Surgical Approach in Patients with Concomitant Surgical Approach in Patients with Concomitant

Carotid and Coronary Artery DiseaseCarotid and Coronary Artery Disease

Rashad MAHMUDOV Rashad MAHMUDOV

Central Hospital of Central Hospital of

Oilworkers, Baku-AzerbaijanOilworkers, Baku-Azerbaijan

Carotid artery disease: OverviewCarotid artery disease: Overview

StrokeStroke is the third leading cause of death is the third leading cause of death (795,000 people suffer a stroke, 164,000 (795,000 people suffer a stroke, 164,000 deaths/year) and leading cause of serious long-deaths/year) and leading cause of serious long-term disability in the U.S.term disability in the U.S.

AtherosclerosisAtherosclerosis accounts for up to one-third of accounts for up to one-third of all strokes.all strokes.

15-20% 15-20% of strokes is due to CAOD.of strokes is due to CAOD. 80% strokes 80% strokes occur in asymptomatic patients. occur in asymptomatic patients.

Cause of stroke and TIACause of stroke and TIA

EmbolusEmbolus Carotid atheromaCarotid atheroma Cardiac Cardiac

Atrial fibrillationAtrial fibrillation Mural thrombusMural thrombus Patent foramen ovalePatent foramen ovale

ThrombosisThrombosis Abnormality of vesselsAbnormality of vessels

AtherosclerosisAtherosclerosis Autiimmune diseaseAutiimmune disease VasculitisVasculitis Wall dissectionWall dissection

Abnormal clottingAbnormal clotting PolycythemiaPolycythemia ThrombocythemiaThrombocythemia HyperviscosityHyperviscosity Clotting disordersClotting disorders

• Inherited Inherited • acquiredacquired

Migraine?Migraine?

Prophylactic carotid revascularisation would

prevent 40 - 50% of perioperative stroke in asymptomatic patients.

Extracranial and Intracranial Extracranial and Intracranial circulationcirculation

The proximal internal carotid artery and the carotid bifurcation are most frequently involved

Risk factors for carotid stenosisRisk factors for carotid stenosis

AgeAge

Sex: man > womanSex: man > woman

Diabetes mellitusDiabetes mellitus

HypertensionHypertension

Smoking, alcoholSmoking, alcohol

DyslipidemiaDyslipidemia

Symptoms of carotid stenosisSymptoms of carotid stenosis

Temporary monocular blindness Temporary monocular blindness (embolization to the (embolization to the

ophthalmic artery).ophthalmic artery).

Transient Ischemic Attack (Transient Ischemic Attack (TIATIA).).

StrokeStroke (stroke risk (stroke risk symptomatic >>symptomatic >> asymptomatic). 70- asymptomatic). 70-

99% stenosis 2 yrs risk = 26%.99% stenosis 2 yrs risk = 26%.

A A carotid bruitcarotid bruit should be heard in the majority of patients should be heard in the majority of patients

with carotid stenosis > 75%.with carotid stenosis > 75%.

Evaluation of carotid artery stenosis Evaluation of carotid artery stenosis

Carotid duplex ultrasonographyCarotid duplex ultrasonography

Transcranial Doppler Transcranial Doppler

MR angiography (MRA)MR angiography (MRA)

CT angiography (CTA)CT angiography (CTA)

Carotid angiography Carotid angiography - the gold standard (1.3% - the gold standard (1.3%

neurological complication rate).neurological complication rate).

Carotid Artery StenosisCarotid Artery Stenosis

Carotid angiography

Treatment optionsTreatment options

Medical therapy (BMT)AspirinStatinHypertensionDiabetesDyslipidemia

Carotid artery stenting (CAS)

Carotid endarterectomy (CEA)

Best treatment --- ???

Concomitant Coronary and Concomitant Coronary and

Carotid Artery DiseaseCarotid Artery Disease

Concomitant Concomitant CoronaryCoronary andand CarotidCarotid Artery DiseaseArtery Disease

Patients referred for Patients referred for CABGCABG have a prevalence of have a prevalence of 17 - 22%17 - 22% for carotid stenosis for carotid stenosis > 50% > 50% and and 6 -12% for carotid stenosis 6 -12% for carotid stenosis > 80% (asymptomatic)> 80% (asymptomatic).. Conversely, significant CAD occurs Conversely, significant CAD occurs in nearly one third of pts with high-grade carotid stenosis who in nearly one third of pts with high-grade carotid stenosis who are being considered for CEA. are being considered for CEA.

The risk of The risk of perioperative strokeperioperative stroke after CABG: after CABG: 2% for carotid stenosis < 50% 2% for carotid stenosis < 50% 10% for carotid stenosis 50 – 80%10% for carotid stenosis 50 – 80% 19% for carotid stenosis greater than 80%.19% for carotid stenosis greater than 80%.

Plaque morphology: Plaque morphology: the presence of the presence of hypoechoichypoechoic or or echolucentecholucent plaque, plaque, plaque ulceration plaque ulceration etc.etc.

Prevalence of CS in CADPrevalence of CS in CAD

Tanimoto et al. Stroke, 2005.

