Carotid Stenting Prior to Coronary Bypass Surgery: An Updated Systematic Review and Meta-Analysis

Area of Science:

• Cardiovascular Surgery
• Interventional Cardiology
• Neurology

Background:

• Concurrent carotid and cardiac disease presents a complex management challenge.
• Carotid artery stenting (CAS) and coronary artery bypass grafting (CABG) are common interventions for these conditions.
• The optimal timing and sequence of CAS and CABG remain subjects of investigation.

Purpose of the Study:

• To determine 30-day outcomes in patients with concurrent carotid and cardiac disease undergoing CAS followed by CABG.
• To compare outcomes between same-day and staged CAS + CABG procedures.
• To evaluate the impact of different antiplatelet strategies on outcomes.

Main Methods:

• A systematic review of PubMed/Medline, Embase, and Cochrane databases was conducted.
• Studies involving "same-day" CAS + CABG and "staged" interventions (at least 1 day apart) were included.
• Data on 30-day mortality, stroke, and myocardial infarction were extracted and analyzed.

Main Results:

• 31 studies with 2727 patients were analyzed; 80% were asymptomatic with unilateral stenoses.
• The overall 30-day death/stroke rate was 7.9%.
• Staged CAS + CABG had a 30-day death/stroke rate of 8.5% versus 5.9% for same-day procedures. Symptomatic patients had higher stroke rates (15%).
• Different antiplatelet strategies showed varying rates of death/stroke/MI and bleeding complications, with insufficient data for definitive conclusions on optimal regimens.

Conclusions:

• In predominantly asymptomatic patients with unilateral carotid stenoses, the 30-day death/stroke rate after CAS + CABG is approximately 8%.
• This meta-analysis did not find evidence of significantly higher adverse outcomes with same-day CAS + CABG compared to staged procedures.
• Outcomes were poorer in neurologically symptomatic patients, and further research is needed to determine the optimal antiplatelet strategy.