (OR: 0.27;95% CI: 0.02-3.12; I² = 0%), transient ischemic attacks (TIA) (OR: 0.60; 95% CI: 0.04- 9.20; I² = 0.0%), acute kidney injury (AKI) (OR: 0.34; 95% CI: 0.03-4.03; I² = 0.0%) and atrial fibrillation rates (OR:0.27; 95% CI: 0.02-3.12; I² = 0.0%) were similar between the two groups. Synchronous CAS-CABG and staged CAS followed by CABG were associated with similar rates of late mortality (OR: 3.75; 95% CI: 0.50-27.94; I² = 0.0%), MI (OR: 0.33; 95% CI: 0.01-12.03; I² = 0.0%) and stroke (OR:3.58; 95% CI:0.84-15.20; I² = 0.0%) after a mean follow-up of 47 months.

Conclusion: The simultaneous approach was associated with an increased risk of 30-day stroke compared to staged CAS and CABG. However, no statistically significant difference was found in long-term results of mortality, MI and stroke between the two approaches. Future studies are warranted to validate our results.

Keywords: Coronary artery bypass graft; carotid artery stenting; carotid endarterectomy; carotid stent.