Management of patients with concomitant coronary and carotid artery disease

ABSTRACT

Introduction: Ideal management of concomitant carotid and coronary artery occlusive disease remains under investigation. Although researchers have advocated the potential benefits of varying treatment strategies based on either concomitant or staged surgical treatment, there is no consensus in treatment guidelines. With emerging data suggesting favorable outcome of carotid artery stenting (CAS) compared to carotid endarterectomy (CEA) in patients with critical coronary artery disease, physicians must consider these diverging therapeutic options.

Areas covered: This review presents current evidence regarding the prevalence of carotid stenosis in patients with coronary artery disease, the common pathophysiologic links with an emphasis on the diverse mechanisms of stroke in the coronary artery bypass grafting (CABG) setting and discusses the contemporary registries and observational studies comparing outcomes of various revascularization strategies in high-risk patients. Authors conducted a literature search in two bibliographic databases including papers published from 1983 until 2018 (PubMed, Scopus).

Expert opinion: Symptoms should drive the need to intervene on carotid stenosis in patients undergoing coronary revascularization. Carotid artery stenting has gained significant ground, especially among those individuals considered of high surgical risk. PCI may be considered as an alternative option for the management of severe concurrent coronary disease.

KEYWORDS:

• Coronary artery disease
• carotid artery stenosis
• CABG
• carotid endarterectomy
• carotid artery stenting

Article highlights

• The precise mechanisms of stroke in the CABG setting are contentious. Among others, macroembolization during manipulation of an atheromatous aorta, microemboli due to contact activation in the bypass circuit which interact with carotid plaques causing thrombosis at sites of carotid stenosis, intra-operative hypotension, poor left ventricular function (LV), atrial fibrillation and/or altered intracranial hemodynamics seem to be the most prominent mechanisms for stroke.

• Current guidelines recommend carotid screening in selected patients scheduled for CABG with high-risk features such as age>65 years, left main coronary stenosis, peripheral artery disease, history of cerebrovascular event, hypertension, smoking and/or diabetes mellitus.

• The ACC/AHA guidelines of 2011 for CABG recommend carotid revascularization in conjunction with CABG in patients with a previous TIA or stroke and a significant (50% to 99%) CS, adding that sequence and timing of interventions should be determined by the patient’s relative magnitudes of cerebral and myocardial dysfunction.

• Combined or synchronous treatment of CEA and CABG results in higher stroke and death rates, due to several reasons. Synchronous CEA and CABG procedures are more technically challenging, from both a surgical and an anesthesia standpoint, thereby resulting in greater perioperative complications. The synchronous approach is generally reserved for patients with severe symptoms involving both carotid and coronary vascular territories. The staged approach with CEA prior to CABG is favored due to perceived advantage of reduced operative time and minimized surgical complexity. This approach is generally reserved for patients with stable coronary symptoms who can undergo the initial CEA procedure followed by a variable time interval of recovery before undergoing coronary revascularization.

• The theoretical advantages of CAS are related to the minimally invasiveness and avoidance of general anesthesia, which may reduce cardiac complications. With regard to incorporating CAS treatment in patients who require CABG, there are three potential treatment strategies: 1) CAS followed by CABG in the same operating room under general anesthesia (true hybrid approach), 2) CAS followed by CABG on the same day, with CAS in the catheterization laboratory and then transfer patient to the operating room (same day hybrid approach), and 3) CAS in the catheterization laboratory followed by CABG several days or weeks later during the same or another hospitalization (traditional-staged approach).

• Off-pump CABG has been shown to result in a reduced incidence of postoperative stroke compared to on-pump CABG in patients undergoing synchronous CEA and coronary revascularization.

• All patients with severe coronary and carotid disease should be aggressively treated with statins, blood pressure control and antiplatelet agents, in addition to aggressive lifestyle modification with smoking cessation and exercise as tolerated.

• It seems rational to proceed to immediate coronary revascularization with either subsequent staged carotid intervention or synchronous carotid intervention in patients with unstable CAD.

Declaration of interest

K Toutouzas is a proctor for Medtronic. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.