Carotid artery stenting (CAS) was associated with lower mortality risk but higher stroke risk compared with carotid endarterectomy (CEA) in patients with concomitant carotid and coronary artery disease undergoing coronary artery bypass graft (CABG), according to a study published in JACC: Cardiovascular Interventions.1
Carotid artery disease and coronary artery disease often co-occur, and approximately 6% to 14% of patients undergoing CABG have significant carotid disease.2,3 While these comorbid diseases increase the risk of stroke after CABG, experts disagree on the optimal management approach in such patients. Although CEA, either staged or combined with CABG, has been shown to reduce death and stroke risk postsurgery, it is associated with a 10% to 12% incidence of adverse events.4,5
The researchers of the present study explained that CAS is a “minimally invasive endovascular alternative to CEA, particularly in patients considered to be poor candidates for CEA because of advanced age, high-risk anatomic features, or medical comorbidities.”6,7 While recent trials have found similar outcomes between CAS and CEA in terms of stroke risk, myocardial infarction, and death, there is a scarcity of trials comparing the 2 approaches in patients undergoing CABG.8,9
Researchers from several US universities used the Nationwide Inpatient Sample (NIS) database to compare 3 treatment strategies in 22,501 patients: combined CEA + CABG (68.4%), staged CEA + CABG (28%), and staged CAS + CABG (3.6%). The primary composite end points were defined as in-hospital all-cause death, stroke, and death/stroke. Their results revealed the following trends and outcomes.
- A 16% reduction in the overall rate of CEA and CABG between 2004 and 2012 (Ptrend =.03);
- No significant change in the rate of CAS + CABG during those years (Ptrend =.10);
- Increased adjusted risk of death and reduced stroke risk with combined CEA + CABG (death odds ratio [OR]: 2.08; 95% CI, 1.08-3.97; P =.03; stroke OR: 0.65; 95% CI, 0.42-1.01; P =.06) compared with CAS + CABG;
- Increased adjusted risk of death and reduced stroke risk with staged CEA + CABG (death OR: 2.40; 95% CI, 1.43-4.05; P =.001; stroke OR: 0.50; 95% CI, 0.31-0.80; P =.004) compared with CAS + CABG;
- Similar adjusted risk of death or stroke in all 3 groups
The CAS + CABG group demonstrated the greatest improvement between 2004 to 2008 and 2009 to 2012 (death OR, 0.19; 95% CI, 0.04-0.92; P =.04 and death/stroke OR, 0.33; 95% CI, 0.14-0.79; P =.01).
In addition, in patients with symptomatic carotid disease, better outcomes were observed with CAS + CABG compared with both CEA approaches. For the combined CEA + CABG strategy, the adjusted death OR was 3.06 (95% CI, 1.10-8.52; P =.03), and the adjusted stroke OR was 4.07 (95% CI, 2.21-7.47; P <.001). For the staged CEA + CABG strategy, the risk of death was similar to that of CAS + CABG, while the adjusted stroke OR was 4.70 (95% CI, 2.60-8.48; P <.001).
“Given potentially important improvements in medical management of carotid disease since the 1990s, as well as concerns about risks/ benefits of revascularization, particularly in high-risk asymptomatic elderly patients, further trials are needed to address this controversy [regarding the best revascularization strategy for such patients undergoing concurrent CABG],” the researchers concluded.
Disclosures: Dr Feldman discloses that he is a consultant and speaker bureau member for Abbott Vascular, Medtronic, and St. Jude Medical.
- Feldman DN, Swaminathan RV, Geleris JD, et al. Comparison of trends and in-hospital outcomes of concurrent carotid artery revascularization and coronary artery bypass graft surgery. The United States experience 2004 to 2012. JACC Cardiovasc Interv. 2017;10(3):286-298. doi:10.1016/j.jcin.2016.11.032
- Borger MA, Fremes SE, Weisel RD, et al. Coronary bypass and carotid endarterectomy: does a combined approach increase risk? A meta-analysis. Ann Thorac Surg. 1999;68(1):14-20; discussion 21.
- Schwartz LB, Bridgman AH, Kieffer RW, et al. Asymptomatic carotid artery stenosis and stroke in patients undergoing cardiopulmonary bypass. J Vasc Surg. 1995;21(1):146-153.
- Hines GL, Scott WC, Schubach SL, Kofsky E, Wehbe U, Cabasino E. Prophylactic carotid endarterectomy in patients with high-grade carotid stenosis undergoing coronary bypass: does it decrease the incidence of perioperative stroke? Ann Vasc Surg. 1998;12(1):23-27.
- Fareed KR, Rothwell PM, Mehta Z, Naylor AR. Synchronous carotid endarterectomy and off-pump coronary bypass: an updated, systematic review of early outcomes. Eur J Vasc Endovasc Surg. 2009;37(4):375-378. doi:10.1016/j.ejvs.2008.12.008
- Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting vs endarterectomy in high-risk patients. N Engl J Med. 2004;351(15):1493-1501. doi:10.1056/NEJMoa040127
- Brott TG, Hobson RW, Howard G, et al. Stenting vs endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11-23. doi:10.1056/NEJMoa0912321
- Brott TG, Howard G, Roubin GS, et al. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med. 2016; 374: 1021-1031. doi: 10.1056/NEJMoa1505215
- Rosenfield K, Matsumura JS, Chaturvedi S, et al. Randomized trial of stent versus surgery for asymptomatic carotid stenosis. N Engl J Med. 2016; 374:1011-1120. doi: 10.1056/NEJMoa1515706