Current concepts on the management of concomitant carotid and coronary disease
1Division of Cardiology, University Hospital, Rue Micheli-du-Crest 24, Geneva, Switzerland. Marco.Roffi@hcuge.ch
Insights
Managing severe carotid and coronary artery disease (CAD) before heart surgery is complex. Revascularizing severe carotid stenosis may prevent stroke, with carotid artery stenting (CAS) potentially reducing heart attack risk compared to surgery.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Interventional Cardiology
Background:
- Optimal management for patients with severe carotid and coronary artery disease (CAD) undergoing coronary bypass grafting (CABG) lacks randomized data.
- Multilevel atherosclerotic disease typically requires treating the symptomatic vascular territory first.
- Combined surgical approach (carotid endarterectomy [CEA] and CABG) carries high event rates.
Purpose of the Study:
- To explore optimal management strategies for severe carotid and CAD, particularly in patients considered for CABG.
- To evaluate the role of revascularization in preventing perioperative stroke and improving long-term outcomes.
- To compare carotid artery stenting (CAS) versus CEA in patients with advanced CAD.
Main Methods:
- Review of current literature and clinical guidelines regarding management of concurrent severe carotid and coronary artery disease.
- Consideration of percutaneous coronary intervention (PCI) as an alternative to CABG.
- Evaluation of carotid artery stenting (CAS) as a strategy prior to open-heart surgery when PCI is not feasible.
Main Results:
- Reassessing CABG indication and exploring PCI feasibility is recommended when severe carotid disease is identified pre-cardiac surgery.
- CAS prior to open-heart surgery may be considered if expertise is available and PCI is not an option.
- Treatment of severe bilateral carotid stenosis appears reasonable for perioperative stroke prevention; unilateral stenosis aims for long-term stroke prevention.
- CAS may offer an advantage over CEA in patients with advanced CAD by reducing perioperative myocardial infarction.
Conclusions:
- Management of severe carotid and CAD requires individualized assessment, often favoring less invasive options like PCI or CAS.
- Carotid revascularization, particularly CAS, can be a valuable strategy for stroke and myocardial infarction prevention in specific patient groups.
- Further randomized data is needed to definitively establish optimal treatment algorithms for these complex patients.
Abstract:
In the absence of randomized data, the optimal management of patients with severe carotid and coronary artery disease (CAD), especially those undergoing coronary bypass grafting (CABG), remains unsettled. As a general rule, in patients with multilevel atherosclerotic disease the symptomatic vascular discrict should be treated first. The entirely surgical approach with carotid endarterectomy (CEA) and CABG is associated with high event rates. Therefore, whenever in the work-up prior to cardiac surgery severe carotid disease is identified, the indication for CABG should be reassessed and the feasibility of percutaneous coronary intervention (PCI) as an alternative treatment should be explored. If PCI is not an option, carotid artery stenting (CAS) prior to open heart should be considered if the expertise is available. Although perioperative stroke is multifactorial and the value of revascularization of asymptomatic carotid disease prior to open heart surgery remains controversial, treatment of patients with severe bilateral carotid stenosis appears reasonable for perioperative stroke prevention. The aim of carotid revascularization in patient with unilateral severe carotid stenosis should more long-term stroke prevention than merely perioperative stroke reduction. The main advantage of CAS compared with CEA in patients with advanced CAD is the reduction of perioperative myocardial infarction, an event associated to long term mortality.
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