Approach in combined CAD and CSApproach in combined CAD and CS

Fix the more Fix the more clinically active clinically active bed first in a staged bed first in a staged manner manner ????

Address the vascular bed with the Address the vascular bed with the tightest tightest stenosis stenosis ????

Revascularize the coronaries and the carotids Revascularize the coronaries and the carotids at at the same time the same time ????

Or…

Or…

Treatment options in concomitant CAD Treatment options in concomitant CAD and CSand CS

CEA ‘CEA ‘stagedstaged’ prior to CABG ’ prior to CABG

CEA ‘CEA ‘combinedcombined’ with CABG during the same ’ with CABG during the same anesthesia. anesthesia.

‘‘Reverse stagedReverse staged’, wherein CABG is performed ’, wherein CABG is performed prior to CEA (for emergency CABG situations prior to CEA (for emergency CABG situations only).only).

Study resultsStudy results Chiappini et alChiappini et al. 202 patients: The rate of perioperative stroke did not differ . 202 patients: The rate of perioperative stroke did not differ

significantly between the simultaneous CABG - CEA group and the sequential significantly between the simultaneous CABG - CEA group and the sequential operations group (operations group (6.4% vs 4.8%6.4% vs 4.8%). ).

Naylor Naylor et alet al.. 97 published studies (8,900 patients): the risk of stroke or death in 97 published studies (8,900 patients): the risk of stroke or death in CEA-CABG pts > than in pts undergoing staged procedures (CEA-CABG pts > than in pts undergoing staged procedures (8.7% vs. 6.1%8.7% vs. 6.1%). ).

Ricotta Ricotta et alet al.: increased incidence of stroke and death in patients undergoing .: increased incidence of stroke and death in patients undergoing the simultaneous CEA - CABG surgery approach.the simultaneous CEA - CABG surgery approach.

Hill et alHill et al.: combined rate of stroke and mortality of 13.0% with the joint .: combined rate of stroke and mortality of 13.0% with the joint procedure compared with 4.9% for CABG surgery alone.procedure compared with 4.9% for CABG surgery alone.

No study has shown the superiority of the combined procedure over the two-No study has shown the superiority of the combined procedure over the two-staged approach.staged approach.

High-risk subgroup with combinedHigh-risk subgroup with combinedcarotid and coronary artery diseasecarotid and coronary artery disease

Neurological symptoms (stroke / TIA).Neurological symptoms (stroke / TIA).

Bilateral carotid stenosis 80–99%.Bilateral carotid stenosis 80–99%.

Unilateral 50–99% carotid stenosis with Unilateral 50–99% carotid stenosis with

contralateral occlusion.contralateral occlusion.

Asymptomatic 80–99% carotid stenosis with Asymptomatic 80–99% carotid stenosis with

impaired cerebral perfusion reserve.impaired cerebral perfusion reserve.

Advantage of concomitant CEA-Advantage of concomitant CEA-CABGCABG

Lower costLower cost

One anesthesiaOne anesthesia

Shorter hospital stayShorter hospital stay

CEA continues to be CEA continues to be the gold standard the gold standard for treatment for for treatment for carotid stenosis. carotid stenosis. CAS has an expanding role for CAS has an expanding role for revascularization, particularly in high-risk patients.revascularization, particularly in high-risk patients.

Patients undergoing combined CABG-CEA enjoy Patients undergoing combined CABG-CEA enjoy excellent long-term excellent long-term freedom from strokefreedom from stroke, as well as, , as well as, good long-term survivalgood long-term survival. .

ConclusionsConclusions

The most recent guidelines suggest that CEA is The most recent guidelines suggest that CEA is recommended before or concomitant to CABG in recommended before or concomitant to CABG in patients with symptomatic carotid stenosis greater than patients with symptomatic carotid stenosis greater than 50% or asymptomatic carotid stenosis greater than 80%. 50% or asymptomatic carotid stenosis greater than 80%. If the procedures are to be staged, complication rates If the procedures are to be staged, complication rates are lower when carotid revascularization precedes are lower when carotid revascularization precedes CABG.CABG.

With the available observational studies, off-pump With the available observational studies, off-pump CABG may be considered in the setting of combined CABG may be considered in the setting of combined CEA-CABG when feasible.CEA-CABG when feasible.

ConclusionsConclusions

At last, At last,

the best management strategy for patients with the best management strategy for patients with concomitant surgical coronary artery disease in need of concomitant surgical coronary artery disease in need of CABG and significant carotid artery stenosis should be CABG and significant carotid artery stenosis should be based on individual patient characteristics, urgency of based on individual patient characteristics, urgency of revascularization, prioritization based on the revascularization, prioritization based on the symptomatic vascular territory, local expertise with an symptomatic vascular territory, local expertise with an integrated team approach by interventionalists, integrated team approach by interventionalists, neurologists and cardiothoracic surgeons, preferably in neurologists and cardiothoracic surgeons, preferably in high-volume centers.high-volume centers.

ConclusionsConclusions

Thank you Thank you for your attention !for your attention !