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Safety and effectiveness of selective carotid angioplasty prior to cardiac surgery: a single-centre matched
Zahra Hasani1, Rudolf W M Keunen1, Dénes L J Tavy1
1Department of Neurology and Clinical Neurophysiology, Haga Teaching Hospitals, The Hague, Netherlands.
Insights
Selective carotid angioplasty before cardiac surgery may reduce severe strokes in high-risk patients. This approach appears safe and shifts stroke type toward less severe embolic events, improving outcomes.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Interventional Cardiology
Background:
- Postoperative stroke after cardiac surgery is a significant challenge, particularly for patients with cerebrovascular disease.
- Carotid angioplasty for all high-grade carotid stenosis has not proven effective in reducing post-surgical stroke rates.
Purpose of the Study:
- To evaluate the safety and effectiveness of selective carotid angioplasty in patients with poor intracranial collaterals undergoing cardiac surgery.
- To assess if this selective approach modifies the type and outcome of postoperative strokes.
Main Methods:
- A single-centre study comparing postangioplasty complications with symptomatic carotid angioplasty patients.
- Comparing post-cardiac surgery complication rates with matched case controls to determine effectiveness.
Main Results:
- Twenty-two patients underwent selective carotid angioplasty without persistent major neurological complications.
- All but one patient proceeded to surgery, with no persistent major neurological disabilities; two deaths occurred due to cardiogenic shock.
Conclusions:
- Selective carotid angioplasty prior to cardiac surgery is relatively safe and effective for high-risk patients.
- The strategy appears to shift stroke type from severe hemodynamic to minor embolic, with favorable outcomes.
- Larger studies are needed to confirm the elimination of hemodynamic stroke post-cardiac surgery.
Objectives:
Reducing the rate of postoperative stroke after cardiac surgery remains challenging, especially in patients with occlusive cerebrovascular disease. Angioplasty in all patients with high-grade carotid artery stenosis has not been shown to be effective in reducing the post-surgical stroke rate. In this study, we present the initial results of a different approach using selective carotid angioplasty only in patients with poor intracranial collaterals.
Methods:
We conducted a single-centre study to assess the safety of this procedure. The postangioplasty complication rate of the study group was compared to that of patients who were scheduled for symptomatic carotid artery angioplasty. To determine the effectiveness of this procedure, the post-cardiac surgery complication rate of the study group was compared with that of the matched case controls.
Results:
Twenty-two patients were treated with selective carotid angioplasty without developing persistent major neurological complications. All patients except 1 patient subsequently underwent surgery without developing persistent major neurological disabilities. Two patients died of cardiogenic shock within 30 days.
Conclusions:
Selective carotid angioplasty prior to cardiac surgery in patients with a presumed high risk of stroke was relatively safe and effective in this study group. Although this strategy does not prevent stroke in these high-risk patients, data suggest that this approach shifts the postoperative type of stroke from a severe haemodynamic stroke towards a minor embolic stroke with favourable neurological outcomes. Larger studies are needed to determine whether this strategy can effectively eliminate the occurrence of haemodynamic stroke after cardiac surgery.
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