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Simultaneous Carotid Artery Stenting and Coronary Artery Bypass Grafting in Urgent Patients: A Single Center
Mariafrancesca Fiorentino1, Elisa Mikus1, Roberto Nerla1
1Cardiovascular Department, Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy.
Insights
Simultaneous carotid artery stenting (CAS) and coronary artery bypass grafting (CABG) is safe and effective. This combined procedure shows low mortality, stroke risk, and bleeding complications, with good long-term survival.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Vascular Surgery
Background:
- Coexisting coronary artery disease and critical carotid stenosis pose significant revascularization challenges, especially in urgent surgical scenarios.
- Combined carotid artery stenting (CAS) and coronary artery bypass grafting (CABG) is an increasingly adopted strategy for managing these complex cases.
Purpose of the Study:
- To evaluate the safety and efficacy of a simultaneous CAS and CABG procedure.
- To assess perioperative outcomes, including mortality, stroke, bleeding, and long-term survival.
Main Methods:
- Analysis of 36 patients undergoing simultaneous CAS and CABG between 2014 and 2024.
- CAS performed first with awake patient for neurocognitive monitoring; clopidogrel loading dose 3 hours post-op.
- Dual antiplatelet therapy initiated on postoperative day 1.
Main Results:
- No in-hospital mortality or postoperative stroke observed in 36 patients.
- Low median postoperative bleeding (500 mL) with one patient requiring resternotomy.
- Excellent survival rates: 93.7% at 1 year, 81.5% at 5 years, 60.2% at 10 years.
- High freedom from percutaneous transluminal coronary angioplasty/percutaneous coronary intervention (PTCA/PCI): 100% at 1 year, 96.7% at 5 years, 87.5% at 10 years.
Conclusions:
- Simultaneous CAS and CABG is a safe and effective revascularization strategy.
- The employed protocol demonstrates low perioperative stroke and bleeding risks.
- Early antiplatelet therapy does not elevate postoperative bleeding complications.
Abstract:
Background: Coexisting coronary artery disease and critical carotid stenosis present challenges in revascularization, particularly in urgent cases requiring surgery. Combining carotid artery stenting (CAS) with coronary artery bypass grafting (CABG) has gained popularity. Methods: This study analyzed 36 patients who underwent simultaneous CAS and CABG from 2014 to 2024. CAS was performed first, with the patient awake for real-time neurocognitive assessment. A clopidogrel loading dose was administered three hours post-surgery. From postoperative day 1, dual antiplatelet therapy was initiated. Results: The median age was 72 years (64-77) and 22.2% were females. The median EuroSCORE II was 2.80 (2.06-3.58). Nine patients (25%) underwent associated procedures. The median cardiopulmonary bypass and cross-clamp times were 66 (54-89) and 51 (41-72) minutes. We observed no in-hospital mortality and no postoperative stroke. The median postoperative bleeding in 24 h was 500 mL and only one (2.8%) patient needed resternotomy for bleeding. The median ventilation time was 9 h (6-12). The median intensive care unit and postoperative length of stay were 2 (2-4) days and 8 (7-11) days, respectively. The median follow-up time was 6 years. Survival at 1, 5, and 10 years was 93.7%, 81.5%, and 60.2%, respectively, while freedom from PTCA/PCI at 1, 5, and 10 years was 100%, 96.7%, and 87.5%, respectively. Conclusions: Simultaneous CAS and CABG is a safe and effective procedure with low in-hospital mortality and morbidity. Our protocol carries a low risk of perioperative stroke. Antiplatelet therapy administration on the day of surgery does not increase the risk of postoperative bleeding.
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