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Late outcomes best with carotid artery stenting followed by open-heart surgery
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Of the three most common treatment approaches for patients with severe carotid artery disease and severe CAD, patients who underwent carotid artery stenting followed by open-heart surgery had the best outcomes, according to results of a new study.
Mehdi H. Shishehbor, DO, MPH, PhD, and colleagues conducted a retrospective study of 350 patients at the Cleveland Clinic who had carotid revascularization within 90 days of CABG from January 1997 to August 2009. Patients who underwent carotid artery stenting (CAS) followed by open-heart surgery were less likely to experience MI, stroke or death compared with patients who underwent a staged endarterectomy followed by open-heart surgery.
The researchers evaluated outcomes for three different treatment approaches:
- Carotid endarterectomy (CEA) followed by open-heart surgery a few weeks later (n=45).
- CEA performed simultaneously with open-heart surgery (n=195).
- CAS followed by open-heart surgery a few weeks later (n=110).
The types of open-heart surgery performed included CABG, CABG combined with other cardiac procedures, and non-CABG procedures such as isolated valve or aortic repair surgery. Patients who received CEA or CAS after open-heart surgery were not included in the study. Median follow-up time was 3.7 years after CEA or CAS.
Mehdi H. Shishehbor
“This is a very controversial area, and these are very high-risk patients,” Shishehbor, who is director of Endovascular Services in the Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic, told Cardiology Today’s Intervention. “Our hope is that this study will change the way … we treat patients with severe carotid and coronary disease.”
The primary composite outcome was MI, stroke and all-cause mortality. Patients who underwent CAS followed by open-heart surgery had a higher rate of prior stroke (P=.03) and required more complex open-heart surgery than patients who received other treatments.
After 30 days, those who received CAS followed by open-heart surgery or CEA combined with open-heart surgery showed better event rates compared with those who received CEA followed by open-heart surgery (P=.003), mainly because the latter group had a higher rate of MI. After 1 year, event rates for those who received CAS followed by open-heart surgery and those who received CEA combined with open-heart surgery remained similar (adjusted HR=0.99; 95% CI, 0.61-1.62). Event rates for CEA followed by open-heart surgery were higher.
However, after 1 year, patients who received CAS followed by open-heart surgery experienced fewer events compared with patients who received either CEA combined with open-heart surgery (adjusted HR=0.35; 95% CI, 0.18-0.7) or CEA followed by open-heart surgery (adjusted HR=0.33; 95% CI, 0.15-0.77).
“Cardiac surgeons always fear that they are going to take a patient, do a beautiful job of fixing their heart … and then the patient is going to have a stroke in the perioperative period,” Shishehbor, who is a member of the Cardiology Today’s Intervention Editorial Board, said in an interview. “Many people believe that in the perioperative period, when [patients] are undergoing open-heart surgery, there are a lot of changes in BP and fluid, and [patients] experience hypotension. So if you have severe carotid disease, the risk for stroke may be higher. Because of that, the cardiac surgeons are demanding something to be done. And what we are seeing, in [this] very rigorous study … is that stenting is actually superior to the combined approach.”
Shishehbor said the study findings have changed practice at Cleveland Clinic, but an obstacle for more widespread change is that CMS does not reimburse for many carotid stenting procedures.
Disclosure: Shishehbor is a speaker and consultant for Abbott Vascular, Gore and Medtronic, but does not accept compensation.
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